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Objective: To examine the immediate impact of 30 minutes of targeted voice exercises on measures of vocal function and lesion characteristics in female speakers with phonotraumatic vocal fold lesions (PVFLs)., Study Design: Prospective cohort study., Method: Twenty-nine (n = 29) female subjects with PVFLs completed a 30 minutes targeted voice exercise protocol and a multidimensional voice analysis was conducted immediately pre and post-exercise. Analysis included expert perceptual evaluation of connected speech and stroboscopy recordings, instrumental analysis by selected aerodynamic and acoustic parameters, and self-ratings of effort and vocal function by participants. The direction and magnitude of the change from pre- to post-exercise for each individual across parameters was assessed against a Minimal Clinically Important Difference criteria., Results: Variability was observed among participants in their response to exercise and across parameters. Multidirectional change in function was demonstrated across instrumental parameters, with observations of both improvement and decline. The most consistent change observed was a reduced PTP post-exercises for 38% of participants (n = 11), and the greatest magnitude of change was observed in aerodynamic measures of airflow and pressure, and the acoustic parameter semitone range. Variability in the direction of change across instrumental measures was observed for 24% of participants (n = 7), while consistent improved function was seen for 45% (n = 13), declined function for 17% (n = 5) and no change for 14% (n = 4). Participant's self-reported effort and function post-exercise was also multidirectional, with the greatest number reporting improvement. Comparatively little change was observed in perceptual evaluation of speech and stroboscopy recordings. Findings suggest that individuals with all lesion types, sizes and liabilities have the potential to improve vocal function immediately post-exercises according to instrumental measures, with the greatest magnitude of change observed in participants with large lesions. Although participants' characteristics did not differentiate, those with nodules or polyps tended to report improvement in function and reduced effort post-exercise, whereas those with a diagnosis of pseudocyst/s or a unilateral lesion appeared to report no change or declined function., Conclusion: Change in measures of vocal function was observed in female speakers with PVFLs immediately following a 30 minutes targeted exercises protocol. Many demonstrated improvement but a high degree of variability was observed in the way speakers respond, and it is likely an individual's response is influenced by a range of factors. Self-rating scales, along with key instrumental parameters sensitive to the presence of PVFLs, may prove most useful in tracking initial change in the immediate and short-term duration in this population, and in assessing stimulability and candidacy for therapy. Further exploration is warranted of stimulability for immediate and cumulative change to achieve sustained improvement in function and efficiency across time., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To explore the correlation between detection results of pepsin in vocal fold polyp tissues and the postoperative efficacy., Methods: The clinical data of 112 patients with vocal fold polyp who received surgical procedures in our hospital from June 2019 to March 2021 were retrospectively analyzed. The vocal fold morphology and vocal acoustic function were assessed at postoperative week 12. Using binary logistic regression, we explored whether the factors, ie, detection result of pepsin in vocal fold polyp tissue, microscopic suturing, the use of CO 2 laser, and the history of smoking, affected the postoperative morphological repair of vocal fold polyps. Then, to observe and compare the influence of the detection results of pepsin on the recovery of vocal acoustic function, we divided the enrolled patients into the pepsin group and the pepsin-free group based on the postoperative detection results of pepsin in the polyp tissues by immunohistochemistry, RESULTS: In the 112 patients with vocal fold polyps, positive staining of pepsin in the postoperative samples was found in 76 patients (67.86%) and negative in 36 (32.14%). Totally 80 patients returned to normal in vocal fold morphology, among whom 32 (88.89%) were in pepsin-free group and 48 (63.16%) in pepsin group. Binary logistic regression showed that pepsin was a clinically significant indicator that affected the postoperative morphological recovery of the vocal fold (P = 0.003). Although hoarse voice was improved in all patients at postoperative week 12, the differences were statistically significant in the proportion of patients with grade, roughness, breathiness, asthenia, strain class G, voice handicap index, maximum phonation time, Jitter, Shimmer and noise-to-harmonic ratio between the pepsin group and the pepsin-free group (P < 0.05), with the pepsin-free group being superior to the pepsin group in the improvement of vocal acoustic function., Conclusion: Pepsin in vocal fold polyps is a clinically significant indicator affecting the postoperative morphological recovery and acoustic efficacy, and patients with negative pepsin are superior to those with positive pepsin in the postoperative recovery of vocal fold morphology and function., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the effect of a combination indirect voice therapy approach on the management of vocal nodules in the pediatric population., Methods: A prospective cohort study with thirty children (24 males and 6 females; mean age 8.8 ± 2.2) with a diagnosis of vocal fold nodule (VFN) was conducted. All participants were included in an 8-week voice therapy program consisting of vocal hygiene education and parental rule-setting. Videolaryngoscopic examination, auditory-perceptual evaluation, and acoustic voice analysis were performed immediately before and after the intervention., Results: The comparison of videolaryngoscopic findings before and after the therapy revealed that the size of the nodules decreased significantly (P < 0.001). Findings from the laryngeal examination showed that the vast majority of children 73.3% (n = 22) had no VFN anymore after the intervention. The auditory-perceptual evaluation showed that overall severity of dysphonia decreased significantly [from 50 (40-70) to 38 (30-45), P < 0.001]. Jitter local (P = 0.031) and Jitter local abs (P = 0.043) parameters statistically differed after the therapy. There were not any statistically significant differences for mean F0, shimmer local (%), shimmer local (dB), and mean HNR., Conclusions: The voice therapy method in this study has a clear benefit on the voice of children with VFN and can be used in clinical practice. Specifically, clinicians should consider the parents as a core component of voice therapies and pay attention to vocal hygiene education for optimal management of VFN related childhood dysphonia., Competing Interests: Conflicts of interest The authors declare that they have no conflict of interests., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Exposure to chlorine gas can cause many problems for people who work in chlorine chemical production factories. The present study was conducted to investigate the prevalence of laryngeal and voice symptoms and related factors among workers in a chlorine chemical production factory., Design: A case-control study., Patients and Methods: A total number of 208 workers, including 138 workers (13 females, 125 males) who work in a chlorine chemical production factory and 70 (three females, 67 males) workers of a non-chlorine producing factory (producing metal materials), participated in the study. All participants completed self-reported questionnaires to investigate laryngeal or voice problems. These questionnaires investigated workplace vocal health, presence of voice or laryngeal problems, voice symptoms and laryngeal discomforts, and complications of voice problems., Results: The prevalence of laryngeal or voice problems in the workers of the chlorine factory group (18.8%) was higher than in the control group (7%) and this difference was statistically significant (P = 0.018). For all of the voice and laryngeal symptoms, workers in the chlorine factory had more symptoms than workers in the control group. Results of a Chi-Square test showed that workers in the chlorine factory had more significant vocal fatigue and dry throat symptoms than the control group (P < 0.05). Regression logistic analyses showed that age (P = 0.008; OR = 1.09; CI = 1.02-1.17), inadequate humidity (P = 0.015; OR = 2.78; CI = 1.21-6.38), and unavailability of water (P = 0.021; OR = 3.80; CI = 1.22-11.76) raised the chances of increasing the laryngeal and voice symptoms among workers. The most common side effects of laryngeal symptoms and voice problems for workers were: difficulty speaking in crowded environments, low self-esteem while talking, need for repetition to understand speech, and anxiety when speaking., Conclusion: Laryngeal and voice problems were more prevalent in the chlorine factory workers group than in the control group. The factors of age, inadequate humidity, and unavailability of water increased the probability for laryngeal or voice symptoms among chlorine factory workers. These findings indicate the need for further research with this population., Competing Interests: CONFLICT OF INTEREST The authors declare that they have no conflict of interests., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: This study empirically evaluated the influence of phonatory break duration and pause time on auditory-perceptual measures of speech produced by 26 adult speakers diagnosed with adductor-type laryngeal dystonia (AdLD)., Type of Study: Experimental., Methods: Fifteen inexperienced, young adult normal-hearing listeners provided ratings of speech acceptability and listener comfort for samples of running speech. Four phonatory break and pause time conditions were assessed using visual analog scaling methods. All stimuli were randomized for presentation and listeners were presented with experimental stimuli in a counterbalanced manner., Results: Results indicate that the duration of phonatory breaks directly influenced listener ratings of speech acceptability (P < 0.001) and listener comfort (P < 0.001), with significant differences between original and modified recordings for both. Speech acceptability and listener comfort ratings were strongly correlated across all timing conditions (r = 0.85-0.97)., Conclusions: The duration of phonatory breaks and pauses have significantly influence judgments of speech acceptability and listener comfort for AdLD. This suggests that temporal factors such as phonatory break duration and pause time in AdLD may carry substantial negative impact on listeners' perception relative to other auditory-perceptual features that co-exist in the signal., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the effect of a vocal loading task on measures of vocal structure and function in females with benign vocal fold lesions (BVFLs) and determine if change is observed in voice and lesion characteristics., Study Design: Prospective cohort