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Essential voice tremor (EVT) is a voice disorder resulting from dyscoordination within the laryngeal musculature. A low-frequency fluctuations of fundamental voice frequency or the strength of excitation amplitude is the main consequence of the disorder. The automatic classification of healthy control and EVT is useful tool for the clinicians. A typical automatic EVT classification involves three steps. The first step is to compute the pitch contour from the speech. The second step is to compute the features from the pitch contour, and the final step is to use a classifier to classify the features into healthy or EVT. It is shown that a high-resolution pitch contour estimated from the glottal closure instants (GCIs) is useful for EVT classification. The HPRC estimation can be very poor in the presence of noise. Hence, a probabilistic source filter model based noise robust GCI detection is used for HPRC estimation. The Empirical mode decomposition based feature extraction is used followed by a support vector machine classifier. The EVT classification performance is evaluated using recordings from 45 subjects. The proposed method is found to perform better than the baseline techniques in eight different additive noise conditions with six SNR levels.

To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency.Retrospective study of professional singers and actors who presented for a vocal evaluation.A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR).A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n = 33), followed by cyst 27% (n = 25) and acute laryngitis, 14% (n = 13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n = 47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P = 0.008).Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

Summary Objectives A whole body vibration platform using vertical oscillation has been shown to be efficacious in reducing vocal fatigue in adults. This study aimed to investigate whether this platform-generated whole body vibration was unique in reducing vocal fatigue by comparing it with self-generated whole body vibration. Methods Twenty-four female adults (mean age = 23.96 years) were randomly assigned to one of the following three groups: a machine-generated whole body vibration group (N = 8), a self-generated whole body vibration group (N = 8), and a placebo vocal resting group (N = 8). All participants performed a karaoke singing task for at least 95 minutes. Each participant received 10 minutes of platform-generated vibration, self-vibration, or sham localised vibration (placebo group with basically voice rest only), according to their group allocation. Vocal function ability, measured by the highest fundamental frequency produced, and a self-reported vocal fatigue score were evaluated at three time points: baseline (prefatigue), after the singing task (post-fatigue) and post-vibration. Results The study revealed that machine-generated whole body vibration was significantly better at improving vocal fatigue than self-generated whole body vibration or voice rest. Conclusion The findings support previous research that machine-generated whole body vibration is effective in reducing vocal fatigue. The non-significant results of self-generated whole body vibration in terms of relieving vocal fatigue suggest that inadequate vibration frequency or amplitude together with leg muscle fatigue may have been the main factor of ineffectiveness.

Presbyphonia negatively impacts quality of life in patients with age-related voice changes. A proof-of-concept study showed promise for high vocal intensity exercise to treat presbyphonia, which became the basis for a novel intervention for age-related voice changes known as Phonation Resistance Training Exercises (PhoRTE). Expiratory Muscle Strength Training (EMST) has also been proposed as an additional intervention to target and strengthen the aging respiratory system; however, EMST has undergone limited evaluation as an adjunct treatment for elderly patients undergoing voice therapy for presbyphonia. This study determined if the addition of EMST to PhoRTE voice therapy (PhoRTE + EMST) is at least as effective at voice improvement as PhoRTE alone.Prospective, randomized, controlled, single-blinded, non-inferiority.Participants aged 55 years or older with a diagnosis of vocal fold atrophy were randomized to complete PhoRTE therapy or PhoRTE + EMST. The primary outcome was change in Voice Handicap Index-10 (VHI-10). Secondary outcomes included the Aging Voice Index, maximum expiratory pressure, and acoustic and aerodynamic measures of voice. Repeated measures linear mixed models were constructed to analyze outcomes at a significance level of α = 0.10.Twenty-six participants were recruited for the study, and 24 participants were randomized to either treatment arm. Sixteen participants completed the entire study. Both treatment arms showed statistically significant and clinically meaningful improvements in VHI-10 (PhoRTE mean [M] = -8.20, P0.001; PhoRTE + EMST M = -9.58, P0.001), and PhoRTE + EMST was noninferior to PhoRTE alone (P = 0.069). Both groups experienced a statistically significant pre-post treatment decrease (improvement) in AVI scores (PhoRTE M = -18.40, P = 0.004; PhoRTE + EMST M = -16.28, P = 0.005). PhoRTE+EMST had statistically significantly greater changes in maximum expiratory pressure compared to PhoRTE alone (PhoRTE M = 8.24 cm HThis study demonstrates that voice therapy targeting high vocal intensity exercise (eg, PhoRTE) and EMST can play a role in improving voice outcomes for patients with presbyphonia.

SUMMARY Objective To review the authors experience in un-sedated office-based biopsies of patients with vocal fold leukoplakia and to review the literature. Material and Method A retrospective review of 29 patients was conducted. Results A total of 41 office-based procedures were performed (eight patients had bilateral vocal fold lesions and four patients had the procedure performed twice). In 26 out of the 41 biopsies, the pathology revealed benign lesion. In eight cases, the pathology showed dysplasia (four high-grade and four low-grade). Seven biopsies revealed squamous cell carcinoma. Five patients underwent suspension micro-laryngoscopy for definitive diagnosis. Four of whom had a change in their diagnosis. Conclusion Un-sedated office-based biopsy of vocal fold leukoplakia is an alternative to suspension microlaryngoscopy in case of carcinoma or nonmalignant lesions.

Summary Objective The diffusion characteristics of water molecules were measured in the vocal folds of canines exhibiting unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation. These characteristics were used in conjunction with a histological examination of the microstructural changes of vocal fold muscle fibers to explore the feasibility of diffusion tensor imaging (DTI) in distinguishing unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation as well as evaluating microstructural changes. Methods Ten beagles were randomly divided into three groups: four in the unilateral vocal fold paralysis group, four in the unilateral cricoarytenoid joint dislocation group, and two in the normal group. Unilateral recurrent laryngeal nerve resection was performed in the vocal fold paralysis group. Unilateral cricoarytenoid joint dislocation surgery was performed in the dislocation group. No intervention was performed in the normal group. Four months postintervention, the larynges were excised and put into a magnetic resonance imaging (MRI) system (9.4T BioSpec MRI, Bruker, German) for scanning, followed by an analysis of diffusion parameters among the different groups for statistical significance. After MRI scanning, the vocal folds were cut into sections, stained with hematoxylin and eosin, and scanned digitally. The mean cross-sectional area of muscle fibers, and the mean diameter of muscle fibers in the vocal folds were calculated by target detection and extraction technology. Mean values of each measurement were used to compare the differences among the three groups. Pearson correlation analysis was performed on the DTI parameters and the results from histological section extraction. Results The paralysis group had significantly higher Fractional Anisotropy (FA) compared to the dislocation group and normal group (P = 0.004). The paralysis group also had a significantly lower Tensor Trace value compared to the dislocation group and normal group (P = 0.000). The average cross-sectional area of vocal fold muscle fibers in the paralysis group was significantly smaller than the dislocation group and normal group (P = 0.000). Pearson correlation analysis yielded values of, r = -0.785, P = 0.01 between the average cross-sectional area of vocal muscle fibers and FA, and values of r = 0.881, P = 0.00 between Tensor Trace and the average cross-sectional area of vocal muscle. Conclusion FA and Tensor Trace can be used as effective parameters to reflect the changes of microstructure in vocal fold paralysis and cricoarytenoid joint dislocation. DTI is an objective and quantitative method to effectively evaluate unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation, also capable of noninvasively evaluating vocal fold muscle fiber microstructure.

The aim of the study was comparing the diagnostic role of the white light (WL) endoscopy, video laryngostroboscopy (VLS), and narrow-band imaging (NBI) in the evaluation of the benign vocal fold lesions.From March 2018 to June 2019, a total of 118 cases were enrolled in this study. Ninety-eight patients were suspected with vocal fold nodules, cysts, polyps, and sulcus vocalis and 20 patients without a history of dysphonia. Each patient was examined by WL, VLS, and NBI endoscopy. Recorded images and videos were analyzed and scored by three otorhinolaryngologists who had at least 3 years of experience in phoniatrics field. The evaluation results were compared between the methods and the physicians.A total of 118 cases were grouped by their confirmed diagnosis, vocal fold nodules (n = 28), vocal fold cyst (n = 24), vocal fold polyp (n = 9), and sulcus vocalis (n = 37). When the correct diagnosis rates of the physicians were compared, the statistical significance was found between the physicians in the WL and VLS method (P= 0.014, P= 0.027). No statistically significant difference was found among physicians in NBI method (P = 0.368). The difference between the diagnostic methods was found to be statistically significant in reaching the accurate diagnosis for benign vocal fold lesions (P0.001). While the difference between NBI-WL and VLS-WL was statistically significant (P0.001 and P0.001). The difference between NBI-VLS was not statistically significant while evaluating the vocal fold nodules, cysts, and sulcus vocalis separately (P= 0.102, P = 0.026, P = 0.157). Otherwise, it was statistically significant (P= 0.002) while evaluating total benign lesions in the study. The difference between NBI-VLS combination and VLS, NBI-VLS combination and VLS-WL combination were statistically significant (P0.001 and P= 0.001).This study showed that NBI assessments have similar accuracy and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to VLS and have a higher value than WL endoscopy in reaching the diagnosis for benign vocal fold lesions. Therefore, NBI can be accepted as a promising approach to identify benign laryngeal lesions due to its optical properties.

