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ntroduction: The publication describes the characteristics of the glottis in FDs objectified by OQ, measured with VSK and EGG. Aim: The aim of the study was to objectify glottal function in different types of FDs. The scope was to use open quotients gained from various mucosal wave imaging techniques for differential diagnosis of FDs. Material and Method: The study included 204 individuals. In the study, each patient underwent otolaryngological and phoniatric examination. LVS, EGG and VSK were conducted, their results were recorded and stored using an EndoSTROB-DX- -Xion GmbH (Berlin) device with DIVAS software. Results: All patients with FDs had abnormalities in LVS. A statistical analysis showed differences in LVS characteristics according to the type of FD. The mean value of OQVSK was 0.521 in the control group and 0.565 in the study group (P < 0.05). Significant differences were found between patients with hypofunctional – 0.584 and hyperfunctional dysphonia – 0.55. The QOQEGG mean value in patients with FDs was 0.581 and in the control group 0.549 (P < 0.01). There were statistically significant differences between groups of patients with hyper- and hypofunctional dysphonias. Medians amounted to 0.574 and 0.604, respectively. Authors observed different relations of OQ with the type of FD. They decided to introduce a new parameter, illustrating the proportion of QOQEGG/OQVSK. Conclusions: Videostrobokymographic and electroglottographic open quotients differentiate euphony from dysphony. The value of OQVSK and QOQEGG and their proportion varies depending on different types of functional dysphonias. The OQVSK and QOQEGG should be included in the diagnostic algorithm of voice.

Summary Objectives The validity and sensitivity to change of instrumental acoustic measurements in patients with functional dysphonia have been controversially discussed. This work examines combined voice therapy effects on standard acoustic measurements, and if these agree with perceptual and subjective voice outcomes. Study design Retrospective study. Methods Thirty-nine patients (26 women, 13 men) aged 20–70 years (mean: 46.3, standard deviation 12.8) with functional dysphonia were investigated before and after combined voice therapy. Instrumental parameters included mean and range of speaking fundamental frequency (fo) and intensity (SPL (dBA)); maximum SPL and mean fo of calling voice; minimum, maximum, range of singing voice fo and SPL, jitter (%), and the Dysphonia Severity Index. Voice Handicap Index-9 international was used for subjective and Grading-Roughness-Breathiness-Asthenia-Strain scale for perceptual assessment. Differences were investigated by Wilcoxon signed ranks test and coherences by Spearman rank correlation coefficient. Results After treatment, the speaking voice fo range (7–8.13 semitones) and SPL range (12.9–14.85 dB(A)) were significantly larger (P 0.05). Conclusions Significantly improved subjective and perceptual findings verify positive combined voice therapy effects in patients with functional dysphonia. The larger fo and SPL speaking voice range after treatment indicate an altered voice technique. These instrumental measures may be clinical indicators of therapy success and transfer effects.

Objectives: To confirm the data reported in our previous studies on the analysis of the variability of the electroglottographic signal in the pathological voice; to evaluate possible differences in variability between organic and functional pathologies; to identify any distinctive/typical EGG patterns for these pathologies. Methods: One hundred twenty-five subjects were enrolled (36 euphonic and 89 pathological: 24 functional dysphonia, 21 bilateral vocal nodules, 23 unilateral polyps and 21 unilateral cysts). All subjects were studied with videolaryngostroboscopy, spectrographic analysis of voice and electroglottography (EGG). The EGG signal variability was then investigated using amplitude-speed combined analysis, by means of a proprietary software algorithm. Amplitude and Speed variation were expressed as a new parameter, the Variability Index (VI), calculated both for the whole EGG signal recorded (VI-tot) and in each phase of the glottic cycle (VI-Q, absolute value; VI-Q%, percentage value). Results: In the comparison of VI values between pathological and normal groups, VI-tot and VI-Q2% (which corresponds to the final phase of vocal fold contact) were significantly greater in pathological subjects (P= 0.002). The comparison of VI values among subgroups of the various pathologies showed a difference for VI-tot (P< 0.0001) and VI-Q2% (P= 0.001); this difference was more marked in the cysts than in the functional dysphonia. The cut-off values of VI-tot and VI-Q2% were 0.191 and 18.17%, respectively (sensitivity and specificity 65.2% and 66.7% for VI-tot and 84.3% and 77.8% for VI-Q2%). Conclusions: The variability of the EGG signal investigated through the combined analysis of the amplitude and the speed of vibration using a proprietary algorithm software has proved useful not only to distinguish the normal voice from the pathological voice, but also to characterize which phases are more altered in the various voice pathologies studied, both functional and organic. Furthermore, the analysis of the VI parameter allowed to propose cut-off values characterized by a good sensitivity and specificity to discriminate dysphonia from the euphonic voice. Larger groups of patients will be needed to confirm these results.