study., Methods: Twenty-eight (n = 28) female subjects with phonotraumatic BVFLs completed a vocal loading task of 30 minutes of reading aloud at 75-85 dBA. Multidimensional voice evaluation was completed pre- and post-load, including audio and videostroboscopy recordings and images for expert perceptual ratings and acoustic and aerodynamic evaluation. Subjects also scored themselves using a 10 cm visual analogue scale for Perceived Phonatory Effort, and completed the Evaluation of Ability to Voice Easily, a 12 item self-report scale of current perceived speaking voice function. An exploratory rather than confirmatory approach to data analysis was adopted. The direction and magnitude of the change scores (pre- to post-load) for each individual, across a wide variety of instrumental and self-report measures, were assessed against a Minimal Clinically Important Difference criteria., Results: Observations of change and the direction of change in vocal response of individuals with BVFLs to 30 minutes of loud vocal load was variable. Minimal to no change was noted for participants pre- to post-load as rated perceptually, for auditory and videostroboscopy samples. For most instrumental measures, change was shown for many participants including an overall improvement in aerodynamic and acoustic measures of function and efficiency post-load for 20 participants (77%) and decline in function for 4 participants (15%). Self-reported effort and vocal function post-load was multidirectional with similar numbers of participants reporting no change, improved function or a decline., Conclusion: Subjects with BVFLs demonstrate change in vocal function following 30 minutes of vocal load. While this change can be variable and multidirectional, overall improvement was observed in instrumental measures of function and efficiency for most participants. Some participants perceived this change to be an increase in effort, some a reduction in effort and some perceived no change. Improved vocal function despite relative lesion stability can seemingly occur after loading in some pathological voices., Competing Interests: Declarations of interest none, (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the effect of proton pump inhibitor (PPI) after laryngeal microsurgery (LMS) in patients with benign vocal fold (VF) mucosal disease and in patients with overt reflux symptom according to subjective and objective voice assessment., Methods: The improvement of voice handicap index-10 (VHI-10) score, reflux symptom index (RSI) score, grade, roughness, breathiness, asthenia, and strain (GRBAS) score, Jitter, Shimmer, noise to harmonics ratio (NHR), maximum phonation time of acoustic voice analysis RESULTS: A total of 47 patients (PPI group [n = 24] and non-PPI group [n = 23]) completed the study. The scores for VHI-10, RSI, GRBAS, and acoustic parameters significantly improved in both groups after surgery. In the subgroup analysis of patients with overt reflux symptoms (RSI ≥ 13; non-PPI group [n = 12], PPI group [n = 15]), significant between-group differences were observed in terms of the improvement in NHR and the strain factor., Conclusion: Postoperative PPI administration in patients with VF benign mucosal disease with reflux symptoms might improve subjective and objective voice outcomes after LMS., Competing Interests: Conflict of interest No potential conflict of interest relevant to this article was reported., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: A prospective single blinded randomized control trial was conducted to study if early initiation of voice therapy after microlaryngeal produces a better voice outcome in patients with benign vocal fold lesions., Methods: In this Patients undergoing microlaryngeal surgery for benign vocal fold lesions were recruited for the study and underwent voice evaluation and videostroboscopy preoperatively. Participants were randomised into two groups depending on the duration of voice rest-A (2 days voice rest) and B (5 days voice rest). Following the period of voice rest, voice therapy (tube phonation) was carried out for a month. Postoperative evaluation was done at 6 weeks (over telephone) and 3 months (in person visit) follow up. Outcome measures included the VHI-10, auditory-perceptual voice ratings, acoustic analysis and videostroboscopic vibratory ratings., Results: Of the 50 subjects, 35 completed the follow up evaluation. The overall compliance to absolute voice rest was 43%. Among the various parameters used for voice evaluation, there was no statistically significant difference between the two groups except for jitter, where the improvement in 5 day voice rest group compared to the 2 day voice rest group was statistically significant., Conclusion: Prolonged voice rest after microlaryngeal surgery is difficult to comply with. As there was no significant difference between the two study groups, clinicians may prescribe a shorter duration of voice rest followed by early initiation of voice therapy after microlaryngeal surgery., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the anatomical and voice results of conservative management of patients diagnosed with contralateral reactive lesions (CRL) in our voice unit., Methods: A retrospective chart review was conducted of all new adult patients with benign vocal fold lesions with or without CRL, treated in the voice unit at Universidad Católica Clinical Hospital between 2015 and 2019. Patients were divided into two groups, without CRL (group A) and with CRL (group B). Analysis of preoperative and 1 month after surgery videostroboscopy, GRBASI, Voice Handicap Index-10 (VHI-10), Voice Related Quality of Life (VRQOL) surveys and management of CRL was conducted., Results: A total of 62 patients were included, 45 (72.6%) had CRL. When compared, bivariate and multivariate analysis revealed that age was significantly associated as a mild protective factor of presenting a CRL (P < 0.05). No significative differences were found between preoperative group A and B perceptual voice analysis or voice surveys. In terms of CRL management, 30 (66.6%) were injected, conservative management with observation was performed in 12 patients (26.7%) and, three (6.7%) were surgically resected. After 1 month follow-up, 32 (71.1%) had complete CRL resolution, eight (17.8%) had CRL persistence and, five (11.1%) had CRL recurrence. Postoperative vocal outcomes, GRBASI, VHI-10 and VRQOL showed significative improvement as compared with preoperative data for each group. No differences were seen between group A and B in terms of postoperative vocal outcomes., Conclusion: CRL are prevalent, and their management is controversial. On our study 72.6% of BFVL presented with CRL and 93.3% of them were conservatively managed. Improvement in perceptual voice analysis and quality of life surveys were similar in both groups., Competing Interests: Conflict of interest The authors declare no conflict of interests., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: Voice change is one of the major symptoms in patients with vocal fold polyp. As a result, phonomicrosurgery is commonly required in these patients. Since voice outcomes after polyp treatment can be variable according to polyp characteristics, we aimed to investigate the predicting factors of postoperative voice improvements in terms of polyp characteristics in patients with vocal fold polyp who underwent cold knife surgery., Materials and Methods: A total of 77 patients who were diagnosed with vocal fold polyp and underwent phonomicrosurgery with cold knife instruments. The polyp characteristics of color, size, shape, and location were evaluated at baseline. Acoustic and aerodynamic analyses, voice handicap index questionnaire and grade, roughness, breathiness, asthenia, strain scale were evaluated at baseline and 6 weeks after surgery., Results: All values of postoperative voice parameters improved after cold knife surgery. (P < 0.05) In patient with an organized vocal fold polyp, less improvement in postoperative values of maximum phonation time were observed. (P < 0.05) Likewise, less improvement of voice handicap index questionnaire score and grade, roughness, breathiness, asthenia, strain scale after surgery was shown in organized vocal fold polyp. (P < 0.05) CONCLUSIONS: Among the various polyp characteristics, the organized polyp was significantly related to relatively less improvement of objective and subjective voice parameters after surgery. These polyp characteristics would help to predict postoperative voice improvement and plan for personalized treatment in patients with vocal fold polyp., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: To determine the consistency and accuracy of preoperative diagnosis in the voice clinic with intraoperative diagnosis and to suggest a standardized laryngeal examination protocol in the UK that is supported by evidence-based findings., Method: From January 2011-September 2014, 164 patients were referred to the Multidisciplinary Team voice clinic and diagnosed with laryngeal pathology that required phonosurgery. The visualization (videostrobolaryngoscopy) in clinic was performed using either rigid laryngoscope or a video-naso-laryngoscope. Intraoperatively, laryngeal visualization and surgical procedure was conducted using Storz Aida HD system, 10-mm rigid laryngoscope 0° or 5-mm rigid laryngoscope 0°/30° and a Zeiss S7 microscope., Results: Of the 164 patients seen in the multidisciplinary voice clinic, 86 clinic diagnoses were confirmed intraoperatively (52.4%), 15 patients had the diagnosis confirmed intraoperatively with additional lesion found (9.1%). The clinic diagnosis changed intraoperatively in 63 cases (38.4%). 