Measuring the impact of chronic cough on voice quality can be difficult and challenging in daily practice. Evidence about its potential effects on diagnostic tools used in voice evaluation is lacking. We hypothesized that the presence of chronic cough plays a role in patients' perception of dysphonia severity, leading to a mismatch between the subjective, objective, and perceptual evaluations.A retrospective chart review involving patients with a diagnosis of dysphonia and a complete speech voice evaluation was performed. A total of 311 patients were stratified into two different groups according to the presence of chronic cough. A total of 151 patients were assigned to the dysphonia and chronic cough group, while 160 patients were assigned to the dysphonia only group. During the initial evaluation, patients completed the Voice Handicap Index (VHI)-30, Glottal Function Index (GFI), and Reflux Symptoms Index (RSI). Voice evaluation also included aerodynamic/acoustic measures and the application of the GRBAS scale by a speech-language specialist. A paired t test and a linear regression analysis were used to compare subjective, perceptual, and aerodynamic/acoustic measures in both groups.The mean VHI-30 and GFI were elevated in both groups but significantly lower among patients with dysphonia and chronic cough when compared to patients with dysphonia only (P= 0.01). Additionally, a significantly higher RSI was found among patients with dysphonia and chronic cough (P0.01). No difference in aerodynamic/acoustic measures was found between groups (P0.05). Our linear regression model demonstrated a significant effect of the presence of chronic cough on the VHI-30, RSI, and GFI questionnaires (P0.05). Our model also found that the VHI-30 is a significant predictor for the (G), (B), (A), and (S) components of the GRBAS scale (P0.05).The presence of chronic cough has a significant impact on the different patient-reported outcome measures, including VHI-30, RSI, and GFI. The use of VHI-30 as a predictor for the GRBAS scale reinforces the importance of subjective and perceptual assessment among patients with voice disorders and establishes a new area for exploration.

Summary Objectives The vocal tract discomfort scale is a self-rating seven-point Likert scale that quantifies frequency and severity of eight qualitative descriptors including burning, tight, dry, aching, tickling, sore, irritable, and lump in the throat, and ranges from 0 (never/none) to 6 (always/extreme; Mathieson et al. 2009). The objectives of the current study were to compare the vocal tract discomfort scale results between elementary school teachers and high school teachers and between male and female teachers using the Persian vocal tract discomfort scale. Also, teachers in different age ranges and with different experiences were compared regarding vocal tract discomfort symptoms. Methods The researchers chose 20 elementary and high schools by simple random sampling in Khorramabad, Iran. The survey was given to available teachers of the selected schools. Considering the inclusion criteria, required sample size, and after excluding questionnaires that were not correctly answered, 120 were selected such that 30 were chosen for each subgroup. Subjects consisted of 60 elementary school teachers (30 females and 30 males) with the mean age of 40.92 years (standard deviation = 6.07) and 60 high school teachers (30 females and 30 males) with the mean age of 40.67 years (standard deviation = 6.00). SPSS 25 was used for analyzing the data. Results Results indicated that the frequency and severity of the vocal tract discomfort in elementary school teachers were significantly higher than for the high school teachers with a medium to large effect size. Although the frequency and severity of the symptoms were higher in female compared with male teachers, those differences were not significantly different. Younger teachers had lower frequency and severity ratings of vocal tract discomfort symptoms than older teachers. Teaching experience was not an important factor in predicting vocal tract discomfort symptoms in teachers. Conclusions The results of this study suggest that there is higher frequency, greater severity, and higher percentages of vocal tract discomfort symptoms in elementary compared with high school teachers. In addition, although the mean frequency and severity of vocal tract discomfort symptoms were not significantly different between females and males, females reported higher percentages of the symptoms. Because each of the eight vocal tract symptoms was experienced at the time of testing by between 42% (tightness) and 68% (dryness) of the participants, it is suggested that an educational program regarding vocal tract discomfort may be helpful for this profession.

Summary Purpose Medialization laryngoplasty can be performed to treat glottic incompetence after endoscopic laser cordectomy. The aim of this study is to evaluate vocal outcome after this phonosurgical procedure and to analyze the critical aspects of the Montgomery and Gore-Tex laryngoplasty technique. Methods A retrospective observational study of patients with glottic incompetence after endoscopic laser cordectomy, underwent medialization laryngoplasty with Montgomery or Gore-Tex implant between January 2013 to December 2018 at the Bufalini Hospital of Cesena, Italy. The pre- and postphonosurgery evaluation included videolaryngostroboscopy, perceptual, evaluation of dysphonia with the GRBAS (grade, roughness, breathiness, asthenia, strain) scale, Voice Handicap Index-10, Maximum Phonation Time. The outcome was evaluated 6 months after the phonosurgical treatment. Results We treated 22 patients, 19 males and 3 females. Eight cases were treated with Montgomery implant and fourteen with Gore-Tex implant. The postphonosurgical videolaryngostroboscopy showed an improvement of the glottic closure in all patients; the scores of the Voice Handicap Index-10 and of the Maximum Phonation Time showed a statistically significant improvement after phonosurgery. The GRBAS scale scores showed a statistically significant improvement of Global Grade, Breathiness, and Asthenia; the parameter Strain remained unaltered both in pre- and postoperative evaluations, because the voice was never pressed due to glottic insufficiency, especially in preoperative observation. The parameter Roughness (R) did not show a significant difference between pre- and postoperative evaluation. Conclusion Medialization laryngoplasty is an effective phonosurgical procedure to improve voice outcome, after extended endoscopic laser cordectomies, in patients with unacceptable results after voice therapy and injection laryngoplasty. In our experience the Gore-Tex implant allows the surgeon to perform a safer and more “tailored” phonosurgery in cases of cordectomies type IV and V, associated or not with radiotherapy and in revision surgery.

Summary Introduction Inducible laryngeal obstruction is a common and challenging cause of exertional dyspnea. We report a case of an unanticipated cardiac condition that presented with symptoms suggestive of inducible laryngeal obstruction. Discussion A 55-year-old man was evaluated for progressive exertional dyspnea and throat tightness, unexplained after multiple medical evaluations. Resting laryngeal examination was suspicious for laryngopharyngeal reflux and mild vocal fold adduction during quiet expiration. Given progressive and refractory symptoms, maximal cardiopulmonary exercise testing with intermittent laryngeal examination was performed. This study excluded laryngeal causes of exercise limitation and led to an unexpected diagnosis of persistent atrial flutter and hypertrophic cardiomyopathy. Conclusion Cardiopulmonary exercise testing with laryngeal examination can identify unexpected and life-threatening mimics of inducible laryngeal obstruction that may be missed by unmonitored exercise challenges. Suspicion for inducible laryngeal obstruction at rest may not predict the true nature of exercise limitation on cardiopulmonary exercise testing.