Objective To update our knowledge regarding the effectiveness of voice therapy for the treatment of vocal disturbance associated with benign vocal fold lesions, including vocal polyps, nodules and cysts, and for determining the utility of voice therapy in treating organic voice disorders, while highlighting problems for the future development of this clinical field. Methods We conducted a review of the most recent literature on the therapeutic effects of voice therapy, vocal hygiene education or direct vocal training on vocal quality, the lesion appearance and discomfort felt by patients due to the clinical entity of benign vocal fold mass lesions. Results Although voice therapy is principally indicated for the treatment of functional dysphonia without any organic abnormalities in the vocal folds, a number of clinicians have attempted to perform voice therapy even in dysphonic patients with benign mass lesions in the vocal folds. The two major possible reasons for the effectiveness of voice therapy on vocal disturbance associated with benign vocal fold lesions are hypothesized to be the regression of lesions and the correction of excessive/inappropriate muscle contraction of the phonatory organs. According to the current literature, a substantial proportion of vocal polyps certainly tend to shrink after voice therapy, but whether or not the regression results from voice therapy, vocal hygiene education or a natural cure is unclear at present due to the lack of controlled studies comparing two groups with and without interventions. Regarding vocal nodules, no studies have investigated the effectiveness of voice therapy using proper experimental methodology. Vocal cysts are difficult to cure by voice therapy without surgical excision according to previous studies. Evidences remains insufficient to support the use of voice therapy against benign vocal fold lesions. Conclusion Evidences at present is therefore still insufficient to support the use of voice therapy for the treatment of benign vocal fold lesions.

Introduction Electroglottography (EGG) is the most commonly used method of indirect visual examination of vocal fold vibration. Aim The study was conducted with an aim of assessing EGG quasi open quotient (QOQEGG) in different functional dysphonias to develop a differential diagnosis. The second aim was to check the influence of articulation on QOQEGG values. Material and methods There were 20 people without voice problems, 20 patients with hypofunctional dysphonia and 20 patients with hyperfunctional dysphonia included in the study. Electroglottography was recorded during comfortable sustained phonation of [a], [e], [i], [o], [u]. Results There were no statistically significant differences in QOQEGG observed during phonation of different vowels in the control group and patients with hyperfunctional dysphonia. In patients with hypofunctional dysphonia, significantly higher values of QOQEGG were observed during [a] and [e]. Both in the control and in studied groups vowel [i] was vocalized significantly quieter. Conclusions To conclude, EGG can be useful in differential diagnosis of functional dysphonia. QOQEGG is a parameter differentiating hypofunctional dysphonia from hyperfunctional dysphonia. Dissimilarities in articulation of different vowels in patients with various types of dysphonia influence values of QOQEGG. EGG study protocol in cases of functional dysphonia should include a comparison of [a], [e], [i] vowels.

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

Summary Objectives Voice therapy with semioccluded vocal tract exercises (SOVTE) has a long history of use in singers and nonsingers with dysphonia. SOVTE with increased vocal tract impedance leads to increased vocal efficiency and economy. Although there is a growing body of research on the physiological impact of SOVTE, and growing clinical sentiment about its therapeutic benefits, empirical data describing its potential efficacy in singers and nonsingers are lacking. The objective of the current study is to evaluate vocal tract function and voice quality in singers and nonsingers with dysphonia after undergoing SOVTE. Methods Patients who were diagnosed with functional dysphonia, vocal fold nodules and age-related atrophy were assessed (n = 8 singers, n = 8 nonsingers). Stroboscopic examination, aerodynamic assessment, acoustic analysis, formant frequency, and self-assessments were evaluated before and after performing SOVTE. Results In the singer group, expiratory lung pressure, jitter, shimmer, and self-assessment significantly improved after SOVTE. In addition, formant frequency (first, second, third, and fourth), and the standard deviation (SD) of the first, second, and third formant frequency significantly improved. In the nonsinger group, expiratory lung pressure, jitter, shimmer, and Voice Handicap Index-10 significantly improved after SOVTE. However, no significant changes were observed in formant frequency. Conclusions These results suggest that SOVTE may improve voice quality in singers and nonsingers with dysphonia, and SOVTE may be more effective at adjusting the vocal tract function in singers with dysphonia compared to nonsingers.