61 (37.2%) patients seen in the voice clinic were diagnosed with cyst, in 39.3% the diagnosis was confirmed intraoperatively with 5 cases (8.2%) having an additional diagnosis. Twenty (12.2%) patients were diagnosed with polyps, with 80% confirmation intraoperatively; 3 patients (10%) had an additional diagnosis., Conclusion: Videolaryngostroboscopy imaging of the larynx provides an outpatient tool for accurately diagnosing more than 50% of laryngeal pathologies when interpreted by multidisciplinary voice clinicians. However direct laryngeal examination under general anesthesia remains the gold standard when obtaining accurate diagnoses of laryngeal pathology. Patients diagnosed with nonorganic voice disorders should be considered for direct laryngoscopy under general anesthetic should they fail to respond to conservative management., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate patient-level predictors of initiation of voice therapy for paradoxical vocal fold motion disorder (PVFM)., Study Design: Prospective outcomes database study., Methods: Patients consented to the University of Wisconsin Voice and Swallow Clinics Outcomes Database between March 2010 and November 2016 who were diagnosed with PVFM and recommended for voice therapy were eligible. Patients who attended at least one voice therapy session were considered to have initiated therapy. Analyzed variables included age, gender, distance to the clinic, insurance status, socioeconomic factors, comorbidity score, spirometry results, presence of asthma and/or dysphonia diagnoses, length of evaluation and evaluation model, and patient scores on the Voice Handicap Index and Generalized Anxiety Disorder 7-item scale., Results: One-hundred seventy-eight patients met inclusion criteria. Of these, 118 initiated voice therapy as recommended (66.29%). The majority of patients were female (n = 127; 71.35%). Age was the only factor significantly associated with therapy initiation in both univariate (P = 0.0359) and multivariable (P = 0.0295) analyses, with patients aged 30-39 least likely to attend compared with other age groups. Multivariable analysis also showed that patients evaluated by a speech-language pathologist alone were an estimated three times as likely to initiate therapy compared to patients evaluated by speech-language pathologist and otolaryngologist (ENT) together (P = 0.0407). Other variables were not statistically significant for prediction of therapy initiation., Conclusions: This study suggests that age group and evaluation model are associated with initiation of voice therapy for PVFM. Further study is needed to investigate social-cognitive and quality-of-life factors in predicting therapy initiation., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To reveal and to compare the voice pathologies and the detectable laryngeal findings in different phases of rheumatoid arthritis (RA)., Study Design: Prospective clinical study., Methods: Sixty-seven consecutive patients with RA, followed up at our Physical Therapy and Rehabilitation Clinic, were included in the study. Disease activity indices of patients were calculated with Disease Activity Score-28 Index. With Voice Handicap Index (VHI), patients answered 30 questions of functional, physical, and emotional aspects. Videolaryngostroboscopy was performed by the same physician for all patients with a 70° rigid telescope (Karl Storz, Tuttlingen, Germany), and then acoustic voice analysis (PRAAT program) was performed. Reflux Finding Score was used in evaluating the laryngopharyngeal reflux., Results: Posterior comissure hypertrophy (25.3%) and hyperemia/edema in arytenoid mucosa (22.3%) were detected as the most frequent findings. Other common findings were thick endolaryngeal mucus, vocal cord varices. Twenty-two patients had reflux findings (32.8%). Fundamental frequency, shimmer, maximum phonation time and VHI value were not significantly different between active and remission phases of the disease (P > 0.05). In remission phase, the jitter value and the noise to harmonic ratio value were significantly higher (P < 0.05) than active phase of the disease (P < 0.05). Abnormal laryngeal findings are higher in active phase (28% in remission phase, 54% in active phase). The mean VHI score of patients in remission phase was lower than that in active phase., Conclusion: RA should be included in the differential diagnosis of patients with voice disorders. Nonspecific pathologies are more prevalent in the picture. There are more objective findings and subjective complaints of patients in active phase of the disease than in the remission phase., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Vocal fold injection augmentation (VFIA) is employed diagnostically for patients with subtle glottic insufficiency. Its use in patients with both vocal fold atrophy and benign essential voice tremor (EVT) has been reported but not after durable augmentation. This study intends to evaluate the success of durable VFIA using either autologous fat or calcium hydroxylapatite in patients with both vocal fold atrophy and comorbid EVT., Methods/design: Retrospective review. Subjects included demonstrated subtle glottic insufficiency from true vocal fold atrophy and comorbid EVT with no other vocal fold pathology. Voice Handicap Index (VHI-10), aerodynamic data including subglottic pressure and airflow, and the tremor scoring scale were evaluated before diagnostic VFIA with carboxymethylcellulose and after durable VFIA with calcium hydroxylapatite or autologous fat., Results: Seven patients met inclusion criteria. Six subjects went on to durable VFIA. Three of six demonstrated meaningful improvement in the VHI-10 score. Subglottic pressure improved significantly in those subjects with meaningful VHI-10 improvement compared to those that did not. The tremor did not resolve completely in any subject, but patient satisfaction and function was improved in four of the six., Conclusions: VFIA for EVT in the setting of true vocal fold atrophy appears to offer benefit and may be an alternative treatment pathway for EVT patients. More than half of the subjects who underwent durable VFIA after successful diagnostic VFIA reported improvement in their communication despite inconsistent objective outcomes. Subglottic pressure improved significantly in half of the subjects who also reported a substantive improvement in their VHI-10., (Copyright © 2018. Published by Elsevier Inc.)

Fitness instructors are at risk for phonotraumatic injury caused by a combination of occupation-driven environmental and physiologic factors., Objectives: This study analyzes phonotraumatic injury in a cohort of fitness instructors to define the spectrum of disease, inform treatment, and make educational recommendations., Study Design: Retrospective chart review., Methods: Fitness instructors seen over a 2-year period comprised the study population. Stroboscopic findings, recommended treatment modalities, and treatment outcomes, including postoperative recurrence (when applicable) were analyzed. Demographic information (gender, age), past medical history, VHI-10 scores, and concurrent relevant vocal demands (performer vs. non-performer) were reviewed. Descriptive statistics and bivariate analyses with Fisher's exact test and Wilcoxon rank sum test were used to determine statistical significance of various factors in relation to phonotraumatic injury and response to treatment. Cochran-Armitage trend tests were performed to analyze trends in injuries across fitness types in relation to increased vocal demand. Occupational concerns reported by subjects were analyzed descriptively., Results: The subject cohort consisted of 24 fitness instructors (20F; 4M) who taught a variety of fitness methods. Thirteen subjects (54.2%) were diagnosed with pseudocysts (five unilateral, eight bilateral), five (20.8%) with bilateral midfold masses, five (20.8%) with polyps (four unilateral, one bilateral), and one (4.2%) with cyst. Fourteen subjects (58.3%) were prescribed medication (oral steroids, reflux medication, and/or allergy medication). All were referred for behavioral management. Ten (41.7%) chose surgical intervention after failure to return to satisfactory function with behavioral management; Four (40%) experienced postoperative lesion recurrence. There were no statistically significant findings in relation to demographic information, past medical history, concurrent relevant vocal demands, or occupational vocal demands with choice for surgery. Trend test analysis found that lesions that are typically more likely to require surgical intervention (eg, polyps) tended to be found more frequently as vocal demand increased. The primary occupational concerns reported by subjects were related to amplification (lack of amplification, inadequate amplification/amplification problems) and scheduling (too many consecutive classes without adequate breaks)., Conclusion: Fitness instructors are subject to a variety of phonotraumatic vocal fold injuries, nearly half which require surgical treatment. One in four recurs after such intervention. Instructors could benefit greatly from education on vocal health, strategies to improve and/or reduce voice use while in the fitness environment, and to help aid in recognizing early "red flags" for phonotraumatic injury. Occupational factors that place fitness instructors at risk for phonotraumatic injury (scheduling, environment, amplification) may be improved with education directed to studio owners and managers., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Vocal fold nodules are benign vocal fold lesions that can adversely affect quality of life. Differential diagnosis and treatment modalities of this disease are variable and patients often tend to use online materials to learn the insights. Access to knowledge via Internet is very easy; however, it is important to choose wisely because false and biased information might lead the patient to an inappropriate decision. In this study, we have evaluated the quality, readability, and understandability of online materials for vocal fold nodules., Methods: An Internet search was performed for "Vocal fold nodule," "vocal fold nodule treatment," and "voice therapy for vocal fold nodule" by using Google search engine. Readability of each website was evaluated by using www.readable.io. Understandability and actionability of pages were measured by using the Patient Education Materials Assessment Tool (PEMAT). In the end, DISCERN instrument was used to measure the quality of information presented., Results: After exclusion, total of 26 web pages were evaluated during the study. Four web pages graded as A level, 5 as B level, 11 as C level, and 5 as D level for language use. Average grade level for all of the web pages is 11.14 ± 1.75. Overall understandability score was found 59.0+ 12.1 (26.7-77.1), and overall quality score was measured 34.95 + 6.58 (53.75-26.5)., Conclusion: The quality, readability, and understandability of the written materials are very low and in order for patients to read and learn from the online sources, contents of the written materials should be revised., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: This study investigated the relationship between the acoustic measure smoothed cepstral peak prominence (CPPS), teacher's quality of life as measured by the voice activity and participation profile (VAPP), laryngeal signs and symptoms, voice related health problems and laryngoscopic findings in Finnish teachers. The relationship between CPPS and sound pressure level (SPL) was also assessed., Methods: Vowel and text samples from 183 healthy Finnish teachers (99 kindergarten teachers [KT] and 84 primary school teachers [PST]) were analyzed for CPPS. Text reading was recorded in conversational loudness by PST, and KT were recorded wearing headphones, while listening to a masking noise of children talking to simulate their classroom voice and environment. CPPS values were correlated with the VAPP, self-reported laryngeal signs and symptoms, voice related health variables, and laryngoscopic findings., Results: There was a significant difference between the two groups for CPPS text, PST showed significantly lower CPPS values (10.44) than KT (11.52). There was no difference between the two groups for CPPS vowel phonation. There was a significant correlation between SPL text and CPPS text for KT (P < 0.001, r = 0.43) but not for PST (P < 0.10, r = 0.16). There was a significant correlation between SPL vowel and CPPS vowel for both PST (P < 0.001, r = 0.47) and KT (P < 0.001, r = 0.45). CPPS did not correlate with the VAPP, laryngeal signs and symptoms, health variables or laryngeal findings. Factorial analysis of variance resulted in a significant relationship between the VAPP, laryngeal signs and symptoms, and teacher type. Teacher type and symptoms had a significant effect on VAPP scores., Conclusions: In the present work CPPS does not correlate with