Summary Introduction Vocal cord vibration after transoral CO2 LASER-guided thyroarytenoid (TA) myoneurectomy in adductor spasmodic dysphonia (AdSD) patients is unclear to date. The precise vibratory patterns in AdSD patients are difficult to evaluate with routine videolaryngostroboscopy. High-speed videolaryngoscopy (HSV) is an ideal choice to evaluate such patients. This study was performed to compare pre- and postoperative, after 6 months, vocal fold vibratory onset delay (VFVOD) and closed phase glottal cycle (CPGC) in AdSD patients following transoral CO2 LASER-guided TA myoneurectomy using the HSV. Materials and methods Retrospective study, conducted from January, 2016 to January, 2019, of the AdSD patients who underwent transoral CO2 LASER-guided TA myoneurectomy using the HSV. Patient data were acquired from the hospital database to evaluate VFVOD and CPGC from HSV recordings of the patients. VFVOD was calculated as sum of prephonatory delay (PPD) and steady-state delay (SSD). The PPD and SSD were evaluated and compared separately for each patient. The MedCal Version 19.2.6 was used for data analysis. Paired sample t test was performed to compute the significance of the difference between the mean of the dataset. A P value less than 0.05 was considered significant. Results A total of nine patients were included in the study, out of which three were females and six were males. The average age was 45.5 ± 6.9 years. The mean of postoperative PPD (166.8 ± 22.1), SSD (76.5 ± 8.6), and CPGC (62.6 ± 4.8) were significantly less than mean of preoperative PPD (222.6 ± 22.1), SSD (97.7 ± 9.5), and CPGC (71.6 ± 5 %), with P values of 0.0007, 0.0001, and 0.0001, respectively. Conclusions There was a significant decrease in VFVOD and CPGC posttransoral CO2 LASER-guided TA myoneurectomy in AdSD patients after 6 months follow-up. This study also establishes efficiency of the HSV to measure the vocal cord vibration in the patients with AdSD. The primary limitations of the study were the small sample size and its retrospective nature. Future prospective studies with increased sample size can further substantiate the findings of the work performed here.

Summary Objective Singers undergoing tonsillectomy are understandably concerned about possible sequelae to their voice. The surgical risks of laryngeal damage from intubation and upper airway scarring are valid reasons for singers to carefully consider their options for treatment of tonsil-related symptoms. No prior studies have statistically assessed objective voice outcomes in a group of adult singers undergoing tonsillectomy. This study determined the impact of tonsillectomy on the adult singing voice by determining if there were statistically significant changes in preoperative versus postoperative acoustic, aerodynamic, and Voice-Related Quality of Life (VRQOL) measures. Study Design Prospective cohort study. Setting Tertiary Referral Academic Hospital Subjects Thirty singers undergoing tonsillectomy from 2012 to 2019. Methods Acoustic recordings were obtained with Computerized Speech Lab (CSL) (Pentax CSL 4500) and analyzed with the Multidimensional Voice Program (MDVP) (Pentax MDVP) and Pratt Acoustic Analysis Software. Estimates of aerodynamic vocal efficiency were obtained and analyzed using the Phonatory Aerodynamic System (Pentax PAS 6600). Preoperative VRQOL scores were recorded, and singers were instructed to refrain from singing for 3 weeks following tonsillectomy. Repeat acoustic and aerodynamic measures as well as VRQOL scores were obtained at the first postoperative visit. Results Average postoperative acoustic (jitter, shimmer, HNR) and aerodynamic (sound pressure level divided by subglottal pressure) parameters related to laryngeal phonatory function did not differ significantly from preoperative measures. The only statistically significant change in postoperative measures of resonance was a decrease in the 3rd formant (F3) for the /a/ vowel. Average postoperative VRQOL scores (79.8, SD18.7) improved significantly from preoperative VRQOL scores (89, SD12.2) (P = 0.007). Conclusions Tonsillectomy does not appear to alter laryngeal voice production in adult singers as measured by standard acoustic and aerodynamic parameters. The observed decrease in F3 for the /a/ vowel is hypothetically related to increasing the pharyngeal cross-sectional area by removing tonsillar tissue, but this would not be expected to appreciably impact the perceptual characteristics of the vowel. Singers’ self-assessment (VRQOL) improved after tonsillectomy.

Summary Objectives To introduce a novel surgical technique for the management of posterior glottic stenosis (PGS). Methods Literature review (PubMed 1973-2020) and case example of a patient treated with novel technique by principal investigator (R.T.S.) Results Numerous techniques for the treatment of PGS have had varying success. Our patient, a 67-year-old male with a 2-year history of posterior glottic stenosis secondary to multiple, prolonged intubations previously had been treated with several surgical and medical interventions. Three weeks following an additional endotracheal intubation, he presented to our office with PGS recurrence, exhibiting hoarseness, and shortness of breath with any physical activity. He was treated with a silastic sheet placed through a tunnel in the stenosis and sutured posteriorly as a stent. The stent was removed 3 weeks later and the remaining stenosis was divided, successfully treating our patient's PGS with long-term improvement in both respiratory and voice complaints. This led to the design of a stent to be used for this purpose. Conclusions This new surgical technique addresses a complex clinical problem and provides otolaryngologists with a minimally invasive option for the surgical treatment of PGS that offers advantages over existing techniques. The two-stage procedure should reduce the risk of recurrence, but more experience is needed. This novel implant may be a valuable tool in the treatment of select patients with mild-moderate PGS.

To differentiate arytenoid subluxation and vocal fold paralysis by CT cine mode scanning combined with three-dimensional (3D) reconstruction image.Seventy-six patients with suspected vocal fold dyskinesia were collected. All patients were examined being asked to inhale deeply and then make "Yi" sound continuously during CT scanning with cine mode. The optimal maximum opening and minimum closing phases of glottis were selected and 3D reconstruction images were performed. The length of vocal fold, the width of glottis, and the subglottal convergence angle, anteversion angle, elevation angle, valgus angle, and varus angle of cricoarytenoid joints were measured. Vocal fold deformation was divided into three types: type I, type II, and type III. Kappa test was used to compare the consistency between CT diagnosis and clinical diagnosis. Single-factor analysis of variance was used to analyze the statistical differences among arytenoid subluxation, vocal fold paralysis, and normal vocal fold.There was high consistency between CT diagnosis and clinical diagnosis (k = 0.731, P0.05), as well as significant differences in the opening width of glottis between type I and type III, the valgus and varus angles of cricoarytenoid joints between type I and type II or type III, and the subglottal convergence angles among the three types of vocal fold deformation.CT scanning with cine mode combined with 3D reconstruction can display the changes of larynx structures in vocal fold dyskinesia, and can be used for the differential diagnosis of arytenoid cartilage subluxation and vocal fold paralysis.

Objective To verify the association between vocal perception and Common Mental Disorders (CMD) suspicion in trans women. Methods Cross-sectional observational study including 24 adult trans women with a minimum time of presentation as a woman of six months. The sampling of the subjects was supported by the “Snowball" technique. Three questionnaires were applied for data collection: sociodemographic and health data, Self-Reporting Questionnaire (SRQ-20) and Trans Woman Voice Questionnaire (TWVQ). The sociodemographic and health data collected were: age, marital status, education, smoking habits, speech therapy, use of hormones, and whether they had undergone Sex Reassignment Surgery (SRG). SRQ-20 was used for suspicion of CMD evaluation, such as depressive and anxiety symptoms. TWVQ is a vocal self-report questionnaire for trans women living the full-time gender role in which they self-identify. TWVQ has a minimum score of 30 points and a maximum of 120 points. Higher scores are associated with perceptions of a higher frequency of voice-related difficulties and psychosocial impacts. For statistical analysis, data were analyzed descriptively and statistically using Fisher's and Mann-Whitney's exact tests, both with a significance level of 5%. Results The average participants’ age in this study was 28.2 years old (SD = 6.5 / minimum = 21 and maximum = 48); 83.3% were single; most (41.7%) were high school graduates; and most (95.83%) had not undergone Sex Reassignment Surgery. All subjects reported using hormones; 37.5% were smokers; 4.2% had undergone speech therapy; and the average number of years of experience in the female role was 8.8 years (SD = 7.2). The average TWVQ score was 55.4 points (SD = 4.3). Through SRQ-20, it was verified the prevalence of suspected CMD in 58.3% of the participants. The study results indicated that communicative dissatisfaction in trans women due to inconsistent voice with the recognized gender is associated with probable CMD such as depression and anxiety (P= 0.001). Conclusion Trans women who reported greater difficulties and voice-related effects in their lives had more symptoms of anxiety and depression. Although more research is needed, results indicate the need for inter-professional preventive and therapeutic actions directed towards assisting trans women. This fact encourages reflection on the care of this population and the role of health professionals, enhancing scientific production, clinical practice and the inclusion of the “transsexuality” theme in Speech Language and Hearing Sciences.