Background There are no reliable outcome predictors for functional dysphonia (FD) patients. Objectives To investigate if any clinical or phoniatric characteristics could identify FD patients at risk of negative outcome after speech therapy. Methods We retrospectively reviewed the results of 78 FD patients treated with the proprioceptive elastic method. Before and one-month after therapy, patients underwent endoscopy, acoustic analysis with Multi-Dimensional Voice Program, and Voice Handicap Index-10 questionnaire (VHI-10). Negative outcome was the persistence of VHI-10 ≥ 13. Results 26 FD patients had negative outcome (i.e. VHI-10 ≥ 13) after speech therapy. At univariate analysis, clinical variables (i.e. sex, age, comorbidities, dysphonia duration, and professional voice use) were not associated with the outcome. Elevated Jitter% (Jitt; p = 0.03), Shimmer% (Shim; statistical trend, p = 0.06), and Noise to Harmonics Ratio (statistical trend, p = 0.06) were found in patients with poor results. At multivariate analysis, higher Jitt was an independent negative prognostic factor (p = 0.02), while a statically trend was identified for Shim (p = 0.06). A panel of Jitt >1.5 and Shim >5.1 showed an acceptable discriminatory power (AUC [ROC] = 0.76) according to Hosmer and Lemeshow scale. Conclusion A panel of two acoustic analysis parameters could help in identifying FD patients at risk of speech therapy failure. Further studies in these patients are needed to evaluate the most efficient treatment protocol.

