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Purpose: The aim was to determine and compare the short-term effects of two intensive semi-occluded vocal tract (SOVT) programs, "straw phonation" (SP) and "resonant voice therapy" (RVT), on the phonation of children with vocal fold nodules., Method: A pretest-posttest randomized controlled study design was used. Thirty children aged 6-12 years were randomly assigned to the SP group ( n = 11), RVT group ( n = 11), or control group receiving indirect treatment ( n = 8) for their voice problems. All participants received 11 hr of group voice therapy over four consecutive days. A multidimensional voice assessment consisting of both objective (dysphonia severity index and acoustic voice quality index) and subjective (pediatric voice handicap index and perceptual rating of overall severity) measures was performed pre- and posttherapy. Voice therapy effectiveness was evaluated using group-level analyses (linear mixed models) and individual-level analyses to investigate what proportion of participants changed to a clinically relevant degree., Results: Group-level analyses found no significant Time × Group interactions, indicating that the evolution over time did not differ among the three groups. Within-group effects of time showed a significant and equal improvement in dysphonia severity index in the SP and RVT groups and a significant improvement in perceptual rating of overall severity in the SP group. For dysphonia severity index, individual-level analyses showed that 36% and 45% of participants improved to a clinically relevant degree in the SP and RVT groups, respectively. For acoustic voice quality index, 38% improved to a clinically relevant degree in the SP group., Conclusions: Results suggest that short-term intensive SOVT programs may have a positive effect on voice quality and vocal capacities of children with vocal fold nodules. Participants seem to benefit more from a SP program than a RVT program.

Objective: Unilateral vocal fold paralysis (UVFP) frequently causes severe dysphonia, which necessitates multidisciplinary treatment. Literature on outcomes of interventions has primarily focused on vocal fold motility or instrumental vocal outcomes, but the perspectives of patients about the treatment process have not yet been investigated. The purpose of the study was therefore to explore patient experiences with healthcare for UVFP., Methods: Twenty-four adults with UVFP (age range: 39 - 84 years) participated in the study. Semi-structured interviews were conducted, transcribed, and analyzed with the software program NVivo. An inductive thematic approach was used to code and analyze the interviews., Results: Three themes were identified through the qualitative analyses: (1) the healthcare professional (HCP), (2) experiences with treatment, and (3) patient support. The laryngologist and speech-language pathologist (SLP) were crucial HCPs during treatment, and patients relied heavily on their advice, so they expected them to be knowledgeable about UVFP and empathic towards their patients. Voice therapy was mostly a positive experience due to the collaborative therapeutic relationship with the SLP, even though it did not yield sufficient voice improvements. Medialization surgery was a relief for some participants, while others expected more or felt too vulnerable to undergo surgery. Sources of patient support included personal connections such as relatives and fellow patients, but participants expressed a need for increased support and guidance from the healthcare system., Conclusion: Overall, participants were satisfied with the care that they had received, but certain barriers and needs within UVFP healthcare were identified. The findings from the current study can help guide the development of initiatives to better support patients and HCPs and improve patient-centered care in UVFP., Competing Interests: Declaration of competing interest The authors declare there are no relevant conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: The objectives of this study were to investigate (1) the knowledge of primary school teachers regarding voice and voice disorders, (2) the primary school teacher's ability to identify and refer a dysphonic child to a speech-language pathologist (SLP), and (3) potential contributing factors that might affect this ability., Method and Materials: Thirty-one primary school teachers (30 women, one man) with a mean age of 33 years (range: 22-57 years; SD: 11.1 years) were included in this study. They filled out an online questionnaire, gathering demographic information, estimations of their knowledge regarding voice and voice disorders, and their ability to refer a dysphonic child to an SLP. Furthermore, they completed an online quiz (maximum score: 9) with basic questions about the voice, vocal health and voice disorders., Results: Most teachers (58.1%) rated their knowledge as basic, 16.1% as adequate and 25.8% as good. One out of four teachers (25.8%) received voice-related information during their education. A substantial part (38.7%) gathered information through other channels, such as voice therapy. Almost all participants (90%) reported to have no or little experience with dysphonic children. Half of them (51.6%) felt unsure about their ability to refer a dysphonic child to an SLP, and 54.8% were willing to attend extra voice workshops. A significant association was found between the estimated knowledge regarding voice (disorders) and attendance of voice therapy (P = 0.020). More than half of the teachers who attended voice therapy (57.1%) estimated their voice-related knowledge as good, compared to only 16.7% of the teachers who did not attend voice therapy. Moreover, a significant association was found between the years of teaching experience and the quiz total score (P = 0.040). The majority of the teachers with the least teaching experience (57.1%) achieved a score between 4 and 6, whereas the teachers with more experience achieved a score between 7 and 9., Conclusion: This study suggests that the voice-related knowledge of primary school teachers is limited. Consequently, teachers do not feel confident in referring a dysphonic child to an SLP. As teachers can be important sources in indirect assessment of pediatric dysphonia, they need to be well informed and extensively trained in using voice screening protocols. Interdisciplinary cooperation between SLPs and teachers should be optimized to provide the best available care and improve the children's quality of life., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Voice-related quality of life (Qol) questionnaires provide the clinician with information regarding the impact of voice disorders on the patient's well-being. The available voice-related QoL tools for Dutch-speaking children are parent-proxy in nature. However, the use of proxy measurements has been debated in the literature. The Children's Voice Handicap Index-10 (CVHI-10) is a self-reported QoL tool for dysphonic children. Therefore, the aim of this study is to develop and validate a Dutch version of the CVHI-10., Study Design: Observational, prospective, cross-sectional study., Methods: The original version of the CVHI-10 was translated and adapted to Dutch according to the recommendations of the Quality of Life Special Interest Group - Translation and Cultural Adaptation group. Subsequently, the questionnaire was individually completed by 77 children (dysphonic group: n = 30, control group: n = 47) between eight and 14 years. In order to investigate test-retest reliability, 50% of the participants were asked to complete the questionnaire twice with an interval of 2 weeks. Internal consistency, test-retest reliability and construct validity were calculated. A receiver operating characteristic (ROC) analysis was conducted to check the sensitivity and specificity levels of the instrument., Results: Internal consistency measured with Cronbach's alpha coefficient was 0.745. Test-retest reliability measured with intraclass correlation coefficients was 0.718. Mean total CVHI-10 score was 6.17 ± 2.7 in the dysphonic group and 2.68 ± 2.6 in the control group. The difference in total score between the groups was statistically significant (P < 0.001), suggesting that the tool has good construct validity. ROC analysis demonstrated moderate diagnostic accuracy (area under the curve = 0.869) and suggested a cut-off score of 3.5., Conclusions: The Dutch CVHI-10 is the first self-reported voice-related QoL tool for dysphonic Dutch-speaking children. It is a valid, reliable and sensitive tool to assess the impact of a voice disorder on the child's well-being., Competing Interests: DECLARATIONS OF INTEREST None., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Although psychological factors have been implicated in patients with functional dysphonia (FD), conventional voice therapy (CVT) typically targets the aberrant voice symptoms exclusively. Yet, CVT is not always successful, and in view of the significant adverse quality of life impact combined with the financial burden on the healthcare system and society, research is needed to elucidate the underlying psychophysiology of FD and improve treatment outcomes., Objectives: The first objective of this research project is to compare the occurrence and frequency of symptoms and/or disorders related to autonomic nervous system (ANS) dysfunction in patients with FD with gender- and age-matched vocally healthy controls, using a case-control study. The second objective is to compare the effects of a novel therapy for FD based on ANS regulation (i.e., ANS therapy: heart rate variability (HRV) biofeedback) on both autonomic function and voice function versus CVT alone or in combination with ANS therapy (i.e., ANS therapy + CVT), using a randomized controlled trial (RCT)., Methods: Case-control study: Autonomic (dys)function of patients with FD will be compared with gender- and age-matched vocally healthy controls, using both physiological measures (e.g., HRV, skin conductance level) and psychological patient-reported outcome measures (PROMs, e.g., Neuroception of Psychological Safety Scale, Depression Anxiety and Stress Scale). RCT: The FD group will be randomly assigned to the innovative ANS therapy group, the CVT group or the ANS therapy + CVT group. All patients received 1 month of treatment with 20 min of daily practice. Both the autonomic assessment and the voice assessment will be performed pretherapy and immediately after therapy by assessors blinded to group allocation and study phase., Expected Results: Higher occurrences of symptoms and/or disorders related to autonomic dysfunction are expected in patients with FD compared with vocally healthy controls. Physiological outcomes: lower HRV, lower cardiac pre-ejection period, higher respiration rate and higher skin conductance level are hypothesized in patients with FD compared with vocally healthy controls. Psychological PROMs: higher self-report of feelings/symptoms related to autonomic dysfunction (e.g., perceived stress, anxiety) is expected in patients with FD compared with vocally healthy controls. The autonomic function is hypothesized to improve more after the ANS therapy and the ANS therapy + CVT compared with the CVT only. Voice function is expected to improve more after the ANS therapy + CVT compared with the ANS therapy and the CVT alone., What This Paper Adds: What is already known on the subject Autonomic dysfunction is well recognized in the field of psychology but remains understudied in the area of voice. Given that the vagus nerve, innervating the larynx, also helps to regulate the ANS, and psychological symptoms commonly observed in patients with FD may reflect ANS dysregulation, research in this area is needed. There is some preliminary evidence that autonomic dysfunction might indeed be associated with FD. However, physiological ANS measures are needed, as well as validated psychological PROMs. What this paper adds to the existing knowledge The first objective of this study is to investigate the occurrence and frequency of symptoms and/or disorders related to autonomic dysfunction in patients with FD as compared with a gender- and age-matched vocally healthy control group. Autonomic (dys)function will be determined by employing both physiological measures (e.g., HRV, skin conductance level) and psychological PROMs (e.g., Neuroception of Psychological Safety Scale, Depression Anxiety and Stress Scale). The second objective is to compare the effects of a novel therapy for FD based on ANS regulation (HRV biofeedback) versus CVT alone or in combination with ANS therapy. What are the potential or actual clinical implications of this work? Success rates of symptomatic CVT for FD are highly variable. This study is expected to lead to innovative results related to the pathogenesis and psychophysiology of FD, a prevalent voice disorder associated with a significant adverse quality of life impact and a substantial financial burden on the healthcare system and society. The results of this study will lead to crucial new insights into both the diagnosis and treatment of FD, contributing to evidence-based practice in the field of voice., (© 2024 Royal College of Speech and Language Therapists.)