Summary Background The field of laryngology has grown exponentially since the advent of the transnasal flexible laryngoscopy. Flexible laryngoscopy when performed skillfully using the proper technique, facilitates a good view of the hidden areas of the larynx. Objective To compare the effectiveness of the topical agents in providing a more comfortable experience for the patient, allowing the practitioner to advance the endoscope with less friction, pain and discomfort for the patient using 10% lidocaine spray, 2% lidocaine gel, 4% lidocaine with xylometazoline (1:1) soaked pledgets, or aqueous gel. Materials and Methods A prospective randomized single-blinded clinical trial was conducted in a tertiary care teaching hospital in South India where 376 patients were recruited and allocated into four groups based on the topical preparation used. Following endoscopy, each subject filled a questionnaire grading their experience on a visual analogue scale. The clinician also then answered a questionnaire on aspects of the endoscopy performed. Results The pain score and the ease of performing the procedure among the different groups were comparable. Those in the 10% lidocaine arm experienced significant burning sensation (P = 0.0001). The other variables such as throat pain (P = 0.783), gag reflex (P = 0.318), unpleasant taste (P = 0.092), globus (P = 0.190), swallowing difficulty after the procedure (P = 0.273), difficulty in breathing (P = 0.744) and willingness to have a repeat procedure (P = 0.883) were also comparable. Conclusion Aqueous gel can be used topically during a flexible nasopharyngolaryngoscopy instead of an anesthetic agent alone or one combined with a nasal decongestant.

Summary Objective The aim of this study is to explore the accuracy of two different approaches: transoral versus transnasal office-based laryngeal biopsy. Design Cohort-selection cross-sectional study. Setting Outpatient clinic of Phoniatrics in El Demerdash Hospital, faculty of medicine, Ain Sham University, Cairo, Egypt). Participants The study included all patients aged 18 years or more with suspicious lesions of the larynx or the oropharynx who are eligible for biopsy who came to the outpatient clinic due to different reasons during the period of March 2017 and March 2020. Main outcome measures Patients with suspicious lesions were referred for office-based-based biopsy—either transnasal biopsy or transoral biopsy. All patients were referred for subsequent direct laryngoscopy for definitive diagnosis. Results The overall sample was 60 cases with 30 in each group. The majority of both groups were smokers. The most frequent cause of referral for biopsy was suspicious laryngeal mass. The number of biopsies obtained was significantly higher in the transoral group. Both approaches were tolerated by all patients with few limited aspiration or epistaxis. The sensitivity of the transoral approach was compared with that of direct laryngoscopy and was 95.8% with a specificity of 83.3%. The sensitivity of the transnasal approach was compared with that of direct laryngoscopy and was 26.3%; the specificity was 90.9%. Conclusion The transoral approach to obtaining a biopsy from the upper aero-digestive tract has better diagnostic accuracy than the transnasal approach when combined with transnasal visualization and transcricothyroid anesthesia.

The aim of our study is to evaluate objective and subjective vocal outcomes in patients undergoing vagus nerve stimulation (VNS) therapy for drug-resistant epilepsy and to assess the vocal outcome in the known laryngeal dysmotility patterns induced by VNS. We enrolled 16 adult patients without cognitive impairment who had undergone VNS implant for drug-resistant epilepsy at least 1 year prior. They were evaluated by flexible fibreoptic laryngeal examination and Voice Handicap Index questionnaire administration; acoustic and perceptual voice analysis was performed both at rest and during VNS activation. All recruited patients were admitted to the study. The VNS implant systematically determined laryngeal motility alterations, which were in turn mirrored by perceptual, subjective, and/or acoustic analysis voice alterations in all patients. Patients with intact vocal fold function at rest performed worse during acoustic voice analysis in terms of jitter during VNS activation and shimmer at rest when compared to other laryngeal patterns (P= 0.027 and P = 0.034, respectively, Kruskal-Wallis test). Furthermore, VNS activation determined an overall worsening of the perceptual and acoustically analysed voice quality: the grade of hoarseness, instability and breathiness parameters of the GRBASI (grade, roughness, breathiness, asthenia, strain, instability) scale and the jitter, shimmer and noise-to-harmonic ratio of the acoustic analysis worsened significantly during VNS activation (P = 0.001, P = 0.021, P = 0.012, P.001, P = 00.002, P = 0.039, respectively, Wilcoxon test). According to our results, the VNS implant determines a significantly impaired vocal outcome that has a surprisingly mild impact on Voice Handicap Index scores. Such impairment is significantly greater in patients with intact vocal fold function at rest.

Summary Objective/Hypothesis There is an increased need for vocal education programs in group fitness instructors due to the reported risk of phonotraumatic injury in this population. Most research has focused on aerobics class instructors with limited research detailing the vocal demand response of cycling instruction, specifically. We hypothesized that instruction of a single indoor cycling class would produce evidence of acute vocal fold edema manifested by worsening of acoustic and self-perceptual voice measures and changes in ratings of laryngeal appearance. Study Design Prospective Cohort study. Methods Acoustic and self-perceptual voice measures that were potentially sensitive to laryngeal edema were collected from ten cycling instructors (Mean age: 31 ± 6.14 years, 3M and 7F) before and after instruction of a typical 45-minute cycling class. Two laryngologists then rated pairs of laryngeal exams from five instructors (Mean age: 30 ± 6.22 years, 1M and 4F) on the measure of vocal fold edema using a 10-inch Visual Analogue Scale. Paired t-test comparisons were completed on normalized data to compare pre- and postinstruction. Results Majority of acoustic and self-perceptual measures significantly worsened following cycling instruction but the magnitude of change in these measures were small. In terms of laryngeal appearance, no measurable change in vocal fold edema was observed at both time points. Conclusion The vocal demand response to a single cycling class may be insufficient to cause significant vocal fold edema in our cycling instructors. Future research is required to determine the effects of repeated cycling instruction.

Summary Objective Tessitura—the habitual pitch range of a musical piece or role—is widely accepted as a significant factor in determining whether a singer should perform a given piece or role. However, attempts to quantify tessitura have historically relied on laborious hand calculations. The current study introduces a novel MATLAB program (“Tessa”) that automates tessitura analysis of digital sheet music in the MusicXML format. This program will allow voice teachers and singing voice specialists to assess the appropriateness of musical pieces or roles for their students and clients. Methods Tessa converts sheet music in the open-source MusicXML (MXL or XML) format to a MATLAB-compatible structure array (MAT). Once converted, the program extracts pitch, duration, and lyric information from the structure file, then saves relevant arrays to the user's computer. Finally, Tessa performs analyses on the piece's tessitura data, including histogram, box plot, and descriptive statistical analyses. Variables such as tempo, score part number, and the piece's title are automatically saved in order to facilitate repeated analyses. Results A sample analysis of Franz Schubert's song cycle Winterreise, D.911 is presented, with specific reference to the songs “3. Gefrorne Tranen” and “4. Erstarrung” as examples of pieces with markedly different tessituras—and, consequently, markedly different levels of vocal demand. Discussion Tessa is hosted on a GitHub repository ( https://github.com/Allerseelen/Tessa ) and is intended for open-source use and modification under the GNU General Public License v3.0. Voice teachers, singing voice specialists, and musicians may compare Tessa's analyses with voice range profiles or other assessment tools in order to evaluate repertoire and plan pacing strategies for extended performances.

Summary Background The aim of our study was to determine the presence and pattern of ventricular hyperadduction (VH) following unilateral vocal fold (VF) paralysis/paresis and that following unilateral cordectomy (UC). Methods The authors independently reviewed charts and flexible videostroboscopic recordings of 214 patients diagnosed with unilateral VF paralysis/paresis and those who had undergone UC from 2015 to 2018. The presence and pattern of VH was noted. VH was considered to be present when the false vocal fold (FVF) obliterated 50% or more of the true vocal fold width during phonation, with or without FVF vibration. The true vocal fold width was considered to be that which was visible on abduction of the VFs. Categorical variables were presented in numbers and percentages and qualitative variables were correlated using Chi-Square test. Odds ratio with 95% Confidence Interval was calculated. Results In 154 patients diagnosed as unilateral VF paralysis/paresis 85 patients had a VH pattern (55.19%) with contralateral VH observed in 74 (87.05%), ipsilateral VH observed in 6 (7.05%) and bilateral VH observed in five patients (5.88 %). The total number of patients of UC was 60 with 36 of these patients developing a VH (60%). Ipsilateral VH was observed in 28 of these 36 patients (77.77%), three patients developed contralateral VH (8.33%) and five patients developed bilateral VH (13.88%). Conclusion Ipsilateral ventricular hyper-adduction following unilateral cordectomy in the group of patients that develop hyperadduction is a significant finding in our study suggesting possibility of unilateral central phonatory control of the FVF. Contralateral ventricular hyper-adduction following unilateral paralysis and paresis, in the group of patients that develop hyperadduction is a significant finding in our study and this finding resonates with previously published papers. A finding of unilateral VH may serve as a possible indicator of the occasionally challenging diagnosis of vocal fold paresis. Study type : Retrospective, Observational