Confronto dell’indice di variabilità EGG nella voce eufonica e patologica.In un recente lavoro abbiamo presentato un nuovo approccio allo studio del tracciato elettroglottografico; il metodo di studio si basava sulla valutazione della variazione del segnale EGG e della sua derivata prima, mediante un nuovo software ideato dalla scuola foniatrica pisana. Tale software permette di ottenere indici quantitativi relativi alle fasi di contatto e decontatto delle corde vocali durante la fonazione, mediante lo studio della variabilità combinata dell’ampiezza e della velocità di vibrazione (derivata prima del segnale EGG). La voce patologica presenta un segnale EGG più variabile rispetto alla voce normale: la vibrazione cordale è resa irregolare dalla presenza di patologia del piano glottico. Al fine di dimostrare differenze tra voce normale e patologica relative alla variabilità combinata tra ampiezza e velocità di vibrazione, abbiamo introdotto un nuovo parametro quantitativo denominato “variability index, VI”. Abbiamo studiato 95 soggetti (35 normali e 60 con voce patologica); tra i patologici, 15 mostravano disfonia disfunzionale e 45 disfonia organica. I soggetti affetti da disfonia organica presentavano: 15 noduli vocali bilaterali, 15 polipi unilaterali e 15 cisti unilaterali. Tutti i soggetti venivano studiati con videolaringostroboscopia, i parametri elettroacustici della voce venivano analizzati attraverso il sistema KayPENTAX CSL (Model 4500). L’esame EGG veniva effettuato attraverso il KAY Model 6103 collegato al sistema CSL. Il nuovo software di analisi del segnale EGG permette non solo di ottenere un VI totale (VI-total) relativo alla variabilità durante tutta la registrazione, ma anche VI parziali relativi alle varie fasi del ciclo glottico. Applicando la variazione di ampiezza e della derivata prima su un grafico di Lissajous, è possibile dividere l’intero ciclo glottico in 4 fasi (rappresentate da 4 quadranti nel grafico): la fase iniziale di contatto delle corde vocali (VI-Q1), la fase finale di contatto delle corde vocali (VI-Q2), la fase iniziale di de-contatto delle corde vocali (VI-Q3) e la fase finale, fino al completo de-contatto delle corde vocali (VI-Q4). Per ciascun quadrante, inoltre, è possibile calcolare l’indice di variabilità percentuale. Comparando gli indici di variabilità nei gruppi normali e patologici, abbiamo ottenuto i seguenti risultati: il VI totale era significativamente maggiore nel gruppo di soggetti patologici (0,25 vs 0,18; p = 0,01); il valore assoluto di VI in 3 quadranti era maggiore nei patologici anche se non in maniera statisticamente significativa (VI-Q2, 0,041 vs 0,029; VI-Q3, 0,065 vs 0,058; VI-Q4, 0,054 vs 0,052). La variabilità percentuale del quadrante Q2 (VI-Q2%), era significativamente più elevata nei soggetti patologici rispetto ai normali (0,22 vs 0,16) (p = 0,01). I risultati di questo studio hanno confermato che il nostro nuovo software di analisi del tracciato EGG permette di distinguere la voce normale da quella patologica sulla base di un nuovo parametro quantitativo, il VI. Lo studio mette in evidenza come la fase che più caratterizza la differenza tra voce normale e patologica è quella relativa alla fase finale di contatto delle corde vocali, che presenta una maggiore variabilità di ampiezza e velocità di vibrazione. Ulteriori studi, con un numero maggiore di soggetti, saranno necessari per confermare questi risultati e per dimostrare eventuali differenze di variabilità del segnale EGG nelle diverse patologie delle corde vocali.In a recent study we introduced a new approach for analysis of the electroglottographic (ECG) signal. This method is based on the evaluation of variation of the EGG signal and its first derivative, through new software developed by the Pisan phoniatric school. This software is designed to extract quantitative indices related to the contacting and decontacting phases of the vocal folds during phonation. The software allows us to study the combined variability of vibration amplitude and velocity (i.e. the first derivative of the EGG signal). Pathological voices show a much more variable EGG signal compared to normal voices, since cordal vibration is made irregular due to the presence of glottis plane pathologies. With the aim of demonstrating the differences between normal and pathological voices relevant to combined vibration amplitude and velocity variability, we have introduced a new quantitative parameter named “variability index, VI”. We studied 95 subjects (35 normal and 60 with pathological voice); among pathologic subjects, 15 showed functional dysphonia and 45 showed organic dysphonia. Subjects affected by organic dysphonia presented: 15 bilateral vocal nodules, 15 unilateral polyps and 15 unilateral cysts. All subjects were studied with videolaryngostroboscopy; electro-acoustic parameters of the voice were analysed with the KayPENTAX CSL (Model 4500) system. The EGG signal was recorded using KAY Model 6103 connected to the CSL system. The new software for the analysis of the EGG signal allows us to obtain not only a VI total value relevant to variability during all the recording, but also partial VI values relevant to the different glottis cycle phases. In fact, plotting the amplitude variation and its first derivative on a Lissajous graph, it is possible to divide the whole glottis cycle into four phases (each represented by four quadrants on the graph): the initial vocal folds contacting activity (VI-Q1), the last phase of vocal folds contacting (VI-Q2), the first phase of vocal folds decontacting (VI-Q3) and the last phase, up to the complete decontacting of vocal folds (VI-Q4). For each quadrant, it is also possible to work out the percent variability index. By comparing the variability indices in the normal and pathological groups, we obtained the following results: the total VI was significantly higher in the pathological subjects (0.25 vs 0.18; p = 0.01); the absolute value of VI was higher in pathological subjects, although the difference was not significant (VI-Q2, 0.041 vs 0.029; VI-Q3, 0.065 vs 0.058; VI-Q4, 0.054 vs 0.052). The percent variability in the Q2 quadrant (VI-Q2%) was significantly higher in pathological subjects compared to normal subjects (0.22 vs 0.16) (p = 0.01). The results of this study confirm that our new software for analysis of EGG signal can distinguish normal voice from pathological voice based on the new quantitative parameter VI. Moreover, this study emphasises that the final contact phase of vocal folds is the most representative of the difference between the normal and pathological voice and shows a wider variability in terms of amplitude and vibration velocity. Further studies on larger groups of subjects will be required to confirm these results and assess differences in the EGG signal among the various vocal fold pathologies.