Background: Studies on treatment efficacy in unilateral vocal fold paralysis (UVFP) often lack a predetermined treatment protocol, and little is known about the effects of specific vocal techniques on vocal outcomes and quality of life in UVFP patients. The purpose of this preliminary proof-of-concept study is to investigate the effects and feasibility of two intensive treatment protocols based on water-resistance therapy (WRT) and vocal function exercises (VFE)., Methods: Ten participants with acute or chronic UVFP/paresis were recruited in the study and randomly assigned to the WRT or VFE group. Three of these participants presented with aphonia and could not complete the program as prescribed. The remaining participants completed an intensive therapy program with the assigned vocal technique. Before, during, and after the program, a multidimensional voice assessment was performed. Maximum phonation time, acoustic, perceptual, and patient-reported outcome measures (PROMs) were obtained., Results: WRT and VFE had positive clinical effects on instrumental and auditory-perceptual voice quality, glottal closure, and PROMs, but interindividual variability was high. Studies with larger sample sizes are necessary to confirm or refute these findings., Conclusion: The WRT- and VFE-based therapy programs are both feasible and seem to elicit positive clinical changes in UVFP patients. Suggestions on how to improve the programs are provided, as well as considerations for implementation in clinical practice. Follow-up research is needed to examine the efficacy of both programs on group level., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: One role of a speech-language pathologist (SLP) is to help transgender clients in developing a healthy, gender-congruent communication. Transgender women frequently approach SLPs to train their voices to sound more feminine, however, long-term acoustic effects of the training needs to be rigorously examined in effectiveness studies. The aim of this study was to investigate the long-term effects (follow-up 1: 3months and follow-up 2: 1year after last session) of gender-affirming voice training for transgender women, in terms of acoustic parameters., Study Design: This study was a randomized sham-controlled trial with a cross-over design., Methods: Twenty-six transgender women were included for follow-up 1 and 18 for follow-up 2. All participants received 14weeks of gender-affirming voice training (4weeks sham training, 10weeks of voice feminization training: 5weeks pitch elevation training and 5weeks articulation-resonance training), but in a different order. Speech samples were recorded with Praat at four different time points (pre, post, follow-up 1, follow-up 2). Acoustic analysis included f o of sustained vowel /a:/, reading and spontaneous speech. Formant frequencies (F 1 -F 2 -F 3 ) of vowels /a/, /i/, and /u/ were determined and vowel space was calculated. A linear mixed model was used to compare the acoustic voice measurements between measurements (pre - post, pre - follow-up 1, pre - follow-up 2, post - follow-up 1, post - follow-up 2, follow-up 1 - follow-up 2)., Results: Most of the f o measurements and formant frequencies that increased immediately after the intervention, were stable at both follow-up measurements. The median f o during the sustained vowel, reading and spontaneous speech stayed increased at both follow-ups compared to the pre-measurement. However, a decrease of 16 Hz/1.7 ST (reading) and 12 Hz/1.5 ST (spontaneous speech) was detected between the post-measurement (169 Hz for reading, 144 Hz for spontaneous speech) and 1year after the last session (153 Hz and 132 Hz, respectively). The lower limit of f o did not change during reading and spontaneous speech, both directly after the intervention and during both follow-ups. F 1-2 of vowel /a/ and the vowel space increased after the intervention and both follow-ups. Individual analyses showed that more aspects should be controlled after the intervention, such as exercises that were performed at home, or the duration of extra gender-affirming voice training sessions., Conclusions: After 10 sessions of voice feminization training and follow-up measurements after 3months and 1year, stable increases were found for some formant frequencies and f o measurements, but not all of them. More time should be spent on increasing the fifth percentile of f o , as the lower limit of f o also contributes to the perception of more feminine voice., Competing Interests: Declaration of Competing Interest The authors confirm that there is no conflict of interest., (Copyright © 2024 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Unilateral vocal fold paralysis (UVFP) is often characterized by severe dysphonia and has a significant impact on a patient's communication in daily and vocational situations. Having a better understanding of how UVFP influences quality of life and patient experiences can help improve patient-centered care in this population. Therefore, the purpose of this study was to explore the lived experiences of patients with UVFP., Methods: Twenty-five adults with UVFP (age range: 39-84years) participated in the study. Quantitative data were collected from 22 participants, using the Voice Handicap Index (VHI), Dysphonia Severity Index (DSI), and Acoustic Voice Quality Index (AVQI). Qualitative data were collected from 25 individual semistructured interviews, which were recorded, transcribed, and analyzed with the software program NVivo. The interviews were coded using an inductive thematic approach., Results: Quantitative results showed a mean DSI of - 1.6, mean AVQI of 3.80, and mean VHI of 45.8 in the participant group. A statistically significant, moderate (positive) correlation was found between VHI and time after onset (in years). From the qualitative analysis of the interviews, four main themes were identified: emotional impact, psychosocial impact, physical complaints, and coping strategies. Voice problems caused by UVFP generally had a negative impact on patients' emotional and psychological well-being, with considerable effects on participation, self-identity, and professional activity. Participants demonstrated a combination of problem-focused and emotion-focused coping strategies to accommodate to these issues. Half of the participant group also showed avoidance as a coping style. VHI scores were significantly higher in participants who reported experiencing current emotional and participation problems due to UVFP, and who had not yet accepted their new voice., Conclusion: The themes from this study emphasize the importance of focused anamnesis and emotive counseling in practice, with specific attention to the psychosocial and emotional impact of UVFP., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest., (Copyright © 2024 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose The first purpose of this study was to investigate and compare the short-term effects after a semi-occluded vocal tract (SOVT) therapy session consisting of straw phonation (SP) in air or water on vocal fold vibration and supraglottic activity of adult patients with voice disorders, visualized with strobovideolaryngoscopy (SVL). The second purpose of this study was to investigate and compare immediate changes in the patients' vocal fold vibration and supraglottic activity during SP in air or water, visualized with SVL. Methods Twelve adult patients with voice disorders (eight women and four men, mean age 52 years) were assigned randomly to one of two study groups: SP in air or SP in water. Immediately before and after a therapy session of 15 min, participants underwent a rigid SVL to determine the short-term effects of the SP session. At the posttherapy examination, flexible SVL while performing SP was added to determine the effects occurring during SP. The visual-perceptual ratings were performed blindly and in random order by three laryngologists, using the Voice-Vibratory Assessment with Laryngeal Imaging rating form for stroboscopy. ResultsShort-term effects after SP: After the SP-in-air session, the supraglottic mediolateral compression decreased significantly. The SP-in-water session led to significantly increased left vibrational amplitude. Immediate effects during SP: During SP in air, a significantly increased left amplitude and mucosal wave, and significantly decreased mediolateral supraglottic activity, were found. SP in water tended to decrease the vibrational amplitude during performance of the task. A trend toward higher anteroposterior supraglottic compression was observed during both SP in air and water, being more prominent in the latter. Conclusion SP in air led to less false vocal fold adduction and consequently less hyperfunction. The small increment in anteroposterior supraglottic activity during SP in air and water might be related to epilarynx narrowing, an economic phenomenon associated with SOVT exercises. The effects on vibrational amplitude were rather ambiguous. The small reduction in amplitude during SP in water is expected to diminish vocal fold impact stress and therefore creates an ideal basis for voice therapy. The increment in amplitude and mucosal wave during SP in air might indicate insufficient supraglottic pressure to obtain the favorable effects of semi-occlusion. Whether or not the rise in amplitude after the SP-in-water session is due to voice efficiency or voice fatigue remains unknown. Future larger-scale investigation in subgroups of voice patients is needed to explore these hypotheses., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to 1) describe the age- and sex-specific occurrence of laryngeal pathologies in a treatment-seeking pediatric population in the voice unit of Ghent University Hospital, Belgium, and 2) describe this population in terms of vocal parameters, vocal complaints, influencing factors, and treatment history and recommendation., Study Design: Retrospective, observational study., Methods: All patient records were analyzed for children (0-18 years) who consulted the ear, nose, and throat department of Ghent University Hospital for the first time between July 2015 and June 2021 with complaints of dysphonia. In total, 103 children (66 males, 37 females) with a mean age of 10.01 years (SD: 3.4, range 3.93-17.96) were included in this study. Laryngeal pathology was diagnosed using a flexible videolaryngo(strobo)scopy. The influence of age and sex on laryngeal etiology (organic/functional voice disorder) was examined using a Welch-modified t test and a Fisher's exact test, respectively., Results: Organic lesions were observed in 77.7% of the participants, with vocal fold nodules (VFNs) being the most common diagnosis (66.0%). A functional voice disorder was diagnosed in 22.3% of the children. Children with a functional voice disorder are significantly older than children with an organic voice disorder. There was no statistically significant difference between males and females in laryngeal etiology. Mean dysphonia severity index was -2.7 (SD: 3.2, range -9.3 to +3.7), the mean acoustic voice quality index 4.70 (SD: 1.5, range 2.35-8.27), and the mean pediatric voice handicap index 29.8 (SD: 13.6, range 5-60). The occurrence of vocal misuse was mentioned in 80.6% of the patient records., Conclusion: Organic voice disorders, especially VFNs, are predominant in treatment-seeking children with dysphonia. Functional voice disorders become more common with increasing age during childhood. A disordered vocal quality, reduced vocal capabilities and reduced voice-related quality of life were found., Competing Interests: DECLARATION OF COMPETING INTEREST The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: This study measured and compared the short-term impact of pitch elevation training (PET) and articulation-resonance training (ART) in transgender women, on self-perception, satisfaction and masculinity-femininity perceptions of listeners. Methods: A randomized controlled study with cross-over design was used. Thirty transgender women were included and received fourteen weeks of speech training. All participants started with sham training (four weeks), after which they were randomly assigned to one of two groups: one group continued with PET (five weeks), followed by ART (five weeks), the second group received both trainings in opposite order. Participants were recorded four times, in between the training blocks: pre, post 1 (after sham), post 2 (after training 1) and post 3 (after training 2). Participants did a self-evaluation through the Trans Woman Voice Questionnaire (TWVQ) and visual analogues scales (VAS) concerning their self-perception and satisfaction. Two listening experiments ( n  = 75) were conducted researching the continuous masculinity-femininity rating (through a VAS) and categorical masculinity-femininity attribution. Results and conclusions: Transgender women perceive their voices more feminine after the training and experience a positive impact on the vocal functioning and the voice-related impact on their daily life. However, a lot of the participants acknowledge that they need more speech training after ten weeks. Listeners rate the participants' voices more feminine after training, both during the continuous and categorical questions. Higher femininity scores were detected during self-perception and listener perceptions after the combination of both ART and PET, compared to the separate trainings. No order effects were detected between ART and PET, both for self-perception and listener perceptions. Defining outcome predictors is crucial in future research., Competing Interests: The authors declare that they have no conflict of interest., (© 2023 Taylor & Francis Group, LLC.)