vocal health indicators of functionally healthy teachers. CPPS was significantly influenced by differences in speaking voice SPL, emphasizing the impact of recording conditions and technique. There was a significant relationship between laryngeal signs and symptoms, teacher type and the VAPP. Laryngeal signs and symptoms and teacher type are important variables and should be included in the clinical evaluation of occupational voice users, and voice problems., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine the prevalence and demographics of benign vocal fold lesions (BVFL) and trends in its treatment in Korea based on data collected from the National Health Insurance Service database., Material and Methods: Data for patients diagnosed with BVFL (ICM-10 codes J381, J382, J384) from 2006 to 2015 were selected for analysis. Patient characteristics, including sex, age, income, area of residence, and comorbidity, were analyzed. Treatment was divided into surgical management and conservative management using operation codes., Results: The prevalence and incidence of BVFL increased from 7.07% and 5.29%, respectively, in 2006 to 12.47% and 7.98% in 2015. Compared with the non-BVFL population, patients with BVFL were more likely to be female, reside in an urban area, and have gastroesophageal reflux disease. There was no significant change in the incidence of surgical treatment during the study period (around 6000 per year); however, the surgical treatment rate decreased from 19.29% to 8.38%. The probability of undergoing surgical treatment for BVFL was higher in men, those aged 50-59 years, and those in the lowest quartile for income, except for the medical aid group., Conclusion: In Korea, there was an increase in the number of patients diagnosed with BVFL and a decrease in the operation rate for this condition between 2006 and 2015. Diagnosis of BVFL varied significantly based on income and sex; however, the only variable affecting the operation rate was patient age., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Professional activities of university lecturers involve continued and sustained use of the voice, leading in many cases to increased risk of developing voice disorders. Risk identification followed by the fast application of preventive or corrective measures is a key issue in this context., Objective: Define and implement a preventive program for the vocal health of university lecturers by using acoustic features automatically extracted from voice recordings to identify risk groups and manage preventive or corrective actions MATERIAL AND METHODS: A total of 170 subjects, aged between 18 and 65, were recruited at the San Pedro de Alcántara Hospital and at the University of Extremadura in Cáceres (Spain). They formed three groups-one of 25 people suffering from vocal fold nodules, another of 25 healthy people, and the third of 120 university lecturers. Medical history and voice status assessment was performed, and voice recordings were made following a research protocol. A feature extraction, selection, and classification procedure was applied to the voice recordings to provide the best predictors for discriminating between pathological and healthy voices. The model parameters were then used to determine the lecturers' probability of suffering vocal fold nodules or other pathologies with similar dysphonic speech. These probabilities were used to classify the lecturers into three risk groups-low, medium, and high. These groups were taken as the basis to assign the lecturers to a primary, secondary, or tertiary prevention level. Different preventive or corrective actions were applied for each prevention level., Results: The best set of predictors comprised sample entropy, correlation dimension, pitch period entropy, glottal noise excitation, and sex, achieving an overall accuracy of 92% with a random forest classifier. They all showed statistically significant differences between vocal fold nodules and healthy groups (P < 0.05). Three out of the four best acoustic features were nonlinear, showing the importance of nonlinear dynamics for clinical practice. The model parameters were applied to the predictors of the lecturers so as to assign them to the different risk groups, leading to 60.8% (73 out of 120) of the lecturers in the low-risk group, 29.2% (35 out of 120) in the medium-risk group, and 10% (12 out of 120) in the high-risk group. The prevention levels were assigned on the basis of this classification and the medical history and laryngological evaluation of some specific subjects. A statistically significant association was found between the voice status and the assigned prevention level (P < 0.001), with there being a clear dependence relationship (Cramér's V = 0.630)., Conclusion: It is feasible to develop and apply a preventive voice program for university lecturers that is aided by features automatically extracted from voice recordings. As the program progresses, it is expected that the information automatically provided for the assignment to prevention levels will become ever more precise. The method proposed can be extended to other voice professionals and other voice disorders., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Patients with voice-related disorders are ideally treated by a multidisciplinary team. Acoustic voice analysis and patient-reported outcome measures are recommended parts of the clinical assessment. The present paper aims at further documenting the importance of acoustic voice analyses, maximum phonation time (MPT) and Voice Handicap Index (VHI) into clinical investigations., Study Design: The participants (N = 80 larynx cancer, N = 32 recurrent palsy, N = 23 dysfunctional, N = 75 degenerative/inflammation (N = 19 various excluded)) were included consecutively at the outpatient laryngology clinic at Haukeland University Hospital. In addition, a control group of 98 healthy subjects were included., Method: Voice samples, MPT, and the VHI scores in addition to standard clinical information were obtained. Acoustic analyses were performed from these samples determining level of jitter, shimmer and Noise-to-Harmonic ratio (NHR) as well as analyzing frequency of a prolonged vowel., Results: Jitter, shimmer, and NHR scores correlated strongly (r ≈ 0.8; P < 0.001) to each other. By Analysis of Variance analyses, we have determined significant dependence on diagnostic group analyzing all the obtained acoustic scores (all P < 0.001). All patient groups but the dysfunctional group scored to some extent worse than the control group (mostly at P < 0.001). In addition, jitter scores from dysfunction group were lower than recurrent palsy group (P < 0.05) and shimmer scores were lower among dysfunctional than the cancer group (P < 0.05). Regarding NHR the cancer patients scored higher than the degenerative/inflammatory group (P < 0.05). The cancer group scored with longer MPT than the degenerative/inflammatory (P < 0.001) and recurrent palsy groups (P < 0.05)., Conclusion: Among larynx disease patients acoustic and MPT analyses segregated with all determined analyses between patients and control conditions except the dysfunctional group, but also to some extent between various patient groups. VHI scores correlated to jitter, shimmer and NHR scores among cancer and degenerative/inflammatory disease patients. Acoustic analyses potentially add information useful to laryngological patient studies., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the voice outcome measures of thulium laser therapy as an office procedure in patients with vocal fold polyps., Method: This is a retrospective chart review of all patients with vocal fold polyps who underwent office-based thulium laser treatment between November 2016 and December 2017. Demographic data were collected. Objective voice outcome measures included extent of resolution, type of closure, and mucosal wave characteristics. Also, subjective outcome measures were reported, namely, Voice Handicap Index-10., Results: A total of 20 patients were enrolled with a mean age of 50.95 ± 14.70 years. All patients had unilateral vocal fold polyps except for one who had bilateral polyps. Out of the 20 patients, 16 had complete regression of disease and 4 had partial regression. The number of patients with incomplete glottal closure decreased from 12 pretreatment to only 1 patient posttreatment, and the number of patients with impaired mucosal waves decreased from 13 to 5. There was also a significant decrease in the mean VHI-10 score before and after treatment (15.61 vs. 4.61 P value < 0.001)., Conclusion: Thulium laser can be used as an office procedure for the treatment of vocal fold polyps., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Aim: To examine the systemic and local effects of the lidocaine on the larynx and trachea which is applied after the end of the surgery and through various application methods., Study Design: Randomized controlled prospective study., Method: The study is composed of patients who underwent suspension laryngoscopy (SL) for benign laryngeal diseases (cysts, polyp, granuloma, etc) and American Society of Anesthesiologists (ASA) I, between January 2017 and January 2018. The patients were randomly divided into 3 groups. In the first group nothing is applied at the end of the surgery and called as control group, second group received 7 pufs of aerosolized 10% lidocaine solution (70 mg) over larynx and trachea and third group received cotton swaps that impregnated in 1 ml of 20 mg lidocaine solution over surgical area for 1 minutes. Operation and arousal times, heart rate and mean arterial blood pressure levels were noted and compared. Also laryngospasm, cough, and agitation scores were obtained during arousal., Results: 64 patients were included in the study. Laryngospasm was not observed in any of the patients. In group 2 (aerosolized lidocaine group), patients' blood pressure remained similar while increased in other groups (P < 0.05). Agitation scores were significantly lower in group 2 compared to the other groups (P = 0.012). Cough reflex is observed less in group 2 but result was not statistically significant (P = 0.13) CONCLUSION: The usage of aerosolized lidocaine after suspension laryngoscopy is very effective in blocking the stimulation of superior laryngeal nerve and sympathetic nerves which were responsible for the pressor reflexes. The inhibition of these reflexes before or during arousal could secure a safer arousal., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to evaluate objective and subjective changes in the voices of adults with vocal fold nodules who received resonant voice therapy., Methods: Twenty-six female patients who had bilateral vocal fold nodules and 30 healthy women were included in the study. Patients were treated with vocal hygiene education and resonant voice therapy. Voice records were obtained for acoustic and aerodynamic analysis. Fundamental frequency, jitter, shimmer, and noise-to-harmonic ratio were analyzed for acoustic analysis. Maximum phonation time was used for aerodynamic evaluation. Voice Handicap Index 10 was completed by patients for subjective assessment. After 8 weeks of therapy analyses were repeated., Results: Stroboscopic analysis revealed that 14 patients had total and 9 had partial regression. Fundamental frequency increased