OBJECTIVES/HYPOTHESIS This is a retrospective study investigating the prevalence of globus pharyngeus in patients with dysphonia. STUDY DESIGN Retrospective chart review. METHODS The study examined the prevalence of globus pharyngeus in patients presenting with history of dysphonia at the American University of Beirut Medical Center Voice Center was performed. The etiology of dysphonia was categorized as organic in the presence of laryngeal pathology versus functional in the absence of any laryngeal pathology on laryngeal videostroboscopic examination. Functional dysphonia was further stratified as muscle tension dysphonia (MTD) and non-MTD based on the presence or absence of supraglottic muscle tension patterns. RESULTS The medical records of 300 patients were reviewed. Total prevalence of globus pharyngeus was 14.33%. There was a significant difference in the prevalence of globus pharyngeus between patients with organic dysphonia and patients with functional dysphonia (P < .001). Out of 43 patients with globus, 41.86% had organic voice disorders versus 58.14% who had functional voice disorders. Among those with functional voice disorders, globus pharyngeus was more prevalent in patients with MTD versus non-MTD patients (P = .19). Out of 25 patients with functional voice disorders and globus, 72% had MTD versus 28% who had no MTD (P = .19). CONCLUSIONS Globus pharyngeus is significantly more prevalent in patients with functional dysphonia versus patients with organic dysphonia. Moreover, in patients with functional dysphonia, the prevalence of globus was higher in those with MTD despite not reaching statistical significance. Globus pharyngeus may be either the cause or the result of laryngeal aberrant functional behavior. LEVEL OF EVIDENCE 4 Laryngoscope, 129:930-934, 2019.

Functional and organic impairments of the singing voice are common career-threatening problems of singers presenting in phoniatric and laryngological departments. The objective was to evaluate the efficacy of phonosurgery, logopedic voice treatment and vocal pedagogy in common organic and functional voice problems of singers, including investigation of the recently introduced parameter vocal extent measure (VEM). In a prospective clinical study, the analysis of treatment outcome in 76 singers [57 female, 19 male; 38 ± 11 years (mean ± SD)] was based on pre- and post-therapeutic voice function diagnostics and videolaryngostroboscopy. Examination instruments included auditory-perceptual voice assessment, voice range profile (VRP), the VEM calculated from area and shape of the VRP, acoustic–aerodynamic analysis, and patients’ self-assessment (e.g., Singing Voice Handicap Index). While 28% of all singers (21/76) presented with functional dysphonia, 72% (55/76) were diagnosed with organic vocal fold changes, of which marginal edema (n = 25), nodules (n = 9), and polyps (n = 8) were the most common pathologic changes. Of the 76 singers, 57% (43) received phonosurgery, 43% (33) had conservative pedagogic (14) and logopedic (19) treatment. Three months post-therapeutically, most parameters had significantly improved. The dysphonia severity index (DSI) increased on average from 6.1 ± 2.0 to 7.4 ± 1.8 (p

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

OBJECTIVE: To evaluate diagnostic performance of the emotional domain of the VoiSS questionnaire compared with the Hospital Anxiety and Depression Scale (HADS).DESIGN: Cross sectional questionnaire study.SETTING: Tertiary referral centre voice clinic.PARTICIPANTS: 210 consecutive voice clinic patients.MAIN OUTCOME MEASURES: Screening with VoiSS and HADS questionnaires. Paired comparison, correlation, multinomial logistic regression and receiver operating characteristic (ROC) curve analysis.RESULTS: 177 returned complete datasets. 96 patients (54.2%) had functional dysphonia and 81(45.8%) had organic laryngeal disorders. Mean total VoiSS score =39.7/120 (standard deviation (SD) 22.2). Mean emotional VoiSS subscale =7.6/22 (SD 7.5). Mean HAD anxiety =6.5/21 (SD 5.2) and depression mean =7.1/21 (SD 4.8). There were 35 (20%) borderline anxiety and/or depression scores and 30 (17%) scores considered positive for "caseness". There was strong correlation between emotional VoiSS and HADS anxiety (Spearman's Rho= 0.68, p < .001) and HADS depression (Spearman's Rho= 0.62, p < .001). ROC curve analysis exhibited significant association between emotional VoiSS and HADS "caseness" (area under curve =0.88). In addition functional dysphonia patients had lower mean VoiSS and HADS scores than patients with identifiable laryngeal abnormalities.CONCLUSION: The VoiSS emotional subscale strongly correlates with HADS anxiety and depression scores and could be used as a measure of psychological distress. This could allow targeted psychological strategies, without additional psychometric questionnaires. Functional dysphonia has less association with psychological distress than certain organic laryngological disorders. This article is protected by copyright. All rights reserved.