Purpose: Unilateral vocal fold paralysis (UVFP) is a neurological voice disorder that is often first treated by a speech-language pathologist (SLP). In literature, little consensus is found regarding voice therapy onset, duration, frequency, and content. The aim of the current study is to investigate the clinical practice of SLPs for treatment of UVFP regarding diagnostics and treatment characteristics. Additionally, the study examined the personal experiences of SLPs regarding UVFP care., Method: An online survey was completed by 37 respondents, all SLPs with experience in treating UVFP. Demographic characteristics, experiences with voice assessments and treatment modalities were examined. Lastly, experiences and opinions of SLPs on evidence-based practice and their own clinical practice were surveyed., Results: Almost all respondents used a multidimensional voice assessment with findings from laryngovideostroboscopy to assess UVFP. Laryngeal electromyography is not yet integrated in regular clinical practices. The most commonly used vocal techniques were resonant voice exercises, laryngeal manipulation, semioccluded vocal tract exercises (SOVTEs), vocal hygiene, and Vocal Function Exercises, with SOVTEs most often considered effective. A total of 75% of the respondents feel confident treating UVFP, and 87.6% believe it is important to stay updated on evidence-based practice. Variation in therapy timing and dosage was observed, and 48.4% of SLPs usually started early voice therapy within 4 weeks after UVFP onset., Conclusion: Flemish SLPs generally feel confident treating UVFP patients and show interest in improving evidence-based practice. Initiatives to train clinicians further in UVFP care and encouraging SLPs to provide practice-based evidence will enhance the knowledge base for evidence-based practice in UFVP., Competing Interests: Declaration of Competing Interest None, (Copyright © 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Semi-occluded vocal tract exercises (SOVTEs) are frequently used exercises in voice therapy. An important shortcoming to most SOVTEs is the inability to include continuous speech in these exercises. A variation of water-resistance therapy (WRT), during which a patient phonates through a resonance tube ending in water, was developed to include continuous speech: the semi-occluded water resistance ventilation mask (SOVM-WR). The current study investigated the immediate effects of this innovative technique on vocal outcomes of women with dysphonia., Methods: A pretest-posttest randomized controlled trial was performed. Twenty female participants were randomly assigned to the experimental SOVM-WR group or the WRT (control) group. A blinded multidimensional voice assessment was conducted before and after a 30-minute therapy session with the assigned technique., Results: No significant changes were found in acoustic or auditory-perceptual vocal outcomes in either of the groups, except for a significant increase in lowest frequency in both groups. Patient-reported outcomes (PROMs) showed significant improvements of vocal comfort, vocal effort, and voice quality in both groups, and participants indicated that they would use the techniques at home., Conclusions: The similar results of the SOVM-WR to WRT and promising PROMs confirm its suitability as an alternative to the latter technique. Potential reasons for a lack of improvement of objective and auditory-perceptual vocal outcomes are vocal fatigue, tube dimensions and immersion, and the small sample size. Large-scale and longitudinal research is needed to examine whether the SOVM-WR has a higher transfer to spontaneous speech than WRT after a full therapy program., Competing Interests: Declaration of Competing Interest There is no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: A promising way to obtain vocal economy and efficiency is by semi-occluding the vocal tract while phonating. Current knowledge about the immediate effects of semi-occluded vocal tract (SOVT) phonation on the laryngeal function and configuration is based mainly on computer modelling or excised larynges studies. In in vivo SOVT studies, electroglottography (EGG) has been the most commonly used laryngeal outcome, showing contradictory results between studies. Therefore, exploring these aspects by direct visualisation of the human larynx during SOVT phonation using strobovideolaryngoscopy (SVL) is needed., Aims: The aim of this study was to investigate and compare the immediate effects of straw phonation (SP) in air, SP in 2 cm water, and SP in 5 cm water (with stirring straws), on the laryngeal function and configuration of a homogeneous group of vocally healthy female speech-language pathology students, visualised with flexible SVL., Methods & Procedure: A randomised controlled trial was used. Fifty-two female speech-language pathology students (mean age: 18.7 years, SD: 0.6) were assigned randomly to one of three experimental groups or a control group: (1) SP in air, (2) SP in 2 cm water, (3) SP in 5 cm water or (4) [u] phonation with similar soft onset and slightly pursed lips as in SP but without a straw (control group). The participants underwent flexible SVL during habitual [u] phonation, followed by the specific SOVT exercise of their group assignment. All video samples were evaluated randomly and blindly by two experienced investigators using the Voice-Vibratory Assessment with Laryngeal Imaging (VALI) rating form, first independently and then by consensus., Outcome & Results: Compared to habitual phonation, the vibrational amplitude decreased during SP in 5 cm water and SP in 2 cm water, being more prominent in the first, more flow-resistant exercise. The mucosal wave also decreased during SP in 5 cm water. The anteroposterior (AP) supraglottic compression similarly increased during SP in air, SP in 2 cm water, and SP in 5 cm water. Further, a rise in mediolateral (ML) compression and a decrease in phase symmetry and regularity were found during SP in 2 cm water. A similar decrease in regularity was observed during SP in 5 cm water., Conclusions & Implications: Both SP in air and SP in water cause positive immediate laryngeal effects for voice training opportunities. More AP supraglottic activity found during each SP exercise might indicate epilarynx narrowing, an economic phenomenon associated with SOVT. Immersing the straw in water additionally diminished the vibrational amplitude, lowering vocal fold impact stress and risk for phonotrauma during the exercise. The decreased regularity of the vibrational cycles during SP in water might be due to the varying back pressure created by the water bubbling. The impact of SP in water on ML supraglottic compression needs further investigation., What This Paper Adds: What is already known on the subject A promising way to obtain vocal economy and efficiency is by semi-occluding the vocal tract while phonating. Current knowledge about the immediate effects of semi-occluded vocal tract (SOVT) phonation on the laryngeal function and configuration is based mainly on computer modelling or excised larynges studies. In in vivo SOVT studies, electroglottography (EGG) has been the most commonly used laryngeal outcome, showing contradictory results between studies. Therefore, exploring these aspects by direct visualisation of the human larynx during SOVT phonation using strobovideolaryngoscopy (SVL) is needed. What this paper adds to existing knowledge Group results of the current study generally support earlier computer modelling and in vivo studies, strengthening the current SOVT knowledge. Both SP in air and SP in water cause positive immediate laryngeal effects for voice training opportunities. More anteroposterior (AP) supraglottic activity found during each SP exercise might indicate epilarynx narrowing, an economic phenomenon associated with SOVT. Immersing the straw in water additionally diminished the vibrational amplitude, lowering vocal fold impact stress and risk for phonotrauma during the exercise. The decreased regularity of the vibrational cycles during SP in water might be due to the varying back pressure created by the water bubbling. The impact of SP in water on ML supraglottic compression needs further investigation. What are the potential or actual clinical implications of this work? Current results support that both SP in air and SP in water can be useful exercises in voice training. SP in water has shown the additional gain of lowering the vibrational amplitude during the exercise, hence supporting its appropriateness for vocal warm-ups by minimising vocal fold impact stress and the risk of phonotrauma. In the future, large-scale randomised controlled trials in other subgroups of voice users, including dysphonic patients, are needed to support evidence-based practice. SVL can facilitate the search for individualised training and therapy approaches., (© 2022 Royal College of Speech and Language Therapists.)