Summary Objective Maximum phonation time (MPT) is a test to measure glottic efficiency for laryngeal pathology screening and treatment monitoring. The normative value of MPT for South East Asia population has yet to be reported. It is postulated that MPT may be affected by body mass index (BMI) despite the paucity of evidence. Therefore, this study was designed to establish the normative value of MPT for a South East Asia population and investigate its relation to BMI. Design & Setting This cross-sectional study was conducted in Universiti Kebangsaan Malaysia Medical Center between May and September 2017. Participants and Methods Three hundred males and females with mean age of 30.23 (±11.04) years were recruited in equal number for each gender (n = 150) and divided into 3 groups of 50 according to their BMI (n = 50). The three groups are non-obese (BMI≤22.9kg/m2); obese (BMI between 23 and 34.9 kg/m2); and morbidly obese (BMI >35kg/m2). BMI and Voice Handicap Index-10 (VHI-10) were obtained. The average of three readings of MPT was measured using a stopwatch while the participants phonate /a/, /i/ and /u/. Unpaired t-test and ANOVA were used to compare means between and across groups. Spearman correlation assessed the correlation between MPT and BMI. Main outcome measures The normative values of MPT of both genders and correlation with BMI were analyzed. Results The MPT normative values for males and females in the non-obese group were of 21.41 (±6.85) seconds and 18.05 (±5.06)seconds respectively for /a/. The MPT for all vowels were significantly higher in males across the BMI groups (P ≤ 0.05). There was low negative correlation between MPT and BMI in both genders. Conclusions This pioneering study documented the normative values of MPT among Malaysians showed that males had longer MPT than females across the BMI groups. Obesity affects the MPT in that as BMI increases, the MPT decreases.

Summary Objective To verify the immediate effects of voiced gargling on the electrical activity of extrinsic laryngeal muscles and vocal self-assessment. Methods A sample of 20 individuals of both sexes, mean age of 31.95 (±11.57) years, were equally divided in two groups according to the presence or absence of vocal complaint. Both groups were evaluated by surface electromyography of the suprahyoid (SH) and infrahyoid (IH) muscle areas during rest, phonation of the sustained vowel [Ɛ] in habitual and strong intensities; phonation of rising and falling glissando; and counting from 1 to 10. Surface electromyography was assessed before and after the voiced gargling exercise, which lasted 1 minute. All participants self-rated their voice and phonatory comfort after the exercise. Wilcoxon and Mann-Whitney tests were applied, as well as Fisher's exact test and linear-to-linear test. The level of significance was 5%. Results The percentage of electrical activity of the SH muscle area decreased in the glissando and counting tasks in the group with vocal complaint, as well as in phonation of sustained vowel in strong intensity in the group without complaint. Decrease was also observed in the right IH muscle area at rest and during sustained vowel phonation at habitual and strong intensities. Percentage of muscular electrical activity was lower in the group with complaint in the following situations: IH muscle area on both sides, at rest and during habitual phonation of sustained vowel and glissando before and after the exercise; right IH muscle area, during counting and strong phonation of sustained vowel before and after exercise; left IH muscle area, in the counting task, just after intervention. Most participants noticed improvement in voice (70%) and phonatory comfort (65%). Conclusions Voiced gargling during 1 minute promotes immediate effects on the electrical activity of the extrinsic laryngeal muscles in individuals with or without vocal complaint. Most individuals reported improved voice and phonatory comfort after exercise.

Summary Objectives Evaluation of trends and utilization of speech-language-pathology (SLP) services, including stroboscopy, before and after medialization laryngoplasty (ML) over 11 years. Methods Retrospective national US database study conducted using OptumLabs Data Warehouse. Study cohort included patients (age ≥18 years) who underwent ML between January 2007 and December 2016. Primary outcomes were rates of SLP visits in the 12 months before and 12 months after ML. Linear regression analysis was performed assessing for trends utilization across years. Secondary outcomes were predictors of utilization After-ML using multivariable logistic regression. Results 1114 patients met criteria. Services, including stroboscopy, were utilized by 774 (69%) Before-ML and 697 (63%) After-ML. SLP services, excluding stroboscopy, were utilized by 512 (46%) Before-ML and 478 (43%) After-ML. Vocal cord paralysis was the most common diagnosis, 945 (84.8%) patients. Other service billed were stroboscopy, [Before-ML 676 (60.7%); After-ML 567 (50.9%)], voice evaluation [Before-ML 431(38.7%); After-ML 366 (32.9%)], voice therapy [Before-ML 309 (27.7%); After-ML 339 (30.4%)], laryngeal function studies, [Before-ML 175 (15.7%); After-ML 164 (14.7%)], swallow evaluations [Before-ML 150 (13.5%); After-ML 90 (8.1%)], and swallow therapy [Before-ML 53 (4.8%); After-ML 47 (4.2%)]. SLP utilization Before-ML predicted SLP utilization After-ML [Odds Ratio (95% Confidence Interval): 9.31 (6.78, 12.77)]. Nearly half (49%) of visits occurred in the 6 months around ML. Of those who had voice therapy, the majority (73.7%) had a total of 1 to 5 sessions. Conclusion Based on this retrospective US national database study, SLP services and stroboscopy are a complementary component of assessment and treatment of patients who undergo ML with the majority of services occurring in the 3 months before and after ML. Future work would benefit from outcome data.

Summary Objective To investigate sex bias in laryngology research and publishing. Materials and Methods Articles published in 2019 in seven mainstream otolaryngology journals were reviewed. Original manuscripts were included. Study type (medical, speech-language pathology, basic science, or pedagogy), subject sex, ≥50% sex-matching (SM≥50), sex-based analysis, and bibliometric data including author sex were recorded. Results Of 1619 publications reviewed, 259 patient-centered original laryngology studies were included, totaling 7,130,991 subjects (3,411,741 [47.8%] male; 3,718,694 [52.1%] female; 556 [0.0%] unreported). 29 studies included subjects of a single sex and 14 did not report sex. 114 (44%) studies met SM≥50, and 95 (37%) used sex-based analysis; no differences were found among study types or location. Sex-based analysis was used less in single-institution (33%) than database studies (62%, P = 0.01). No difference in SM≥50 was found among single or multi-institution, or database. There were 1340 total authors (578 [43%] female). First, corresponding, and senior authors were 47%, 39%, and 35% female, respectively. Studies that had female first and/or senior authors did not differ in rates of SM≥50 or sex-based analysis or mean enrollment of females compared to studies with male first and senior authors. The proportion of female physician first and senior authors did not differ from the proportion of female Association of American Medical Colleges otolaryngology faculty, but was non-significantly smaller than the proportion of female laryngology fellows at four academic institutions. Conclusion Laryngology research exhibits sex bias in subject enrollment and sex-based analysis. Female authorship was representative of national demographics and author sex did not influence the rate of sex bias.

Summary Objectives (1) To describe a combination voice rest and steroid regimen to clarify ambiguous diagnoses in singers who present with phonotraumatic lesions and (2) to determine which videostroboscopic parameters show the most consistent response to this regimen. Study Design Chart review. Methods Singers with phonotraumatic vocal fold lesions seen at a tertiary care voice center over a 10-year period were identified. Those who had uncertain diagnoses on initial presentation, completed a combination regimen including voice rest and steroids, and had follow-up examinations were included in the analysis. The effect of this combination regimen was assessed by ratings of pre- and postregimen videostroboscopy examinations and by auditory perceptual ratings. Whether the combination regimen clarified the diagnosis was noted. Results Twenty-nine singers were prescribed the combination regimen with the intent to clarify the diagnosis. In 79% (23/29) of these singers, the regimen helped clarify diagnosis, for example, ruling in or ruling out specific lesions, confirming areas of scar, or distinguishing acute from chronic phonotraumatic injury. Stroboscopic exams were improved in 86% (25/29). The most common stroboscopic finding was a reduction in the lesion size (66%). Auditory perceptual ratings improved in 48% (14/29) of patients. Conclusions A “cool down” combination of voice rest and steroids can improve diagnostic clarity in a subset of singers with phonotraumatic lesions. This combination regimen can be considered, with both the side effect profile of steroids and possible financial ramifications of strict voice rest in mind, when the initial diagnosis is unclear.