from 152.27 ± 28.34 to 199.56 ± 11.25 in study group and this was statistically significant. Jitter, shimmer, and noise-to-harmonic ratio improvements were also significant. Voice Handicap Index scores decreased from 22.25 ± 3.82 to 8.92 ± 5.48 and this was statistically significant., Conclusion: Our finding that resonant voice therapy improved objective and subjective parameters of vocal function in patients with vocal fold nodules indicates that it is an effective treatment for VFNs and should be considered a therapeutic option., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Transnasal flexible laryngoscopy (TFL) is becoming more popular in laryngology clinical practice. There has not been any grading system for TFL to help the physician document and communicate the laryngeal view yet. In this study, we aimed to classify the laryngeal view based on the visualization of the glottic aperture with TFL performed on conscious patients., Methods: The TFL videos of 920 randomized patients were evaluated by three blind observers experienced with laryngology. The laryngeal view, consisting of the basic anatomic landmarks of the glottis, arytenoids, and epiglottis, was examined, and the glottic aperture was classified with a five-point grading system. Interobserver agreements for the grading system scores were assessed by using the kappa (k) statistic., Results: Nine hundred and twenty subjects were enrolled in the study. Six hundred and thirty-eight (69.3%) were men, and 282 (30.6%) were women, and the mean age was 40.13 ± 15.08 (18-89 years). The number of patients constituting grade 1 was 737 (80.1%), while grade 2a was 122 (13.2%), grade 2b was 32 (3.4%), grade 3 was 24 (2.6%), and finally, grade 4 was only 5 (0.5%). The k score was 0.945 (P < 0.001) between the ratings of observer 1 and observer 2, 0.933 (P < 0.001) between observer 1 and observer 3, and 0.91 (P < 0.001) between observer 2 and observer 3., Conclusion: This new grading system for the laryngeal view can help physicians assess the upper airways, and it can also help visualize how much of a glottic opening there is., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the clinical feasibility and diagnostic accuracy of two-dimensional scanning digital kymography (2D DKG) in patients with vocal cord atrophy before and after treatment., Materials and Methods: We analyzed the characteristics of vocal fold vibration in five patients with unilateral vocal fold paralysis and five patients with presbyphonia. In patients with vocal cord paralysis, the status before and after intracordal injection was compared. Furthermore, in patients with presbyphonia, we compared the status before and after voice therapy (Seong-Tae Kim's laryngeal calibration technique). Quantitative parameters such as amplitude and phase symmetry indices, jitter, shimmer, noise-to-harmonic ratio, and maximum phonation time and qualitative parameters such as Voice Handicap Index, glottal gap, amplitude, and phase difference were used to evaluate the pre- and post-treatment status., Results: In cases of vocal cord paralysis, vibratory changes of the vocal folds before and after intracordal injection could be identified immediately using 2D DKG. In overcorrection cases, all of the measured parameters were poor except for improvement of the glottal gap. In addition, 2D DKG showed appropriately the changes in vocal cord vibration before and after voice therapy in patients with presbyphonia., Conclusion: Two-dimensional DKG may be a useful diagnostic tool in evaluation of the vibratory characteristics of entire vocal cords. In addition, it may also play a role in providing a decision for treatment modalities., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this case-control study was to evaluate the overall behavior of children with vocal fold nodules (VNs)., Methods: The study group included children with VNs between 4 and 15 years old diagnosed using fiberoptic video laryngoscopy with stroboscopy in a tertiary university hospital. As a control group, children between 4 and 13 years old without VNs, routinely followed up in a primary care facility, were included in the study. Parents of the participants completed the parent-proxy strengths and difficulties questionnaire (SDQ), a brief behavioral screening questionnaire designed for children. The SDQ evaluates emotional, conduct, and peer problems, and also focuses on hyperactivity and prosocial behavior. Children are classified into "normal," "borderline," or "abnormal" according to the total SDQ score., Results: Twenty-seven children (24 boys and 3 girls) with VNs and 41 controls (33 boys and 8 girls) were enrolled in the study. The two groups did not differ significantly in age or gender (P > 0.05). Statistical analysis revealed that 52% individuals of the VNs group presents borderline or abnormal overall behavioral, which is statistically different from the general population (P < 0.001). Total, hyperactivity, and prosocial SDQ subscales were statistically different between study groups (P < 0.05)., Conclusions: Our findings suggest association between VNs and hyperactivity and also with poorer prosocial behaviors in children for the first time. We propose that every child with VNs must be evaluated from a behavioral point of view to detect and to treat potential underlying psychological conditions that may interfere with VNs treatment and prognosis., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Vocal nodules are frequent in children and tend to be reabsorbed after puberty, especially in boys. The aims of the present study were to analyze the progression of nodules in boys after puberty and to investigate the role of microweb in the persistence of these lesions., Methods: Clinical and videolaryngoscopy evaluations were carried out in boys with vocal nodules treated between 2009 and 2016, followed up to the age of 17 years or until remission of symptoms and reabsorption of the nodules. Boys with vocal nodules who underwent regular vocal therapy are included in the study. The outcomes were remission of symptoms and of the nodular lesions., Results: A total of 34 boys with vocal nodules were diagnosed, of which 21 completed follow-up. Mean age of the first evaluation was 9 years (5-11 years) and of end of treatment was 14 years (13-18 years). Mean number of videolaryngoscopy per child was five. After adolescence there was complete remission of symptoms and of the lesions in 15 children (71.4%), partial remission in four (19.0%), and no remission of symptoms and of the lesions in two cases. In these two, videolaryngoscopy identified the presence of microweb and nodules., Conclusions: Favorable reabsorption of the vocal nodules after adolescence was observed in the majority of the boys who underwent voice therapy; however, in two cases there was no remission of symptoms and of the lesions. The unfavorable course can be attributed to anterior laryngeal microwebs., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Bamboo nodes are band-like submucosal deposits of the middle third of the vocal fold. They are often related to connective tissue disorders, but can also precede them. The aim of this study was to report our experience with conservative treatment of those rare lesions., Methods: This is a retrospective series of 15 patients consulting for hoarseness and presenting bamboo nodes from 2010 to 2016., Results: All patients were women of mean age of 38 years with a moderate or high degree of daily vocal effort. Nine patients (60%) presented with known autoimmune disease at the phoniatric appointment. The other patients (40%) benefited from a systematic biological research for autoimmune disease, which retrieved two poorly symptomatic connective tissue disorders. Patients were clinically improved by speech therapy (53%) or by an optimization or introduction of immunosuppressive treatment (46%). A spontaneous improvement was observed for three patients after voice rest (one after retirement, one after professional change, and last one after resuming professional singing). In our series, no phonosurgery was performed. The vocal profile at last appointment found a moderate Voice Handicap Index at 35.3/120, a low maximum time of phonation at 13.6 seconds, and a high jitter at 1.4, sign of instability of the vibrator., Conclusion: This series emphasizes the importance of diagnosing bamboo nodes in middle-aged female presenting an autoimmune disease. Vice versa for each patient with bamboo nodes, a systematic autoimmune check-up has to be realized to detect a biological asymptomatic autoimmune disease., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study aims to assess utility of pixel-valued movement software in detecting arytenoid dislocation preoperatively., Study Design: This is a retrospective analysis., Methods: Twenty-seven patients diagnosed with unilateral arytenoid dislocation were included. Diagnosis of arytenoid dislocation was confirmed by lack of vocal fold paralysis on preoperative laryngeal electromyography and by intraoperative findings of cricoarytenoid dislocation. A region-tracking software algorithm developed by Zhuang et al was used to analyze 27 preoperative endoscopic videos of patients diagnosed with arytenoid dislocation. Vector analysis measuring cuneiform movement during inspiration was used as an indirect measure of arytenoid movement. Values were normalized using vocal fold length. Two raters blinded to diagnosis of arytenoid dislocation measured vocal fold length and cuneiform movement on both the dislocated and the nondislocated sides., Results: A Wilcoxon signed-rank test indicated that the mean pixel-valued cuneiform movement and standard deviation (SD) were greater for nondislocated (159.24, SD = 73.35) than for dislocated (92.49, SD = 72.11) arytenoids (Z = 3.29, P = 0.001). The interrater correlation coefficient was 0.87 for the dislocated side and 0.75 for the nondislocated side. The intrarater correlation coefficient was 0.87 for the dislocated side and 0.91 for the nondislocated side. The receiver operating characteristic curve revealed an area under the curve between 0.76 and 0.83 (95% confidence interval 0.63-0.90). Analysis by the first and second raters revealed misdiagnosis of laterality of arytenoid dislocation in four and six patients, respectively., Conclusions: The software program developed by Zhuang et al provides a high-degree of precision, with good interrater and intrarater correlation coefficients. However, high rates of misdiagnosis of arytenoid dislocation and the laborious analysis process using this software program make it of limited utility as a clinical diagnostic tool in its present state., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