Purpose: This study investigates the short- and longer-term effects of glottoplasty up to six months after surgery on acoustic voice parameters, listener perceptions, and client's satisfaction in trans women. Secondly, the impact of chondrolaryngoplasty and voice therapy on the glottopasty outcomes was investigated., Method: A prospective longitudinal non-controlled trial was used. Thirty-five trans women undergoing glottoplasty or a combination of glottopasty and chondrolaryngoplasty were included in this study. A voice assessment was conducted before surgery and 1 week, 1 month and 6 months after surgery. The following outcome parameters were measured: fundamental frequency (f o ), intensity, frequency and intensity range, Dysphonia Severity Index (DSI), Acoustic Voice Quality Index (AVQI), Voice Handicap Index (VHI), Trans Woman Voice Questionnaire (TWVQ), and visual analogue scales (VAS) measuring client's satisfaction. Listener perceptions of masculinity-femininity were collected using a listening experiment., Results: Significant differences over time were found for all f o and intensity parameters, DSI, AVQI, VHI and TWVQ scores. Listener perception and self-perception of femininity was higher after surgery. Significant differences in evolution of listener perceptions were found between the groups with and without voice therapy., Conclusion: Glottoplasty improves voice related quality of life and is an effective method to increase the f o and associated perceptual femininity. After glottoplasty an immediate and short-term decrease in voice quality, vocal capacity and frequency range was measured with a progressive recovery on the longer term. Long term side effects of glottoplasty are a reduction in speaking intensity and intensity range. Voice therapy seems to improve the outcomes of glottoplasty, but should be further investigated in future studies., (Copyright © 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Individuals with speech disorders are often judged more negatively than peers without speech disorders. A limited number of studies examined the attitudes of adolescents toward peers with speech disorders due to a cleft lip with or without a cleft of the palate (CL ± P). Therefore, the aim of the present study was to investigate the attitudes of peers toward the speech of adolescents with CL ± P., Method: Seventy-eight typically developing adolescents (15-18 years, 26 boys, 52 girls) judged audio and audiovisual samples of two adolescents with CL ± P based on three attitude components, i.e., cognitive, affective, and behavioral. The degree of speech intelligibility was also scored by their peers. The study investigated whether the three attitudes were determined by speech intelligibility or appearance of an individual with CL ± P. Furthermore, the influence of knowing someone with a cleft, the age, and gender of the listeners on their attitudes were explored., Results: A significantly positive correlation was found between the speech intelligibility percentage and the three different attitude components: more positive attitudes were observed when the speech intelligibility of the speaker was higher. A different appearance due to a cleft lip does not lead to more negative attitudes. Furthermore, boys seem to have more negative attitudes toward individuals with CL ± P compared to girls., Conclusion: This study provided additional evidence that peers show more negative attitudes toward adolescents with less intelligible speech due to CL ± P. Intervention should focus on changing the cognitive, affective, and behavioral attitudes of peers in a more positive direction and remove the stigma of patients with a cleft. Further research is needed to verify these results., Competing Interests: Declaration of competing interest The authors declare that there is no conflict of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Purpose: Bilateral vocal fold paralysis (BVFP) is a severe disorder that can result in respiratory, swallowing, and voice-related problems. Most surgical treatments do not restore laryngeal function and often need to compromise voice quality to preserve respiratory function. Laryngeal reinnervation (LR) may offer a solution to this problem, but literature on longitudinal outcomes of this procedure is scarce. This study aims to report the longitudinal vocal outcomes of BVFP after LR and subsequent voice therapy., Method: The case of a 23-year-old man with BVFP after a traumatic dissection of both recurrent laryngeal nerves is described. Selective bilateral LR of both adductors and abductors was performed 5 months after the onset of BVFP. Voice therapy was provided after the LR procedure. Multidimensional voice assessments, including acoustic, perceptual, and patient-reported outcome measures (PROMs), were conducted 2, 5, 6.5, 8, and 31 months after LR., Results: An improvement of vocal capabilities and voice quality was noticed 6.5 months after LR, after 4.5 months of voice therapy, with normative values after 2.5 years. PROMs showed an improvement of voice-related quality of life, but some limitations to activities of daily living were still present. Inspiratory arytenoid abduction was not observed on laryngeal videostroboscopic findings in this patient, but tracheostomy was not required., Conclusions: Voice therapy after LR helps establish healthy and efficient voice use without increasing compensatory hyperfunctional behavior. More research is needed to examine potential merits of voice therapy in the rehabilitation of vocal and respiratory functions after LR.

Objectves: The Evaluation of the Ability to Sing Easily (EASE) is a self-rating tool that is used to assess the singer's perceptions of the current singing voice status. The purpose of this study was to develop and validate a Dutch translation of the EASE., Methods: The original version of the EASE was translated and adapted to Dutch according to the recommendations of the Quality of Life Special Interest Group - Translation and Cultural Adaptation group. Subsequently, the questionnaire was individually completed by 70 singers with a mean age of 35.2 years before and after a singing activity, together with a demographic questionnaire and the Dutch Singing Voice Handicap Index 10 (SVHI-10-NL). Two groups of singers were included between September and June 2020: a group of healthy singers (n = 54) and a group of dysphonic singers (n = 16). Internal and external consistency, construct and criterion validity, test-retest and split-half reliability were calculated using Cronbach's alpha coefficients, Student's t-test, the paired Wilcoxon tests and Pearson correlation coefficients. Furthermore, the impact of sex and age and the diagnostic accuracy of the EASE-NL was measured using the Mann Whitney U-test, the One Way ANOVA and the Brown Forsythe ANOVA-test., Results: The internal consistency of the EASE was considered good. For the external consistency, the Pearson correlation coefficient showed a positive correlation between the total score of the EASE-NL and the SVHI-10-NL. Dysphonic singers scored significantly higher compared to singers without voice problems and no differences were found between the pre and post singing condition in both groups. Pearson correlations coefficients showed a strong positive correlation between the test and retest condition and between the subscales. A ROC-curve analysis showed a cut-off score of 12.5, with a sensitivity level of 75.0% and a specificity level of 74.1%. No differences for sex and age were found., Conclusions: The original English version of the EASE was translated and validated in Dutch. The EASE-NL is found to be a valid and reliable self-reported tool to assess singer's perceptions of the current status of their singing voice., Competing Interests: CONFLICT OF INTEREST None., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Vocal fold nodules (VFNs) are the main cause of paediatric dysphonia. Voice therapy is recommended as the preferable treatment option for VFNs in children., Aim: The aim of this systematic review is to provide an overview of the existing literature concerning the effects of voice therapy in children with VFNs., Methods & Procedures: This systematic literature review was developed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via PubMed) and Embase were searched and the grey literature was checked. The search strategy was based on three concepts: VFNs, voice therapy and children. Two examiners independently determined article eligibility and extracted all relevant data from the included studies. The methodological quality of the included study was assessed using the QualSyst tool., Main Contributions: By identifying, evaluating and summarizing the results of all relevant studies about voice therapy in paediatric VFNs, this systematic review makes the available evidence more accessible to voice therapists, otolaryngologists and other relevant stakeholders., Conclusions & Implications: 24 studies were included in this systematic review. Eight studies (8/24) reported a significant improvement for at least one outcome parameter after voice therapy. However, five papers (5/24) could not demonstrate significant changes after voice therapy. All studies that did not test for significance (11/24) found improvements for one or more outcome parameters. The overall quality of the included studies is adequate (55%). In sum, there is some evidence that voice therapy is effective in children with VFNs, but further well-designed research, especially randomized controlled trials, is necessary to confirm these results., What This Paper Adds: What is already known on the subject Voice therapy is preferable in children with VFNs because of the phonotraumatic nature of the nodules and the associated high recurrence rate after phonosurgery. Most voice therapists in clinical practice offer an eclectic voice therapy programme, consisting of direct and indirect voice therapy techniques. What this study adds to existing knowledge This systematic review provides a clear overview of the available evidence concerning the effects of voice therapy in paediatric VFNs. There is some evidence that voice therapy is an effective treatment option in children with VFNs, but well-designed research is scarce on this subject. What are the potential or actual clinical implications of this work? This review shows that effectiveness studies with strong designs are very scarce in children with VFNs. Clinicians should be aware that few therapy techniques have been thoroughly investigated in this population. However, this review may guide voice therapists when creating a treatment plan for a child with VFNs because it identifies, evaluates and summarizes the results of all relevant individual studies about voice therapy in paediatric VFNs. Voice therapy seems to be effective in treating paediatric patients with VFNs, given the fact that a considerable number of included studies report significant improvements after voice therapy. Both direct and indirect therapy approaches appear to have a positive effect on the phonation of children with VFNs., (© 2022 Royal College of Speech and Language Therapists.)