Made available in DSpace on 2021-06-25T10:56:45Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-01-01 Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) Smith–Magenis syndrome (SMS) is a rare neurodevelopmental disorder with mild-to-moderate intellectual disability. Speech and language impairments have not been well described as part of the SMS phenotype. This study reports the speech and language characteristics presented by a classical SMS case, a 20-year-old woman with positive deletion in the region 17p11.2. The case presented a borderline IQ on verbal and performance Wechsler scales. Language standardized tests (i.e., Peabody, Token test, CEG test and Boehm test) and naturalistic language sample (i.e. conversation and story generation) were used to assess speech and language performance. Speech characteristics included imprecise speech, with a high speech rate, hoarse voice, hypernasality and intelligibility deficits. The performance in all standardized tests was poor. Socio-communicative deficits included repetitive and persistent verbal behavior, difficulties in the use of linguistic strategies to repair communication breakdowns, limited vocabulary production and short overall length utterances with reduced grammatical components. The results contribute to expanding knowledge about the SMS phenotype, also to highlight the need to include speech and language evaluation as part of the clinical assessment of SMS and, at the same time, to draw attention to the need to include early communications skills in language intervention programs. Departamento de Lingüística Facultad de Filosofía y Letras Universidad autónoma de Madrid Universidad Autónoma de Madrid Universidad de Castilla La Mancha Centro de Educación Superior CUNIMAD Universidad de Alcalá de Henares, Calle de Almansa 101 Departamento de Fonoaudiologia Faculdade de Filosofia e Ciências (FFC) Universidade Estadual Paulista (UNESP), Campus de Marília Departamento de Fonoaudiologia Faculdade de Filosofia e Ciências (FFC) Universidade Estadual Paulista (UNESP), Campus de Marília CNPq: Pq-CNPq 2013-2016

Summary Objective Vocal process granuloma (VPG) has a varied treatment success rate and may frustrate patients and physicians due to poor outcomes. There is still a lack of standard protocols to manage VPG. This study aimed to review the efficiency of a standardized low-dose laryngeal electromyographic (LEMG)-guided botulinum toxin A (BTA) injection in intractable vocal granulomas. Methods Twenty-four patients with intractable VPG were recruited. All patients underwent percutaneous LEMG-guided BTA injection on the thyroarytenoid-lateral cricoarytenoid muscle complex in an office setting. The injecting dose was standardized to 1 U in 0.1 mL normal saline at a time. We evaluated the treatment effect by measuring the lesion size with serial laryngoscope evaluations. Results The postinjection follow-up time varied from 3 to 23 months. Twenty-one patients (87.5%) experienced complete regression of the granuloma over 1–7 months (median 3 months). No major adverse effects were noted during the follow-up period. Conclusion For recalcitrant VPG, LEMG-guided low-dose BTA injection has the potential to be a safe, efficient, and effective treatment.

Summary Objective Dyspnea is a primary characteristic of exercise-induced laryngeal obstruction and prevents individuals from inhaling and exhaling without effort. This single subject research study investigated the effects of inspiratory muscle training (IMT) on exercise-induced symptoms characteristic of exercise-induced laryngeal obstruction in adolescent athletes. Methods Five weeks of IMT was provided to five adolescent athletes, four females and one male, aged 10 to 16. Variables that were measured prior to, during, and after completion of IMT program included maximum phonation time, maximum perceived breathlessness, duration of running, and quality of life regarding dyspnea. Results Results showed a reduction in maximum perceived breathlessness as well as a significant increase in maximum phonation time across participants. The majority of participants rated their quality of life regarding dyspnea as significant improved after IMT. Conclusions These findings contribute to the increasing body of literature investigating the use of alternative therapy strategies for treatment of symptoms of exercise-induced laryngeal obstruction in adolescent athletes.

Summary Objective Semioccluded vocal tract (SOVT) exercises are routinely included in many voice therapy programs because they have been shown to improve acoustic, aerodynamic, and patient-reported voice outcomes. One limitation of the traditional SOVT exercise is that the nature of phonation through straws or semioccluded oral postures allows only for single phoneme production. A variably occluded facemask (VOFM) allows for use of articulated connected speech beyond the production of single phonemes, while still providing occlusion and, presumably, the vocal efficiency benefits that arise from it. This study reports on the effect of time duration of phonation with a variably occluded facemask on voice outcomes in patients with voice disorders. Design Prospective, randomized cohort study. Methods Fifteen patients with voice disorders phonated for 5 minutes through a VOFM with diameter openings of 3.2, 6.4, and 9.6 mm. Acoustic and aerodynamic voice measures were collected before and after each occlusion trial. These results were compared to a historical patient group that received the same phonation training for 2 minutes. Results Positive effect sizes were found for acoustic and aerodynamic improvements for all patients for at least one occlusion diameter. Effect sizes for aerodynamic outcomes were greater in the 5-minute conditions for both the 9.6- and 6.4-mm occlusions than the 2-minute condition. Effect sizes for acoustic outcomes were greater in the 5 minute than 2-minute trial for the 9.6- and 6.4-mm occlusion diameter, but greater in the 2 minute than 5-minute trial for 3.2-mm diameter. Discussion This study provides evidence that all three occlusion sizes may elicit beneficial changes for different patients; however, 5 minutes of phonation into a facemask with end occlusion of 6.4-mm diameter results in improved acoustic and aerodynamic voice outcomes for many patients with voice disorders. Future studies should further explore phonatory physiologic changes of the VOFM in a larger sample of patients and translate effects into clinical treatment for patients with voice disorders.

Summary Objectives/Hypothesis To determine predictors of voice therapy initiation. Study Design Cross-sectional cohort study. Methods All patients were evaluated in an interdisciplinary model at the University of Wisconsin Voice and Swallow Clinics between June 2016 and October 2017. Patients were eligible if they were diagnosed with a voice disorder and recommended for voice therapy as the only treatment. The dependent variable was attendance in at least once voice therapy session. Independent variables included therapeutic alliance, measured using the Session Rating Scale, and patient- and disease-related factors. These factors included gender, age, distance to the clinic, education level, household composition, occupational voice demand, Voice Handicap Index score, auditory-perceptual dysphonia severity (Grade, Roughness, Breathiness, Asthenia, Strain), and medical voice diagnosis. Results Ninety-five patients were enrolled in the study. Voice therapy initiation rate was 70%. Having fewer school-aged children (5-18 years) in the household was significantly different between the group that initiated voice therapy and the group that did not (P = 0.048). There was no difference between groups for all other factors. Conclusions This investigation suggests that household composition, specifically having fewer school-aged children in the household, may predict initiation of voice therapy. This study confirms in a prospective fashion the absence of relationship between voice therapy initiation and most patient- and disease-related factors. Therapeutic alliance should be further investigated for its ability to predict voice therapy initiation using a measure that is validated for the population of patients with dysphonia.

Injection laryngoplasty (IL) is performed to reduce the gap between vocal folds induced by unilateral vocal fold paralysis (UVFP). Voice quality after IL may be different due to other factors that influence voice quality. Voice therapy has been reported to improve voice quality after IL in patients with UVFP. This study evaluated the efficacy of voice therapy combined with IL.Patients with UVFP who underwent IL as primary therapy from March 2017 to June 2019 were evaluated. The enrolled patients were divided into two groups, those who did and did not receive voice therapy after IL. Voice quality was evaluated using perceptual, acoustic, and aerodynamic parameters, and voice handicap index-30 scores one month after IL and after completing each treatment.Of 261 patients who underwent IL during the study period, 40 were enrolled, including 21 who did and 19 who did not receive voice therapy. Voice parameters one month after IL did not differ between these two groups. Jitter, shimmer, noise-to-harmonic ratio, and mean flow rate decreased, while maximum phonation time increased after voice therapy (both P0.05). In the absence of voice therapy, improved voice parameters were maintained for six months after IL. Total voice handicap index-30 scores decreased, from 35.6 to 19.1 (P0.05), in patients who received voice therapy.Voice therapy following IL is beneficial to patients with UVFP. Combined treatment can help to maintain improved voice quality more than six months after IL.

AIM To determine which acoustic parameters may be associated with vocal fatigue among college professors in Bogota-Colombia. METHOD This was a cross-sectional study including 27 voice samples of college professors. RESULTS A gender analysis showed that mean fundamental frequency increased significantly among men and women who reported vocal fatigue compared with the those without fatigue (138.2Hz vs 122.3Hz for males; and 228.7Hz vs 188.9Hz for females; Mann-Whitney U test P value

Summary Objectives Laryngeal Botulinum Toxin injection (LBTX) in the adductor musculature is the current therapy for Adductor Spasmodic Dysphonia. This study explores nonbiological factors that can affect the patient experience during this procedure and their association with better or worse self-reported effectiveness. Methods A 14 item survey was used to evaluate the patient experience in patients who had undergone LBTX in Mayo Clinic Jacksonville, Florida, during 2019. Information from the survey, previous medical history, and demographic data were collected, and a descriptive analysis was performed. Results Of the 36 patients who participated, the mean age was 65 years and a female predominance was found (66%). The average age at onset of symptoms was 57 years, and voice tremor was associated with 36.1% of patients. Preprocedure education was recognized as a factor affecting outcomes in 87% of patients; 11 patients reported that body position used during the injection could affect the results. Pain or stress experienced at the time of procedure was referred in one-third of patients as an influencing factor too. Conclusion This study has shown that nonpharmacological factors such as education before the procedure, body position, pain, and stress sensation before LBTX may have a role in the botulinum toxin effect on Adductor Spasmodic Dysphonia patients. This study is the first to describe these variables qualitatively, and further studies may help to improve the patient experience and outcome of LBTX around the world.