The aim of the study was comparison of voice and life quality after microdirect laryngoscopy in three patient histopathological categories: benign, precancerous, and malignant glottic lesions. A totalnof 137 patients treated with microdirect laryngoscopy were included in the study. Each patient was evaluated with a multidimensional protocol before and 3, 6, and 12 months after treatment. Final 1-year evaluations were achieved in 74.5% (102). The assessment included laryngovideostroboscopy (LVS), perceptual (GRBAS) grading, aerodynamic measures including maximum phonation time and phonation quotient and acoustic measurements (Kay Elemetrics Multi-Speech program), Voice Handicap Index (VHI), Voice-Related Quality of Life questionnaire; and World Health Organization Quality of Life Scale-Brief Version (WHOQoL-BREF). An improvement in mean value of LVS ratings was obtained in all three groups; however, only in benign lesion group was it consistently statistically significant for each time period (P < 0.001). Perceptual evaluation revealed significant improvement of G, R, and B parameters in benign lesions for each time period. In malignant neoplasms R and B parameters improved 3 and 6 months post microsurgery. In patients with benign lesions the maximum phonation time increased, but the improvement was significant only after 3 months. The acoustic parameters improved in all three groups. VHI significantly improved in patients with benign lesions after 3 and 12 months. VHI in the malignant neoplasm group significantly worsened on the first follow-up visit. Considering quality of life (QoL) results, only in patients with benign lesions was there a significant improvement in overall assessment of their QoL and general health., (Copyright © 2019 The Voice Foundation. All rights reserved.)

Objectives: Botulinum toxin A (BtxA) injection is the mainstay treatment for laryngeal dystonias. BtxA product labeling states that reconstituted toxin should be used within 4 hours on a single patient despite several studies that have demonstrated multidose BtxA to be safe and effective. Many insurance carriers mandate the use of an outside pharmacy which necessitates a single-use approach. This study compares the cost savings of multidose BtxA for laryngeal dystonia compared to single-use., Study Design: This is a retrospective review and projected cost savings analysis., Methods: Records and billing information were reviewed for patients receiving BtxA for intralaryngeal injection at a single laryngology division in 2015. Inclusion criteria included CPT 64617 or J0585; exclusion criteria included CPT 64616. The price of BtxA 100 unit vial for calculation was $670., Results: A total of 142 patients were seen for intralaryngeal BtxA injection resulting in 337 visits over 1 year. The average BtxA dose per visit was 2.86 units with an average of 3.06 procedure visits per year. The calculated cost of BtxA treatment using a single vial approach was found to be $2,050 per patient per year. If billed instead for $7/unit with 5 units wastage charge per visit, the yearly per patient charge is $168. Single vial-use of BtxA injection thus represents a 1,118% price increase versus multidose use. When estimated for yearly prevalence of spasmodic dysphonia, multidose BtxA use would save almost $100 million annually., Conclusions: Multidose botulinum toxin A application utilizing per unit billing is significantly less expensive than per single-use vial billing and would save the health-care system significant amount of money without any sacrifice in safety or effectiveness., (Copyright © 2019. Published by Elsevier Inc.)

Opera and chant singers learn to effectively use aerodynamic components by breathing exercises during their education. Aerodynamic components, including subglottic air pressure and airflow, deteriorate in voice disorders. This study aimed to evaluate the changes in aerodynamic parameters and supraglottic structures of men and women with different vocal registers who are in an opera and chant education program. Vocal acoustic characteristics, aerodynamic components, and supraglottic structures were evaluated in 40 opera and chant art branch students. The majority of female students were sopranos, and the male students were baritone or tenor vocalists. The acoustic analyses revealed that the mean fundamental frequency was 152.33 Hz in the males and 218.77 Hz in the females. The estimated mean subglottal pressures were similar in females (14.99 cmH 2 O) and in males (14.48 cmH 2 O). Estimated mean airflow rates were also similar in both groups. The supraglottic structure compression analyses revealed partial anterior-posterior compressions in 2 tenors and 2 sopranos, and false vocal fold compression in 2 sopranos. Opera music is sung in high-pitched sounds. Attempts to sing high-pitched notes and frequently using register transitions overstrain the vocal structures. This intense muscular effort eventually traumatizes the vocal structures and causes supraglottic activity., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: In To analyze laryngostroboscopic findings and ENT/phoniatric examination results in a group of singing students and in a control group of non-singing subjects to emphasize the importance of ENT/phoniatric examination and of laryngostroboscopy before taking up singing., Methods: 56 singing students and 60 healthy euphonic non-singer volunteers were recruited. In each subject a perceptual assessment and a self-assessment (VHI) of the voice were performed. The singing students filled out the Singing-VHI. All subjects underwent flexible fiberoptic endoscopy and laryngostroboscopy. All subjects were evaluated through the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS)., Results: At laryngostroboscopy, 60.7% of students presented pathological findings, versus 20% of controls (P < 0.0001). Incomplete glottic closure (35.7% vs. 13.3%), supraglottic hypertonus (16.1% vs. 5%), organic lesions (bilateral nodules, cysts, sulcus vergeture) (17.9% vs. 3.3%), posterior erythema (16.1% vs. 5%) and laryngeal edema (14.3% vs 3.3%) were more frequent in the students. The most common symptoms in singers were phonasthenia (37.5 % vs 6.7%; P =  0.0001) and mucus sensation (17.9% vs. 5%, P = 0.03). S-VHI showed higher values in students with pathological laryngostroboscopy (P < 0.0001). Finally, average RSI and RFS were higher in students., Conclusions: Due to the high percentage of organic and functional voice disorders in singing students, it would be desirable that every subject who is going to start singing underwent an ENT/phoniatric investigation with videostrobolaryngoscopy to ascertain vocal folds healthy condition., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine nodules using newly developed software with a computer-assisted visual process technique for the calculation of size. The effects of the ratios of nodule base and width were evaluated with voice acoustic analysis., Methods: A total of 72 patients with pediatric vocal nodule were evaluated. Nodules were marked with the ImageJ News program on photographs obtained from the video recordings in the videostroboscopic examination and classified according to the Shah et al scale. Segmentation was applied automatically. The ratios were taken as base of nodule/width and base of nodule/vocal cord. In the voice acoustic analysis, basic frequencies (mean F0), jitter (local %), shimmer (local %), and harmonicity (mean harmonics-to-noise [mean HNR]) were evaluated., Results: A statistically significant negative correlation was determined between the mean F0 value and the nodule base/width ratio (P = 0.042, r = -0.240). A negative statistically significant relationship was determined between jitter (%) and vocal nodule base/width (P = 0.009, r = -0.305). A statistically significant positive correlation was determined between mean HNR and vocal nodule base/width (P = 0.034, r = 0.324). In discriminant analysis, correct classification of the Shah et al scale degrees of the classifying variables was 73.6%., Conclusion: Through collaboration with the biomedical engineering department, the results of this study determined new ratios in patients with pediatric vocal nodule. In voice acoustic analysis, the mean F0 was more affected by the width of the nodule, mean HNR was affected by the length of the base of the nodule, and jitter (%) was affected by the width of the nodule., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Office-based evaluation of glottic lesions has progressed significantly, but there can still be discrepancies compared with direct microlaryngoscopy (DML) in the operating room. We performed a prospective evaluation comparing diagnosis of epithelial and lamina propria glottic lesions on rigid telescopic strobovideolaryngoscopy (RTS) with DML., Methods: Fifty subjects were enrolled and underwent RTS followed by DML. We compared presence and extent (unilateral or bilateral) of lamina propria and epithelial lesions. Primary (diagnoses motivating an operation) and secondary (diagnoses not requiring an operation) were considered. Changes in diagnosis and operative plan based on DML findings were evaluated., Results: Sixty-eight lesions were identified on RTS, including 53 primary (15 epithelial, 38 lamina propria) and 15 secondary diagnoses. RTS was accurate in only 36% of subjects. Ten subjects had a different primary pathology identified on DML. A change in surgical management occurred in 16% of subjects., Conclusions: This is the first prospective study evaluating how both diagnosis and operative plan for epithelial and lamina propria glottic lesions differ based on RTS and DML. Despite significant advances in office-based diagnosis of glottic lesions, there are still notable limitations. Clinicians should consider these findings when counseling patients on interpretation and plan for findings based on RTS. Obtaining a flexible surgical consent and counseling patients on the potential for new diagnoses and interventions based on DML is warranted., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Laryngeal endoscopy with stroboscopy, a critical component of the assessment of voice disorders, is rarely used as a treatment outcome measure in the scientific literature. We hypothesized that this is because of the lack of a widely used standardized, validated, and reliable method to assess and report laryngeal anatomy and physiology, and undertook a systematic literature review to determine the extent of the inconsistencies of the parameters and scales used in voice treatment outcome studies., Study Design: Systematic literature review., Methods: We searched PubMed, Ovid, and Cochrane for studies where laryngeal endoscopy with stroboscopy was used as a treatment outcome measure with search terms representing "stroboscopy" and "treatment" guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards., Results: In the 62 included articles, we identified 141 terms representing 49 different parameters, which were further classified into 20 broad categories. The six most common parameters were magnitude of glottal gap, mucosal wave amplitude, location or shape of glottal gap, regularity of vibration, phase symmetry, and presence and size of specific lesions. Parameters were assessed on scales ranging from binary to 100 points. The number of scales used for each parameter varied from 1 to 24, with an average of four different scales per parameter., Conclusions: There is a lack of agreement in the scientific literature regarding which parameters should be assessed to measure voice treatment outcomes and which terms and scales should be used for each parameter. This greatly diminishes comparison and clinical implementation of the results of treatment outcomes research in voice disorders. We highlight a previously published tool and recommend it for future use in research and clinical settings., (Copyright © 2018. Published by Elsevier Inc.)