Background: The voice use of choir singers is understudied despite the imbalance of high vocal demands versus low vocal education, and consequently increased risk for voice problems. Also, there is a lack of information on the effects of a performance on choristers' voices. Available studies included performances of at least one hour. To date, no studies investigated the effects of a choir performance with a duration resembling vocal warm-ups., Purpose: The first purpose of this study was to determine the voice quality, capacities, symptoms and voice-related quality of life of choir singers. Secondly, the effect of a short choir performance, resembling warm-up duration (15 minutes), on the choristers' voices was investigated., Methods: A randomized controlled trial was used. Thirty adult choir singers (25 women, 5 men; mean age: 32 years) were assigned randomly to an experimental group or a control group. Participants in the experimental group sung in choir for 15 minutes immediately after their pre voice assessment, whereas the control group was instructed to have standard voice use (one-on-one conversation with the investigator, no singing) across that time span. A second voice assessment was repeated afterwards., Results: The choir singers showed excellent voice quality and capacities with mean scores on the Dysphonia Severity Index and Acoustic Voice Quality Index of 7.5 and 2.0, respectively. Auditory-perceptually, the mean grade score was 5/100 corresponding with a normal to mildly deviant voice quality. Patient-reported outcome measures showed mean deviant scores, indicating a considerable singing voice handicap. The choir singers seem vulnerable for stress with a high occurrence rate of 76.7% (23/30). Compared with the control group, the Dysphonia Severity Index significantly improved, whereas the self-perceived presence of vocal fatigue and complaints increased after 15 minutes of choir singing. Fundamental frequency increased in both groups, being more outspoken in the experimental group., Conclusions: Choir singers show excellent voice quality and capacities, that further improve after a short choir performance of 15 minutes. Vocal fatigue and complaints, on the other hand, already increased after that short time span. Realizing that vocal load is much higher in real-life rehearsals, competitions and performances, choristers deserve and need a qualitative voice training and a strict follow-up. Future research should focus on effective vocal warm-up and cool-down programs for this population., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: People with dysphonia are judged more negatively than peers with normal vocal quality. This preliminary study aims to (1) investigate correlations between both auditory-perceptual and objective measures of vocal quality of dysphonic and non-dysphonic speakers and attitudes of listeners, and (2) discover whether these attitudes towards people with dysphonia vary for different types of stimuli: auditory (A) stimuli and combined auditory-visual (AV) stimuli. Visual (V) stimuli were included as a control condition., Method: Ten judges with no experience in the evaluation of dysphonia were asked to rate A, AV and V stimuli of 14 different speakers (10 dysphonic and 4 non-dysphonic speakers) Cognitive attitudes, evaluation of voice characteristics and behavioral attitudes were examined. Pearson and Spearman correlation coefficients were calculated to examine correlations between both Dysphonia Severity Index (DSI) values and perceptual vocal quality as assessed by a speech-language pathologist (PVQ SLP ) or perceptual vocal quality as assessed by the judges (PVQ judge ). Linear mixed model (LMM) analyses were conducted to investigate differences between speakers and stimuli conditions., Results: Statistically significant correlations were found between both perceptual and objective measures of vocal quality and mean attitude scores for A and AV stimuli, indicating increasingly negative attitudes with increasing dysphonia severity. Fewer statistically significant correlations were found for the combined AV stimuli than for A stimuli, and no significant correlations were found for V stimuli. LMM analyses revealed significant group effects for several cognitive attitudes., Conclusion: Generally, people with dysphonia are judged more negatively by listeners than peers without dysphonia. However, the findings of this study suggest a positive influence of visual cues on the judges' cognitive and behavioral attitudes towards dysphonic speakers. Further research is needed to investigate the significance of this influence., Competing Interests: Declaration of Competing Interest There is no conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to measure and compare the voice characteristics and vocal complaints and habits of musical theater actors and musical theater students., Method: Thirty participants were included in the study, 18 musical theater students and 12 professional musical theater actors. Vocal quality was measured by the multiparameter indices Dysphonia Severity Index (DSI) and Acoustic Voice Quality Index (AVQI). A perceptual evaluation of the speaking voice was performed using the GRBASI scale. All participants completed the Voice Handicap Index (VHI), the VHI adapted to the singing voice, the Vocal Tract Discomfort (VTD) Scale and the Corporal Pain Scale., Results: Excellent scores for DSI (resp. 7.3, 7.1) and AVQI (resp. 2.6, 2.5) were found in the musical theater actors and students. All participants reported at least two symptoms of VTD and the mean scores for the VHI adapted to the singing voice were located in the clinical zone. Musical theater students reported significantly more VTD and pain symptoms compared to the professionals. No significant differences in perceptual and objective voice characteristics were found between musical theater actors and students. A higher presence of vocal misuse and stress in the students was observed., Conclusion: Musical theater students and actors are elite vocal performers with comparable excellent objective vocal measures (DSI, AVQI). In both groups, an increased number of VTD and complaints of the singing voice were reported. Especially students were vulnerable for stress, vocal misuse, VTD, and pain symptoms. The findings suggest that musical theater actors are a risk group for developing voice disorders requiring multidimensional voice assessment and voice care., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

State of the Art: Theater actors are a high risk group for developing voice disorders., Aims: The first purpose of this study was to examine and compare the objective and subjective vocal quality between professional theater actors, non-professional theater actors and a control group of professional dancers. Secondly, the impact of one theater performance on the objective and subjective vocal quality was investigated within and between the groups. It is hypothesized that actors will experience vocal fatigue and a deteriorated vocal quality compared with dancers as a result of the vocal load during the performance. Dancers will face more general fatigue and smaller vocal changes due to the impact of a performance including stress, decompensation and physical fatigue., Methods: Recordings of 27 professional actors, 19 non-professional actors and 16 professional dancers were collected before and after a performance using the PRAAT software. Voice samples included sustained vowel phonation, continuous speech, aerodynamic measurements and voice range profile. Both Acoustic Voice Quality Index and Dysphonia Severity Index were computed. For auditory-perceptual evaluations the GRBASI scale was used. Several questionnaires were completed pre and post performance to capture vocal risk factors., Results: Vocal quality between groups showed lower fundamental frequency (f o ) values (female), larger fundamental frequency (female) and intensity ranges and a longer maximum phonation time (female) in professional actors compared to non-professionals. Professional dancers showed higher Acoustic Voice Quality Index values compared to non-professional actors. Dysphonia Severity Index, Voice Handicap Index, Vocal Tract Discomfort Scale and GRBASI results did not differ between groups at the baseline. Both objective measurements and questionnaires did not show significantly different results post performance. Questionnaires revealed poor vocal habits in professional actors., Conclusion: Professional actors have better vocal capacities than non-professionals. Dancers' vocal quality is worse than actors. The results show no impact of one performance on the vocal quality in theater actors and dancers. The long-term impact of performing, however, is subject for further research., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: This study investigates the long-term voice outcome of thyroidectomy up to 10 years after the surgery using a longitudinal prospective study design., Methods: Eighteen participants (6 men and 12 women, mean age: 54 years) who underwent a thyroidectomy between September 2006 and May 2007 were included in this study. A voice assessment protocol consisting of subjective (videolaryngostroboscopic evaluation, auditory- perceptual evaluation, patients' self-report) and objective voice assessments (maximum performance task, acoustic analysis, voice range profile and Dysphonia Severity Index) was used to evaluate the participants' pre- and postoperative voice. Voice measurements were compared before and one week, six weeks, three months and 10 years after the surgery., Results: No significant differences over time in auditory-perceptual and objective voice parameters were found, except for shimmer. Only in the first postoperative condition, significantly more patients reported vocal complaints. A progressive amelioration of the vocal folds' movement patterns was observed in the postoperative conditions., Conclusion: The findings of this small longitudinal prospective study suggest that thyroidectomy without laryngeal nerve injury does not cause a permanent deterioration of the laryngeal aspect or function, vocal fold behavior and the self-perceived, perceptual and objective vocal quality. The increase of the shimmer 10 years post-thyroidectomy may be related to vocal aging., (Copyright © 2021. Published by Elsevier Inc.)