Summary Background and objective Presbyphonia is an age-related voice disorder characterized by vocal fold atrophy and incomplete glottal closure during phonation. The extent to which the effects of presbyphonia may be compounded by age-related declines in the respiratory system and further impact communication and quality of life remains unknown. Therefore, the objective of this study was to determine how variations in respiratory function impacts voice measures in a sample of participants with presbyphonia. Methods In this pilot study, 21 participants with presbyphonia underwent respiratory assessments (spirometry and respiratory muscle strength testing) and voice assessments (videostroboscopy, acoustic analysis, auditory-perceptual ratings, aerodynamic assessment, and self-assessments). Factor and cluster analyses were conducted to extract voice and respiratory constructs and to identify groups of participants with similar profiles. Correlations and regression analyses were conducted to better describe the relationships between voice and respiratory function. Results Respiratory function was found to impact voice via two main pathways: through its physiological effect on voice and through its impact on general health and impairment. A lower respiratory function was associated with a lower vocal fold pliability and regularity of vibration and with an elevated aerodynamic resistance accompanied by laryngeal hyperfunction. Standardized measures of respiratory function were associated with perceived voice-related handicap. Respiratory function did not associate with voice quality, which was mostly influenced by the severity of vocal fold atrophy. Conclusion Poor respiratory health exacerbates the burden of vocal fold atrophy and, therefore, implementation of respiratory screening prior to starting voice therapy may significantly affect the treatment plan and consequently the outcomes of voice therapy in this patient population.

Summary Objective Several techniques have been practiced in the field of voice therapy to balance glottal pressures and improve glottal adduction. As such, Semioccluded Vocal Tract Exercises using narrow diameter straws have shown promise as a technique to increase glottal contact as reflected by Closed Quotients (CQ) measured from electroglottograph (EGG). This study explored the effect of nasal resistance (NR) technique, a manually induced NR approach, on glottal adduction in phononormal subjects as a possible new therapeutic technique to assist in glottal closure. Subjects Thirty-four vocally healthy adult females qualified for this study. All subjects were reportedly and perceptually normal. Methods Subjects were instructed to perform tasks including (a) steady modal phonation, (b) straw phonation, (c) humming, and (d) NR technique in a random order. EGG measures included calculation of the CQ and jitter during the mid-section of each stimuli for a minimum of 10 EGG cycles. One-way repeated measures ANOVAs and Bonferroni post-hoc comparisons were calculated to determine differences between each phonatory task for the outcome measures of CQ and jitter. Results Analyses revealed that the mean CQ was significantly different in all the tasks performed with humming (33.99%) at the lowest and NR technique at highest (43.88%). Though the CQ of straw phonation (40.53%) was higher than modal steady phonation (36.65%), jitter was found to be significantly lower for NR technique (0.23%). Jitter during straw phonation (0.43%) did not differ significantly from modal phonation (0.44%). Conclusion These results provide preliminary evidence that NR technique can increase CQ with lower levels of jitter compared to straw phonation using a narrow diameter of 2 mm. Future studies should expand enrollment to men, larger age ranges, and patients with hypofunctional symptoms (eg, Parkinson disease) to evaluate the potential benefits of NR as a therapeutic technique.

To report the outcome of unsedated office based Thulium laser therapy for Reinke's edema.A retrospective chart review of patients operated between March 2017 and November 2018 was conducted. Twelve patients were included, two of whom had two procedures performed. Demographic data included age, gender, smoking status, and grade of Reinke's edema. Outcome measures included Voice Handicap Index-10 (VHI), perceptual evaluation, extent of disease regression, acoustic analysis, and maximal phonation time.Twelve patients were enrolled in this study, one of whom was lost for follow-up. There were eight females and three males. The mean age was 51.27 ± 9.12 years. Endoscopic evaluation 6-12 weeks after surgery revealed complete and partial regression of disease in three and eight patients, respectively. There was a significant improvement in the mean score of VHI-10 (15.00 ± 9.45 vs 3.07 ± 3.81) and the mean score of GRABS parameters following surgery (P0.05). The mean habitual pitch increased from 125.11 ± 28.48 Hz to 155.86 ± 55.14 Hz (P = 0.070). There was improvement in the mean jitter and shimmer but none reached a statistical significance. There was no significant change in the mean Maximum phonation time (MPT) scores before and after surgery.Unsedated office-based Thulium laser therapy can be considered as an alternative therapy to patients with Reinke's edema who are not willing to undergo conventional microlaryngeal surgery.

Voice signal classification in three types according to their degree of periodicity, a task known as signal typing, is a relevant preprocessing step before computing any perturbation measures. However, it is a time consuming and subjective activity. This has given rise to interest in automatic systems that use objective measures to distinguish among the different signal types. The purpose of this paper is twofold. First, to propose a pattern recognition approach for automatic voice signal typing based on a multi-class linear Support Vector Machine, and using rather well-known parameters like Jitter, Shimmer, Harmonic-to-Noise Ratio, and Cepstral Prominence Peak in combination with nonlinear dynamics measures. Two novel features are also proposed as objective parameters. Second, to validate this approach using a large amount of signals coming from two well-known corpora using cross-dataset experiments to assess the generalizability of the system. A total amount of 1262 signals labeled by professional voice pathologists were used with this purpose. Statistically significant differences between all types were found for all features. Accuracies over 82.71% were estimated in all intra-datasets and inter-datasets using cross-validation. Finally, the use of posterior probabilities is proposed as a measure of the reliability of the assigned type. This could help clinicians to make a more informed decision about the type assigned to a voice. These outcomes suggest that the proposed approach can successfully discriminate among the three voice types, paving the way to a fully automatic tool for voice signal typing in the future. Fil: Miramont, Juan Manuel. Universidad Nacional de Entre Ríos. Instituto de Investigación y Desarrollo en Bioingeniería y Bioinformática - Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Santa Fe. Instituto de Investigación y Desarrollo en Bioingeniería y Bioinformática; Argentina Fil: Restrepo Rinckoar, Juan Felipe. Universidad Nacional de Entre Ríos. Instituto de Investigación y Desarrollo en Bioingeniería y Bioinformática - Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Santa Fe. Instituto de Investigación y Desarrollo en Bioingeniería y Bioinformática; Argentina Fil: Codino, J.. Lakeshore Professionalvoice Center, Lakeshore Ear, Nose; Estados Unidos Fil: Jackson-Menaldi, C.. Wayne State University, School Of Medicine; Estados Unidos Fil: Schlotthauer, Gaston. Universidad Nacional de Entre Ríos. Instituto de Investigación y Desarrollo en Bioingeniería y Bioinformática - Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Santa Fe. Instituto de Investigación y Desarrollo en Bioingeniería y Bioinformática; Argentina

PURPOSE This study evaluated clinician adherence to the American College of Physicians Best Practice Advice for diagnosis of pulmonary embolism. DESIGN A prospective, single-center, descriptive design was utilized. METHODS A heterogeneous sample of 111 hemodynamically stable adult inpatients with a computed tomography pulmonary angiogram ordered was consented. Electronic medical records were reviewed for demographic and clinical variables to determine adherence. The 6 individual best practice statements and the overall adherence were evaluated by taking the sum of "yes" answers divided by the sample size. RESULTS Overall adherence was 0%. Partial adherence was observed with clinician-recorded clinical decisions rules and obtaining d-dimer (3.6% [4/111] and 10.2% [9/88], respectively) of low/intermediate probability scorers. Age adjustment of d-dimer was not recorded. Computed tomography pulmonary angiogram was the first diagnostic test in 89.7% (79/88) in low/intermediate probability patients. CONCLUSION In hemodynamically stable, hospitalized adults, adherence to best practice guidelines for diagnosis of pulmonary embolism was minimal. Clinical utility of the guidelines in hospitalized adults needs further evaluation. Systems problems (eg, lack of standardized orders, age-adjusted d-dimer values, information technology support) likely contributed to poor guideline adherence.