Objective: High-speed videolaryngoscopy is widely used in voice practices as a complement to videostroboscopy, especially when it is desired to visualize asymmetric and nonperiodic vocal fold vibration or voice onset and offset. Because of the requirement for greater illumination at higher frame rates, the high-speed exam is usually performed with a rigid transoral laryngoscope. Although it is possible to obtain color high-speed video images with a flexible fiberoptic nasoendoscope, the results are often disappointing because of the inability to provide adequate lighting inside the larynx. This paper will present the results of a systematic exploration of tools and techniques to optimize the image brightness of flexible color high-speed videolaryngoscopy exams using the KayPENTAX Model 9710 Color High-Speed Video (CHSV) System., Methods: The KayPENTAX CHSV System was used with three PENTAX flexible fiberoptic nasolaryngoscopes and a new supplemental light fiber bundle to perform high-speed examinations of healthy vocal folds. Variables of the investigation included camera frame rate, camera sensitivity (color head versus black-and-white head), optics (camera lens focal length), light coupling, nasoendoscope outer diameter, and endoscopy technique (visually perceived distance of the distal tip of scope from the glottal plane)., Results and Conclusions: The manipulation of camera gain, the proper selection of lens coupler focal length, and the adjustment of scope distal tip distance from the glottal plane were found to be most effective for optimizing image brightness, whereas the supplemental light fiber bundle provided minimal benefits. Other factors considered include patient comfort, practicality, and ease of use by the clinician., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of the present systematic review was to investigate the nonmedical treatments of vocal fold nodules (VFNs)., Study Design: The present study is a systematic review., Methods: The following electronic databases were searched from inception until August 2016: PubMed, Scopus, ScienceDirect, Ovid, ISI (Web of Sciences), Cochrane, PsychINFO, The Cochrane Central Register of Controlled Trials, and Google Scholar. Reference lists of included articles were evaluated for additional data. Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were used to carry out and report the review. The methodological quality of the articles included was evaluated using the Physiotherapy Evidence Database scale. Due to the heterogeneity of the studies, a narrative synthesis of the evidence was performed to summarize the evidence., Results: Out of 2,099 records identified, 21 articles met the inclusion criteria and thus were included in the review. The studies investigated in the present review were different in terms of study design, participant characteristics, types of assessments and treatments, and treatment delivery. However, nonmedical treatments of VFNs were found to be successful in improving vocal quality, decreasing VFN sizes, and resolving these nodules., Conclusions: The results of the present review could provide primary evidence related to the effectiveness of nonmedical treatment of VFNs. Yet further studies with a high level of evidence, a rigorous methodological quality, and long-term follow-up evaluations are required to make stronger claims., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Since the development of distal chip endoscopes with a working channel, diagnostic and therapeutic possibilities in the outpatient clinic in the management of laryngeal pathology have increased. Which of these office-based procedures are currently available, and their clinical indications and possible advantages, remains unclear., Material and Methods: Review of literature on office-based procedures in laryngology and head and neck oncology., Results: Flexible endoscopic biopsy (FEB), vocal cord injection, and laser surgery are well-established office-based procedures that can be performed under topical anesthesia. These procedures demonstrate good patient tolerability and multiple advantages., Conclusion: Office-based procedures under topical anesthesia are currently an established method in the management of laryngeal pathology. These procedures offer medical and economic advantages compared with operating room-performed procedures. Furthermore, office-based procedures enhance the speed and timing of the diagnostic and therapeutic process., (Copyright © 2018 The Voice Foundation. All rights reserved.)

Introduction: Vocal fold cysts are benign mid-membranous lesions of the true vocal fold, classified as mucus retention or epidermal inclusion cysts. Treatment is surgical excision with or without postoperative voice therapy., Methods: A retrospective review was performed of the demographics, treatment approach, and outcomes of patients treated for vocal fold cysts between 2009 and 2014. Voice Handicap Index (VHI)-10 scores before and after treatment were compared using the Wilcoxon Rank-Sum test and the two-tailed Student's t test. Videostroboscopy examinations were reviewed for posttreatment changes in vibratory characteristics of the vocal folds., Results: Twenty-five patients were identified, and one was excluded for incomplete records. Mean age was 41.9 years (66.7% female), and mean follow-up time was 5.58 months. Microflap excision was pursued by 21/24 (87.5%) patients, with 14 patients (58.3%) undergoing perioperative voice therapy. One cyst recurred. Two patients elected for observation, and their cysts persisted. VHI-10 decreased from 23.8 to 6.6 (P < 0.001) overall. There was a statistically significant reduction in VHI-10 in patients undergoing surgery with and without postoperative voice therapy (P < 0.004 and 0.001), but there was no significant difference between these two groups. Mucosal wave was classified as normal or improved in the majority. Cysts were characterized as mucus retention cysts in 19/21 (90%) and as epidermal inclusion cysts in 2/21 (10%)., Conclusions: Vocal fold cysts impact mucosal wave and glottic closure. Surgical excision resulted in low rates of recurrence, and in improvement in the mucosal wave and VHI-10. Perioperative voice therapy did not offer a significant benefit. Mucus retention cysts were the majority, in contrast to other published studies., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Bilateral true vocal fold paralysis is rarely attributable to inflammatory diseases. Sarcoidosis is a rare but important etiology of bilateral true vocal fold paralysis by compressive lymphadenopathy, granulomatous infiltration, and neural involvement. We describe the first reported case of sarcoidosis presenting as bilateral vocal fold immobility caused by direct fixation by granulomatous infiltration severe enough to necessitate tracheostomy insertion. In addition, we discuss the presentation, the pathophysiology, and the treatment of this disease with a review of the literature of previously reported cases of sarcoidosis-related vocal fold immobility. Sarcoidosis should therefore be an important consideration for the otolaryngologist's differential diagnosis of true vocal fold immobility., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to investigate vocal tract discomfort and quality of life in the voice of wind instrumentalists., Method: It is a cross-sectional study. The sample was composed of 37 musicians of the orchestra of Caxias do Sul city, RS, Brazil. The participants answered a nonstandard questionnaire about demographic and professional information, the Voice-Related Quality of Life (V-RQOL), the Vocal Tract Discomfort (VTD) scale, and additional items about fatigue after playing the instrument and pain in the cervical muscles. Correlation analyses were performed using Spearman correlation test., Results: The most frequent symptoms mentioned by musicians in the VTD, for both frequency and intensity of occurrence, were dryness, ache, irritability, and cervical muscle pain, in addition to the frequency of occurrence of fatigue after playing. The musicians showed high scores in the V-RQOL survey. Several symptoms evaluated by the VTD had a negative correlation with the musicians' years of orchestra membership and with V-RQOL scores., Conclusion: Symptoms of vocal tract discomfort are present in wind instrumentalists in low frequency and intensity of occurrence. However, these symptoms affect the musicians' voice-related quality of life, and they occur more in musicians with fewer years of orchestra membership., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Vocal fold motion abnormalities in children are the second most common form of laryngeal pathology seen in children, and often present in the first 24 months of life. A thorough evaluation of the aerodigestive tract will include an examination of the vocal folds, and a proper diagnosis is essential in order to decipher the etiology of swallowing, voicing and breathing abnormalities. This article reviews the workup, management options and clinical outcomes of unilateral and bilateral vocal fold motion impairment in the pediatric population., (Copyright © 2018 Mosby, Inc. All rights reserved.)