Purpose The purpose of this study was to compare the voice patient's opinion regarding three service delivery models for voice therapy: a short-term intensive voice therapy with individual sessions (IVT-I), a short-term intensive voice therapy with group sessions (IVT-G), or a long-term traditional voice therapy with individual sessions (TVT). Method Forty-six adult voice patients who followed either IVT-I, IVT-G, or TVT were contacted by e-mail with the request to fill in an online questionnaire reviewing their opinion about the received therapy. Several items concerning satisfaction, progress, time-related variables, transfer, and need for further therapy were scored by means of visual analog scales. Participants were also asked whether or not they continued voice therapy after the study. Results There were no significant differences between the three groups regarding the patients' perception of vocal quality improvement, degree of resolution of the voice disorder, duration of one session, total therapy duration, degree of transfer, need for further therapy, and actual continuation of therapy. A higher satisfaction rate was found for patients of the IVT-I and TVT groups than patients of the IVT-G group. The IVT-I group rated the therapy as too frequent compared with the TVT group who rated the frequency as optimal. Conclusion Results suggest that patients are equally satisfied and perceive a similar progress after individual short-term intensive voice therapy and individual long-term traditional voice therapy. This finding creates flexibility in selecting time-related variables depending on the specific case and situation. Patients who received individual therapy were more satisfied than patients who received group therapy. Future larger scale investigation is needed to confirm these results.

Objectives: Laryngeal palpation is a routine clinical method for evaluation of patients with muscle tension dysphonia (MTD). The aim of this study was to develop a new comprehensive valid and reliable "laryngeal palpatory scale" (LPS), based on psychometric criteria., Methods: The scale items were selected based on an in-depth analysis of the literature and an expert focus group. Scale item generation and item reduction were followed by a psychometric assessment. Qualitative and quantitative content validity (the content validity ratio (CVR), content validity index (CVI)), the qualitative face validity, and the inter-rater reliability were determined. For this purpose, 531 patients were assessed and finally 55 patients with primary MTD (26 women, mean age: 40.8 years, SD: 12.5; 29 male, mean age: 41.6 years, SD: 11.8) participated in the study. A weighted kappa (k*) statistic was used to examine the inter-rater reliability for each single item., Results: Based on the CVR, three items were omitted because they had a score of less than 0.62. The CVI for all remaining items was greater than 0.79 and the scale CVI was equal to 0.96. The final 45 items were a result of the study. The inter-rater reliability for each single item ranged from 0.41 to 1, indicating moderate to almost perfect agreement., Conclusions: The LPS is a reliable and valid instrument for assessing patients with MTD. However, future studies are needed to provide adequate data on sensitivity, specificity, concurrent validity, and cutoff scores., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background Traditional semi-occluded vocal tract exercises (SOVTEs) are restricted to single-phoneme tasks due to the semi-occlusion at the mouth, which hinders full articulation, continuous speech, and singing. Innovative SOVTEs should overcome this limitation by creating the semi-occlusion outside the oral cavity. Purpose The purpose of this study was to investigate the immediate effects of a semi-occluded water resistance ventilation mask, which allows for continuous speech and singing, on objective (voice range, multiparametric voice quality indices) and subjective (auditory-perceptual, self-report) vocal outcomes in musical theater students. Method A pre-/posttest randomized controlled trial was used. Twenty-four musical theater students (16 women and eight men, with a mean age of 21 years) were randomly assigned into a study group and a control group. The study group received a vocal warm-up session with the innovative water resistance ventilation mask (tube attached to the mask "outside" the mouth), whereas the control group received the traditional water resistance approach (tube "inside" the mouth). Both sessions lasted 30 min and were similar with respect to vocal demand tasks. A multidimensional voice assessment including objective and subjective outcomes was performed pre- and posttraining by an assessor blinded to group allocation. Results The Dysphonia Severity Index significantly and similarly increased (improved) in both the study and control groups, whereas the Acoustic Voice Quality Index solely decreased (improved) in the control group. The intensity range significantly decreased (worsened) and the semitone range significantly increased (improved) in the study group, whereas no differences in voice range profile were found in the control group. Auditory-perceptually, a more strenuous speaking voice was noticed after the use of the traditional water resistance approach. The subjects perceived both SOVTEs as comfortable vocal warm-up exercises that decrease the amount of effort during speaking and singing, with a slight preference for the water resistance ventilation mask. Conclusions Both the innovative water resistance ventilation mask and the traditional water resistance exercise seem effective vocal warm-up exercises for musical theater students. The additional articulatory freedom of the mask might increase the phonatory comfort and the practical implementation of SOVTEs in the daily vocal warm-up of (future) elite vocal performers. The hypothesis of a higher transfer to continuous speech or singing in the mask condition has not been supported by the current study. Larger scale investigation and longer term follow-up studies are needed to confirm these preliminary results. Supplemental Material https://doi.org/10.23641/asha.11991549.

This pilot study evaluated the usability of functional magnetic resonance imaging (fMRI) to detect brain activation during phonation in healthy female singers with supraglottic compression. Four healthy female classical singers (mean age: 26 years) participated in the study. All subjects had normal vocal folds and vocal characteristics and showed supraglottic compression. The fMRI experiment was carried out using a block design paradigm. Brain activation during phonation and exhalation was analyzed using Brain Voyager software (Brain Innovation B.V., Maastricht, The Netherlands). An fMRI data analysis showed a significant effect of phonation control in the bilateral pre/postcentral gyrus, and in the frontal, cingulate, superior and middle temporal gyrus, as well as in the parietal lobe, insula, lingual gyrus, cerebellum, thalamus and brainstem. These activation areas are consistent with previous reports using other fMRI protocols. In addition, a significant effect of phonation compared to exhalation control was found in the bilateral superior temporal gyrus, and the pre/postcentral gyrus. This fMRI pilot study allowed to detect a normal pattern of brain activity during phonation in healthy female singers with supraglottic compression using the proposed protocol. However, the pilot study detected problems with the experimental material/procedures that would necessitate refining the fMRI protocol. The phonation tasks were not capable to show brain activation difference between high-pitched and comfortable phonation. Further fMRI studies manipulating vocal parameters during phonation of the vowels /a/ and /i/ may elicit more distinctive hemodynamic response (HDR) activity patterns relative to voice modulation.

Purpose The aim of this study was to compare the effect of a short-term intensive voice therapy (IVT) with a long-term traditional voice therapy (TVT) on the vocal quality, vocal capacities, psychosocial impact, vocal tract discomfort, laryngological anatomy/physiology, and session attendance of patients with dysphonia. An additional comparison was made between an individual IVT (IVT-I) and a group IVT (IVT-G). Method A longitudinal, prospective controlled trial was used. Forty-six adults diagnosed with dysphonia were assigned to 1 of the 3 treatment groups. The IVT groups practiced with a frequency of 1 hr 20 min a day and a duration of 2 weeks. The TVT group practiced with a frequency of two 30-min sessions a week and a duration of 6 months. Both therapy programs were content-identical and guided by the same voice therapist. A multidimensional voice assessment consisting of both objective (maximum performance task, aerodynamic measurements, voice range profile, acoustic analysis, multiparametric voice quality indices) and subjective (subject's self-report, auditory-perceptual evaluation, flexible videolaryngostroboscopy) outcomes was used to evaluate the participants' voice. Results IVT made an equal progress in only 2 weeks and 12 hr of therapy compared with TVT that needed 6 months and 24 hr of therapy. IVT-I and IVT-G showed comparable results. Session attendance was clearly higher in IVT compared with TVT. Long-term follow-up results (1 year) were positive for the 3 groups, except for the self-reported psychosocial impact that increased in the IVT-I group. Conclusions Short-term IVT is at least equally effective in treating patients with dysphonia as long-term TVT. Group treatment seemed as effective as individual treatment. Attendance and cost-effectiveness are important advantages of IVT. A potential drawback might be an insufficient psychosocial progress. The golden mean between intensive and traditional treatment might therefore be an achievable, effective, and efficient solution for everyday clinical practice. Supplemental Material https://doi.org/10.23641/asha.7761872.