PURPOSE/AIMS The purpose of this quality improvement project was to examine the use of video-simulated scenarios and mobile technology to improve accuracy of emergency department (ED) nurses' triage using the Emergency Severity Index (ESI). DESIGN A quality improvement project with a pre/post educational intervention design consisting of a convenience sample (n = 33) of ED registered nurses (RNs) at a large tertiary hospital in the Midwest was used. METHODS A retrospective chart review (n = 495) was completed to obtain ESI accuracy for each triage RN. For 12 consecutive weeks, the ED RNs received different video simulations via mobile technology to determine the ESI level. After receiving their scores, the project team provided the RNs the correct ESI score with rationale via mobile technology. Post intervention, a retrospective chart review was conducted to evaluate RNs' ESI accuracy. RESULTS Results of this ED triage educational intervention to improve the accuracy of ED nurses' ESI scores were not significant; however, this novel approach may be considered in addition to other teaching strategies to improve outcomes. CONCLUSIONS Triage nurses' ESI scoring accuracy can be inconsistent. Therefore, to ensure patients are receiving prompt and appropriate care for their acuity level, it is important to continuously provide education on ESI scoring.

Spasmodic dysphonia is a chronic voice disorder that is characterized by involuntary spasms of the laryngeal muscles during speech production. Botulinum toxin injection into to the laryngeal muscles is the most common and effective treatment of choice for symptoms of spasmodic dysphonia. We present a 44-year-old man with adductor spasmodic dysphonia who was diagnosed as having upper airway obstruction in a polysomnographic examination during sleep after a botulinum toxin injection.

Ideally, an analysis method for laryngeal high-speed videoendoscopy (LHSV) based on the glottal area waveforms (GAW) requires images of a complete view of the glottis to ensure findings that are representatives of the vibratory behaviors of the whole vocal folds. However, in practice, the preferred images may not be obtained at all times. Often, the only available images that a clinician has to work with consist of a partial view of the glottis. This study aims to examine the effects of using images of a partial view of the glottis (ie, posterior-middle, anterior-middle, or middle) on the LHSV-based measures (ie, fundamental frequency (F0GAW), frequency perturbation (jitterGAW), amplitude perturbation (shimmerGAW), open quotient (OQGAW), and Nyquist plot). The participants consisted of 9 young normophonic females. The procedures involved LHSV recording of the vibration of the vocal folds. The images of the complete view of the glottis were analyzed to obtain the LHSV-based measures. The same images were used to simulate the images of partial views of the glottis by changing the outline of the region of interest to include only either the posterior-middle, anterior-middle, or middle parts of the glottis. The LHSV-based measures from the images of the partial views were then compared to those with the complete view . The results showed that all LHSV-based measures from the images of the posterior-middle view were similar to those of the complete view. However, only the F0GAW, jitterGAW, and shimmerGAW from the images of the anterior-middle and middle views were similar to those of the complete view. Lower OQGAW and different Nyquist plots than those of the complete view were generated by the images of the anterior-middle and middle views. In conclusion, all LHSV-based measures from the images of the posterior-middle view of the glottis, and only the F0GAW, jitterGAW, and shimmerGAW from the images of the anterior-middle and middle views of the glottis reflect the vibratory behaviors of the whole vocal folds. The same conclusion could not be applied to the OQGAW and Nyquist plots of the images of the anterior-middle and middle views of the glottis. A possible effect of the presence or absence of a posterior glottal gap on the findings warrants further confirmation.

The objective of this study was to determine the immediate effects of transcutaneous electrical nervous stimulation (TENS) and semi-occluded vocal tract (SOVT) exercises on acoustic parameters in teachers in the city of Chillan. The study was based on a quantitative methodological perspective, with a comparative descriptive scope and a quasi-experimental longitudinal design. The sample was composed of 30 teachers belonging to the Reyes de Espana School, who were evaluated using Praat software, pre and post treatment. The teachers were divided into 2 groups; control group (semi-occluded vocal tract therapy) and experimental group (semi-occluded vocal tract therapy and electrostimulation) who were treated during a single session of approximately 10 min. The values of the acoustic parameters were then compared [Jitter, Shimmer, Harmonic to Noise Ratio (HNR) and Maximum Phonation Time (MPT)] between both groups. The acoustic analysis showed statistically significant post-intervention changes in all the parameters evaluated for both study groups, however, in the experimental group the means showed a greater difference, with a p value less than .01. Semi-occluded vocal tract exercises in resonance tubes combined with TENS have immediate positive effects on TMF, Jitter, Shimmer and HNR acoustic parameters in teachers without vocal pathology.

PURPOSE The purpose of this clinical nurse specialist-led initiative was to reduce catheter-associated urinary tract infection rates to less than 1 infection per 1000 catheter days, to reduce catheter device utilization, and to improve staff adherence to documentation requirements on a traumatic brain injury rehabilitation unit. DESCRIPTION OF THE PROJECT Catheter-associated urinary tract infections are costly hospital-acquired infections increasing length of stay and morbidity for patients. Following an education intervention, a best practice initiative was implemented. Staff performance based on electronic health record documentation, infection rates, and device utilization were compared before and after a bundle of interventions including education, staff competency, simulation, and audits. OUTCOMES Catheter-associated urinary tract infection rates were reduced from 16.67 to 0 per 1000 catheter days and device utilization ratio from 0.122 to 0.056 per patient day. The unit maintained zero infections upon project completion. Following initiative implementation, documentation improved related to urinary catheter necessity, daily care interventions, patient education, and urine output. CONCLUSION This initiative resulted in reductions in device utilization and catheter infection rates, which were maintained following project completion. Adherence to documentation audit criteria also improved.

Summary Objectives (1) To describe factors influencing the content, timing, and intensity of pre- and postoperative voice therapy for patients undergoing phonosurgery for benign vocal fold lesions. (2) To understand experts’ rationale for decisions made. (3) To critically analyze factors influencing intervention in relation to the wider literature in order to contribute to the development of a complex intervention. Design Qualitative interview study. Setting Multidisciplinary voice clinics in England. Participants Ten expert voice therapists with a mean of 22 years experience. Main outcome measures Participants were asked to describe factors influencing their current practice and views on optimum treatment for patients undergoing phonosurgery for benign vocal fold lesions. Data were analyzed using the Framework Method of thematic analysis. Results Factors influencing intervention related to four key themes. Pathophysiological, Patient, Therapist, and Service factors influenced the content, timing, and duration of the voice therapy provided. Consensus on core elements included delivering indirect and direct therapy preoperatively to manage underlying causative factors and address patient expectations. Postoperative intervention focused on indirect therapy to facilitate wound healing and direct therapy to improve vibratory characteristics of the vocal fold. Elements of therapy were highly individualized within participants according to the four themes above, but similarity between participants on broad parameters of intervention was high. Conclusions Expert voice therapists use direct and indirect methods pre- and postoperatively to treat patients with benign vocal fold lesions. Optimizing wound healing and mobilization of the epithelium postoperatively are concerns for expert voice therapists which distinguish postoperative patients from other dysphonic patients. This study provides an insight into the factors influencing clinician's intervention provision which can contribute to the development of an optimal pre- and postoperative voice therapy intervention. Further research to refine and test the effectiveness of an intervention is now required.

Muscle tension dysphonia (MTD) is a common voice disorder in teachers in which subjective and objective dimensions of quality of voice can be impaired. The study aimed to compare voice handicap index (VHI) and dysphonia severity index (DSI) in teachers with and without MTD as well as study correlation between them.Cross-sectional survey.Fifty female teachers were enrolled in the study in two different groups (1) twenty-five teachers with MTD (with mean age of 42.62 ± 3.58 years) and (2) 25 teachers without MTD (with mean age of 44.50 ± 3.49 years). All participants completed the Persian version of VHI and underwent multiparametric measurement of voice by the DSI; these subjective and objective voice measures were compared between two groups and their relation was studied.There was significant difference in the VHI, DSI, and their components in teachers with and without MTD (P0.05). No significant correlation was found between the total score of VHI and DSI score in the teachers with MTD (rTeachers with MTD demonstrated higher voice handicap and lower voice quality compared to the teachers without MTD. Moreover, dysphonia interrupted relation between the results of self-perceived evaluation and multiparametric measurement of voice in the teachers with MTD in while these assessments were parallel in the healthy teachers. Further studies are recommended to transparent relation between objective and subjective voice assessments in healthy population.