Objective: This study aimed to assess the utility of laryngeal high-speed videoendoscopy (HSV) as a clinical tool., Design: This is a prospective study of 151 patients., Methods: A total of 151 adult patients (52 male, 99 female) underwent both videoendoscopy with stroboscopy (videostroboscopy) and HSV examination as part of a routine clinical voice assessment. At the time of the examination, ratings for videostroboscopy were reported in the clinical report. Next, the clinicians reviewed the HSV examination and indicated the changes in ratings of HSV relative to videostroboscopy. Finally, the clinical reports were reviewed by a clinician not involved in data collection or clinical care of the patients and noted differences between videostroboscopy and HSV clinical ratings, and resulting diagnoses were identified and grouped., Results: Ratings of all vibratory features showed change between videostroboscopy and HSV. Mucosal wave and amplitude of vibration showed the largest percentage change, respectively, in 74% and 53% of the reports. They were followed by the features of glottal closure (36%), phase closure (32%), glottal edge (25%), and phase symmetry (21%). Ratings of supraglottic compression and vocal fold vertical level showed the least change between videostroboscopy and HSV. Changes in initial diagnosis owing to the inclusion of HSV were indicated in 7% of the cases., Conclusions: HSV may be an important laryngeal imaging technique for functional assessment of the pathophysiology of certain voice disorders. HSV could enable important refinements in the diagnosis and management of vocal fold pathology., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The study aimed (1) to evaluate the prevalence of sulcus vocalis (SV) coexisting with vocal fold polyp (SV-VFP), and (2) to determine the effect of their coexistence on voice quality., Study Design: This is a retrospective cohort study in a tertiary referral center., Methods: The medical records of all patients who underwent micro direct laryngoscopy due to VFPs between January 2013 and April 2015 were reviewed. Patients with SV-VFP were identified and data of their demographics, medical history, habits, preoperative and intraoperative laryngeal findings, and pre- and postoperative GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) score, and compared with the data of patients with solitary VFPs (S-VFPs)., Results: Eighty-nine patients were diagnosed with VFPs, 14 (15.7%) of whom were diagnosed with SV-VFPs. Patients with SV-VFPs had significantly lower incidence of concurrent leukoplakia (P = 0.01), higher incidence of contralateral vocal fold lesions (P = 0.04), increased voice roughness score postoperatively (P = 0.01) on the GRBAS score, and had a lower rate of cigarette smoking (P = 0.02) compared with patients with S-VFPs., Conclusions: The possibility of a hidden SV should be considered when detecting VFPs, particularly in patients with contralateral vocal fold lesions and without cigarette smoking history. Because the group of patients with SV-VFP presented with unique features, we suspect that the coexistence of VFPs and SVs is not incidental and that SVs may contribute to the formation of VFPs, possibly by alternating glottic airflow., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to investigate the role of false vocal folds (FVFs) medialization in phonation and the acoustic impact of ventricular hypertrophy by establishing an FVF hypertrophy model., Study Design: A prospective in vitro experiment was carried out., Setting: The study was carried out using a pseudolung platform with high-speed camera in a soundproof room., Materials and Methods: Control, degree I, and degree II FVFs hypertrophy were simulated in 10 excised larynges via fructose injection of 0.1 mL for degree I and 0.25 mL for degree II. Mean flow rate (MFR), fundamental frequencies (F0), formants, and sound pressure level were measured with a subglottal pressure of 1.5 kPa and 2.5 kPa, respectively., Results: When the subglottal pressure was controlled at both at 1.5 kPa and at 2.5 kPa, the degree of FVF hypertrophy significantly influenced the distribution of the formants, F0, and MFR in excised canine larynges. Increasing the degree of hypertrophy was associated with a decrease in F0 and an increase in MFR. In degree II FVF hypertrophy models, the sound pressure level and the first formant were significantly higher (P < 0.05) than in normal models., Conclusion: Hypertrophy of the FVFs has a significant influence on the distribution of sound energy and is associated with changes in sound quality., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: This study proposes a gradient-based method for temporal segmentation of laryngeal high-speed videoendoscopy (HSV) data obtained during connected speech., Methods: A custom-developed HSV system coupled with a flexible fiberoptic nasolaryngoscope was used to record one vocally normal female participant during reading of the "Rainbow Passage." A gradient-based algorithm was developed to generate a motion window. When applied to the HSV data, the motion window acted as a filter tracking the location of the vibrating vocal folds. The glottal area waveform was estimated using a statistical-based image-processing approach. The vocal fold vibratory frequency was computed by an autocorrelation-based extraction of the fundamental frequency (f 0 ) from the glottal area waveform. Temporal segmentation was then performed based on the f 0 contour and automatic detection of the epiglottic obstructions. Additionally, visual temporal segmentation was performed by viewing the HSV images frame by frame to determine the time points of the vocalization onsets and offsets, and the epiglottic obstructions of the glottis., Results: The time points resulting from the automatic and visual temporal segmentation methods were cross-validated. The f 0 -contour patterns of rise and fall resulting from the automatic algorithm were found to be in agreement with the visual inspection of the vibratory frequency change in the HSV data., Conclusions: This study demonstrated the feasibility of automatic temporal segmentation of HSV imaging of connected speech, which allows for mapping the video content into onsets, offsets, and epiglottic obstructions for each vocalization. Automated analysis of HSV imaging of connected speech has significant clinical potential for advancing instrumental voice assessment protocols., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

The aim of the study was to estimate voice defect and the quality of life deterioration in patients with different laryngeal pathologies qualified for microsurgery treatment. The results of videolaryngostroboscopy (VLS), perception, aerodynamics, acoustics, Dysphonia Severity Index, Voice Handicap Index (VHI), and the World Health Organization Quality of Life Scale Brief Version before microsurgery were analyzed. There were 151 patients enrolled in the study. There were 86 patients in group 1 (benign lesions), 34 in group 2 (premalignant conditions), and 31 in group 3 (malignant neoplasms). Significant differences were found in the mean values of VLS between group 1 and group 3 (P = 0.001), maximum phonation time between group 1 and group 2 (P = 0.001), and between group 2 and group 3 (P = 0.04), men's fundamental frequency between group 1 and group 2 (P = 0.03), and between group 1 and group 3 (P = 0.01), and shimmer between group 1 and group 3 (P = 0.01). The correlation between the methods was analyzed, and there was a strong to moderate correlation between VLS and perception (r = 0.57-0.73) in group 1 and group 2. The jitter and shimmer correlated moderately with perception in group 1: grade of hoarseness (G) (r = 0.52 and r = 0.57, respectively), breathiness (B) (r = 0.58), and asthenia (A) (r = 0.57 and r = 0.53, respectively). In group 3, the strongest correlation was observed between maximum phonation time and phonation quotient and G (r = 0.52; 0.58), B (r = 0.54; 0.55), and strain (S) (r = 0.63; 0.72). The VHI results and life quality outcomes were not significantly different between the groups. The VHI did not correlate with any voice measure method., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

High-speed videoendoscopy captures the cycle-to-cycle vibratory motion of each individual vocal fold in normal and severely disordered phonation. Therefore, it provides a direct method to examine the specific vibratory changes following vocal fold surgery. The purpose of this study was to examine the vocal fold vibratory pattern changes in the surgically treated pathologic vocal fold and the contralateral vocal fold in three vocal pathologies: vocal polyp (n = 3), paresis or paralysis (n = 3), and scar (n = 3). Digital kymography was used to extract high-speed kymographic vocal fold images at the mid-membranous region of the vocal fold. Spectral analysis was subsequently applied to the digital kymography to quantify the cycle-to-cycle movements of each vocal fold, expressed as a spectrum. Surgical modification resulted in significantly improved spectral power of the treated pathologic vocal fold. Furthermore, the contralateral vocal fold also presented with improved spectral power irrespective of vocal pathology. In comparison with normal vocal fold spectrum, postsurgical vocal fold vibrations continued to demonstrate decreased vibratory amplitude in both vocal folds., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)