Background: To date, the immediate effects of a semi-occluded vocal tract (SOVT) configuration have been thoroughly demonstrated. However, it is not yet sufficiently confirmed whether a therapy programme (i.e. longer than one session) using SOVT exercises leads to an enhanced phonation and improved vocal quality., Aims: The aim of this study was to investigate the effect of three SOVT therapy programmes: lip trill, water-resistance therapy (WRT) and straw phonation, on the vocal quality, vocal capacities, psychosocial impact and vocal tract discomfort of patients with dysphonia., Methods & Procedures: A blocked-randomized sham-controlled trial was used. Thirty-five patients with dysphonia (mean age = 21 years; 33 women, two men) were assigned to either a lip trill group, a WRT group, a straw phonation group or a control group using blocked randomization. The lip trill, WRT and straw phonation groups practised their respective SOVT exercise across 3 weeks, whereas the control group received a sham treatment across the same time span. A multidimensional voice assessment consisting of both objective (multiparametric indices: Dysphonia Severity Index (DSI), Acoustic Voice Quality Index (AVQI)) and subjective (subject's self-report, auditory-perceptual evaluation) vocal outcomes was performed by a blinded assessor pre- and post-therapy., Outcomes & Results: Lip trill and straw phonation therapy led to a significant improvement in DSI. Auditory-perceptual grade and roughness significantly decreased after straw phonation. Lip trill and WRT both led to a significant decrease in Voice Handicap Index. Subjects reported a better self-perceived vocal quality and a more comfortable voice production after WRT. No changes were found after the sham treatment in the control group., Conclusions & Implications: Results suggest that SOVT therapy programmes including lip trill or straw phonation can improve the objective vocal quality in patients with dysphonia. Auditory-perceptual improvements were found after straw phonation therapy, whereas psychosocial improvements were found after lip trill and WRT. Patients seem to experience more comfort and a better self-perceived vocal quality after WRT. This study supports the use of the three SOVT therapy programmes in clinical practice. They all had a positive impact on one or more outcomes of the multidimensional voice assessment. Strikingly, vocal quality outcomes were not in line with the subject's opinion. Larger-scale investigation is needed to support these preliminary findings., (© 2018 Royal College of Speech and Language Therapists.)

Background: In contrast with most medical and pharmaceutical therapies, the optimal dosage for voice therapy or training is unknown., Aims: The aim of this study was to compare the effect of a short-term intensive voice training (IVT) with a longer-term traditional voice training (TVT) on the vocal quality and vocal capacities of vocally healthy non-professional voice users., Methods & Procedures: A pre-/post-test randomized control group design with follow-up measurements was used. Twenty healthy female non-professional voice users with a mean age of 21.7 years (range = 20-24 years) were randomly assigned into a short-term IVT group (n = 10) or a longer-term TVT group (n = 10). Both groups received an identical 6-h lasting voice training. Only the distribution of practice varied between the groups: 2 h a day for 3 consecutive days for the IVT group versus two 30-min sessions a week for 6 weeks for the TVT group. In both groups, a voice assessment protocol consisting of subjective (questionnaire, participant's self-report, auditory-perceptual evaluation) and objective (maximum performance task, acoustic analysis, voice range profile, dysphonia severity index) measurements and determinations was used to evaluate the participants' voice pre- and post-training and at 6 weeks follow-up. Groups were compared over time using linear mixed models and generalized linear mixed models. Within-group effects of time were determined using post-hoc pairwise comparisons with Bonferroni corrections., Outcomes & Results: No significant time-by-group interactions were found for any of the outcome measures, indicating no significant differences in evolution over time between the groups. Significant time effects were found for maximum phonation time, lowest intensity, lowest frequency, highest frequency and dysphonia severity index, all improving over time in both groups. More in-depth within-group analyses indicate a preference for the IVT group regarding the evolution of maximum phonation time, lowest frequency and dysphonia severity index, and a preference for the TVT group regarding the evolution of lowest intensity., Conclusions & Implications: Short-term IVT may be equally, or even more, effective in training vocally healthy non-professional voice users compared with longer-term TVT., (© 2017 Royal College of Speech and Language Therapists.)

Objectives: The main objectives of this functional magnetic resonance imaging (fMRI) study are (1) to investigate brain activity during phonation in women with muscle tension dysphonia (MTD) in comparison with healthy controls; and (2) to explain the neurophysiological mechanism of laryngeal hyperfunction/tension during phonation in patients with MTD., Methods: Ten women with MTD and fifteen healthy women participated in this study. The fMRI experiment was carried out using a block design paradigm. Brain activation during phonation and exhalation was analyzed using BrainVoyager software., Results: The statistical analysis of fMRI data has demonstrated that MTD patients control phonation by use of the auditory, motor, frontal, parietal, and subcortical areas similar to phonation control by healthy people. Comparison of phonation tasks in the two groups revealed higher brain activities in the precentral gyrus, inferior, middle and superior frontal gyrus, lingual gyrus, insula, cerebellum, midbrain, and brainstem as well as lower brain activities in the cingulate gyrus, superior and middle temporal gyrus, and inferior parietal lobe in the MTD group. No differences were found between the two groups regarding exhalation control., Conclusions: The findings in this study provide insight into phonation and exhalation control in patients with MTD. The imaging results demonstrated that in patients with MTD, altered (higher/lower) brain activities may result in laryngeal tension and vocal hyperfunction., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to determine the short-term effect of 2 semi-occluded vocal tract training programs, "resonant voice training using nasal consonants" versus "straw phonation," on the vocal quality of vocally healthy future occupational voice users., Method: A multigroup pretest-posttest randomized control group design was used. Thirty healthy speech-language pathology students with a mean age of 19 years (range: 17-22 years) were randomly assigned into a resonant voice training group (practicing resonant exercises across 6 weeks, n = 10), a straw phonation group (practicing straw phonation across 6 weeks, n = 10), or a control group (receiving no voice training, n = 10). A voice assessment protocol consisting of both subjective (questionnaire, participant's self-report, auditory-perceptual evaluation) and objective (maximum performance task, aerodynamic assessment, voice range profile, acoustic analysis, acoustic voice quality index, dysphonia severity index) measurements and determinations was used to evaluate the participants' voice pre- and posttraining. Groups were compared over time using linear mixed models and generalized linear mixed models. Within-group effects of time were determined using post hoc pairwise comparisons., Results: No significant time × group interactions were found for any of the outcome measures, indicating no differences in evolution over time among the 3 groups. Within-group effects of time showed a significant improvement in dysphonia severity index in the resonant voice training group, and a significant improvement in the intensity range in the straw phonation group., Conclusions: Results suggest that the semi-occluded vocal tract training programs using resonant voice training and straw phonation may have a positive impact on the vocal quality and vocal capacities of future occupational voice users. The resonant voice training caused an improved dysphonia severity index, and the straw phonation training caused an expansion of the intensity range in this population.

Objectives: The purpose of this study was to investigate vocal quality, vocal complaints, and risk factors for developing voice disorders in theater actors. Secondly, the impact of one vocal performance on the voice was investigated by comparing objective and subjective vocal quality before and after a theater performance., Study Design: Prospective study of the actors' voice prior to and after a performance METHODS: Speech samples of 26 theater actors (15 men, 11 women, mean age 41.9 years) were recorded before and after a theater performance of one and a half hour and analyzed using the software program Praat. Speech samples consisted of the combination of sustained phonation and continuous speech. For each speech sample, the Acoustic Voice Quality Index was calculated. Auditory perceptual evaluations were performed using the GRBASI scale. Questionnaires were used to inventory vocal symptoms and influencing factors., Results: Acoustic analysis showed a mean Acoustic Voice Quality Index (AVQI) of 3.48 corresponding with a mild dysphonia. Fifty percent of the theater actors reported having (sometimes or regularly) vocal complaints after a performance. The questionnaire revealed a high presence of vocally violent behavior and poor vocal hygiene habits. Objective vocal quality, measured by the AVQI, did not change after a theater performance. The auditory perceptual evaluation of the overall grade of dysphonia showed a subtle amelioration of the vocal quality., Conclusions: The results of this study showed the presence of mild dysphonia, regular vocal complaints, and poor vocal hygiene habits in theater actors. A theater performance did not have an impact on the objective vocal quality., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Musical theater performers are a special group of elite vocal performers with a high vocal load as they combine singing, acting, and physical performance. As they are absolutely depending on their voice quality and vocal capacities for their studies and their future profession, an optimal voice production is very important. The purpose of this study was to determine the voice quality of musical theater students. The voice quality of seven students was then reevaluated 1 year after the first assessment., Study Design: Observational study., Methods: Thirty-one musical students (7 men and 24 women) with a mean age of 20 years participated in the study. To determine the voice quality, objective (aerodynamic measurements, voice range profile, acoustic analysis, and Dysphonia Severity Index) and subjective (videolaryngostroboscopy, Voice Handicap Indexes, and questionnaires regarding voice symptoms and risk factors) voice measurements were performed., Results: The median Dysphonia Severity Index in male and female musical students was respectively 5.3 and 5.7, both corresponding with an overall good voice quality. The questionnaires revealed the presence of vocal fatigue, dryness of the throat, vocal tract discomfort, and harmful vocal habits in the majority of students. In 45% of the subjects, videolaryngostroboscopic evaluation of the vocal folds showed an organic lesion. The majority of these lesions are inflammatory lesions (26%). In 68% of the subjects, a certain degree of supraglottic constriction was observed., Conclusion: Despite the overall good voice quality, videolaryngostroboscopy showed a high presence of vocal fold lesions and supraglottic constriction during phonation., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This functional magnetic resonance imaging (fMRI) study investigated the brain activity associated with pitch adaptation during phonation in healthy women without voice disorders., Study Design: This is an interventional prospective study., Methods: Sixteen healthy women (mean age: 24.3 years) participated in a blocked design fMRI experiment involving two phonation (comfortable phonation and high-pitched phonation) and exhalation (prolonged exhalation) tasks. BrainVoyager QX Version 2.4 software was used for group-level general linear model analysis (q[FDR] < 0.05)., Results: Analyses showed a significant main effect of phonation with pitch adaptation compared with rest period in the bilateral precentral gyrus, superior frontal gyrus, posterior cingulate gyrus, superior and middle temporal gyrus, insula and cerebellum, left middle and inferior frontal gyrus, right lingual gyrus, cingulate gyrus, and thalamus. Statistical results also identified a significant main effect of exhalation compared with rest period in the bilateral precentral gyrus, cerebellum, right lingual gyrus, thalamus, and left supramarginal gyrus. In addition, a significant main effect of phonation was found in the bilateral superior temporal gyrus and right insula, as well as in the left midbrain periaqueductal gray for high-pitched phonation only., Conclusions: We demonstrated that a blocked design fMRI is sensitive enough to define a widespread network of activation associated with phonation involving pitch variation. The results of this study will be implemented in our future research on phonation and its disorders., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to determine the effect of the isolated vocal-facilitating techniques Chant Talk and Pitch Inflections on the phonation of healthy female speech-language pathology (SLP) students., Study Design: A multigroup pretest-posttest design was used., Methods: A homogenous group of 40 healthy female SLP students with a mean age of 18.7 years were randomly assigned into 3 groups: a Chant Talk group (practicing Chant Talk across 18 weeks), a Pitch Inflections group (practicing Pitch Inflections across 18 weeks), and a control group (practicing no facilitating techniques). To compare vocal measures before and after this time span, an identical objective voice assessment protocol (aerodynamic measurement, acoustic analysis, voice range profile, and Dysphonia Severity Index) was performed in the 3 groups., Results: Both Chant Talk and Pitch Inflections groups resulted in a significant decrease of the acoustic measure noise-to-harmonics ratio compared with the control group. The Chant Talk group resulted in a significant increase in the acoustic measure fundamental frequency compared with the control group., Conclusions: The results of this pilot study suggest that the facilitating techniques Chant Talk and Pitch Inflections may improve the objective measure of breathiness (noise-to-harmonics ratio) in healthy female SLP students., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to determine how use of the vocal facilitating technique, chewing, affected the phonation of speech-language pathology (SLP) students., Study Design: A pretest-posttest randomized control group design was used., Methods: Twenty-seven healthy female SLP students were randomly assigned into either an experimental group or a control group. The experimental group practiced chewing exercises across 18 weeks, whereas the control group received no vocal facilitating techniques. Both groups completed pre- and post- objective voice assessment measures (aerodynamic measurement, acoustic analysis, voice range profile, and Dysphonia Severity Index). Differences between pre- and post-data were compared between the experimental and control group using an independent sample t test., Results: Compared to the control group, chewing resulted in a significant decrease in jitter and noise-to-harmonic ratio (NHR), a significant increase in fundamental frequency (fo), a significant expansion of the voice range profile, and a significant increase in Dysphonia Severity Index (DSI). Shimmer and maximum phonation time (MPT) were not significantly different between groups., Conclusions: The results of this pilot study suggest that the vocal facilitating technique, chewing, may improve objective vocal measures in healthy female SLP students., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: The Nasality Severity Index 2.0 (NSI 2.0) forms a new, multiparametric approach in the assessment of hypernasality. To enable clinical implementation of this index, the short- and long-term test-retest reliability of this index was explored., Methods: In 40 normal-speaking adults (mean age 32y, SD 11, 18-56y) and 29 normal-speaking children (mean age 8y, SD 2, 4-12y), the acoustic parameters included in the NSI 2.0 (i.e. nasalance of the vowel /u/ and an oral text, and the voice low tone to high tone ratio (VLHR) of the vowel /i/) were obtained twice at the same test moment and during a second assessment two weeks later. After determination of the NSI 2.0, a comprehensive set of statistical measures was applied to determine its reliability., Results: Long-term variability of the NSI 2.0 and its parameters was slightly higher compared to the short-term variability, both in adults and in children. Overall, a difference of 2.82 for adults and 2.68 for children between the results of two consecutive measurements can be interpreted as a genuine change. With an ICC of 0.84 in adults and 0.77 in children, the NSI 2.0 additionally shows an excellent relative consistency. No statistically significant difference was withheld in the reliability of test-retest measurements between adults and children., Conclusion: Reliable test-retest measurements of the NSI 2.0 can be performed. Consequently, the NSI 2.0 can be applied in clinical practice, in which successive NSI 2.0 scores can be reliably compared and interpreted., Learning Outcomes: The reader will be able to describe and discuss both the short-term and long-term test-retest reliability of the Nasality Severity Index 2.0, a new multiparametric approach to hypernasality, and its parameters. Based on this information, the NSI 2.0 can be applied in clinical practice, in which successive NSI 2.0 scores, e.g. before and after surgery or speech therapy, can be compared and interpreted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The main aim of this study was to assess the prevalence of Vocal Tract Discomfort (VTD) in the Flemish population without self-perceived voice disorders using the VTD scale and to examine the relationship between vocal load and VTD symptoms. In addition, consistency between the VTD scale and the Voice Handicap Index (VHI) and the Corporal Pain scale was evaluated., Methods: A total of 333 participants completed the VTD scale, the VHI, and the Corporal Pain scale. Patient information about study and voice-related hobbies (for students), state of (non)professional voice user (for employees), smoking, shouting, allergy, and voice therapy was taken into account., Results: A median number of three VTD symptoms was reported, and 88% of the participants showed at least one symptom of VTD. Dryness (70%), tickling (62%), and lump in the throat (54%) were the most frequently occurring symptoms. The frequency and severity of VTD were significantly higher in participants who followed voice-related studies, played a team sport, were part of a youth movement, shouted frequently, and received voice therapy in the past (P < 0.05). Finally, low correlations were obtained between frequency and severity of the VTD scale and total VHI score (r = 0.226-0.411) or frequency and intensity of the Corporal Pain scale (r = 0.016-0.408)., Conclusions: The prevalence of VTD is relatively high in the Flemish population without self-perceived voice disorders, although the frequency and severity of the symptoms are rather low. Vocal load seems to influence the frequency and severity of VTD. Finally, the VTD scale seems to reveal clinically important information that cannot be gathered from any other protocol., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this retrospective study was to determine the vocal characteristics of a treatment-seeking population with the primary complaint of vocal fatigue (VF)., Methods: Forty-three men (mean age 42 years, range 19-69) and 145 women (mean age 34 years, range 18-68) were included. None of the subjects had received voice therapy or previous laryngeal surgery. A questionnaire, laryngeal and perceptual evaluations, aerodynamic and acoustic parameters, and the Dysphonia Severity Index (DSI) were used to determine vocal characteristics., Results: In 74% of the subjects, flexible laryngeal videostroboscopic evaluation revealed a vocal pathology, with vocal nodules and muscle tension dysphonia as the most frequently diagnosed pathologies. Vocal abuse/misuse was present in 65% of the subjects. A median DSI value of -0.4 and -0.8 was found in female and male patients, respectively. Aerodynamic and acoustic parameters and DSI scores were significantly different from normative data., Conclusion: VF is a vocal sign with a significant need for medical consultation, especially in future professional voice users. Understanding the occurrence and the influencing variables of VF may help to close the gap between early stages of a vocal problem and the starting point of a well-established disorder., (© 2016 S. Karger AG, Basel.)