Summary Purpose The purpose of this study was to determine if voice amplification influenced vocal dose in female teachers with dysphonia. Material and Methods This was an experimental study with comparative intrasubjects in which 15 individuals were compared in two different moments: condition 1 (C1) without voice amplification and condition 2 (C2) with voice amplification. All of them were female, kindergarten and elementary school teachers who presented organic or functional dysphonia. The search was carried out at the school where the teachers work. The professional voice use was considered the teachers' activity for a continuous period of two classes (average recording time of 96 minutes, with no difference in time between C1 and C2). To measure the dose we used the vocal dosimeter composed of a microphone, an accelerometer fixed to the neck, and a portable unit that stores the vocal data. The phonation data (intensity, fundamental frequency, phonation percentage, cycle dose, and distance dose) were analyzed by the equipment software (VoxLog). Results The use of vocal amplification in teachers promotes a reduction of the fundamental frequency (295.6–267.7 Hz), the voice intensity (96.2–93.3 dB sound pressure level), the cycle doses (489.4–345.2 thousand cycles per second), and distance doses (3,800–2,300 m). Conclusion The vocal amplification allows the teacher to maintain the same phonation time (phonation percentage) but decreases the number of vocal fold oscillations (cycle dose) and the total distance traveled by the vocal fold tissue during phonation (distance dose), reducing the exposure of the vocal folds to voice trauma.

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

To describe the opinion of undergraduate health sciences students in the Basque Country universities (UPV/EHU) regarding ethical issues related to HIV-positive persons in schools, workplaces and health centers.Our population consisted of medical, nursing and dental undergraduate students attending UPV/EHU. An opinion survey was conducted among students attending lectures, on a randomly selected date in 2002-2003. The questionnaire included several items on ethical conflicts related to HIV-positive persons in different settings. Item responses consisted of a Likert-type scale with five possible levels of agreement (from "strongly disagree" to "strongly agree"), as well as the option "I do not want to answer/I have no opinion about this".529 completed questionnaires were collected. 69% of respondents reported total disagreement with refusing to admit HIV+ students to primary schools, and 77% with dismissal of HIV+ workers. Approximately 90% of respondents felt managers should be aware of the HIV+ status of their employees. 78% of the students did not report disagreement with having HIV+ schoolmates in classrooms. Respondents generally disagreed with employment limitations for HIV+ health care workers, 60% strongly disagreed with health workers refusing to treat HIV+ persons, 69% considered that HIV testing should be compulsory for health workers, and 55% that health workers should know their patients' HIV status.In general terms, our students are against social and employment limitations targeting HIV+ persons, but favor disclosure of HIV status in schools and health centres.Objetivos: Conocer la opinión de estudiantes de carreras sanitarias de la Universidad del País Vasco (UPV/EHU) acerca de conflictos éticos relacionados con las personas VIH+ en centros docentes, de trabajo y sanitarios. Métodos: La población de interés eran estudiantes de Medicina, Odontología y Enfermería de la UPV/EHU en todos los cursos de dichas titulaciones. A los alumnos presentes en el aula en fecha escogida aleatoriamente en el curso académico 2002-2003, se les ofreció rellenar una encuesta en la que se recogía su opinión sobre situaciones conflictivas relacionadas con la presencia de personas seropositivas (VIH+) en lugares de trabajo y centros públicos. Las opciones de respuesta eran cerradas, sobre una escala de cinco grados de acuerdo desde “Totalmente en desacuerdo” hasta “Totalmente de acuerdo”, incluyendo también las opciones “No deseo opinar” y “No tengo opinión formada sobre el tema”. Resultados: Se obtuvieron un total de 529 cuestionarios cumplimentados. Un 69% de los encuestados se manifiesta en total desacuerdo con no admitir niños VIH+ en colegios, y un 77% con el despido de trabajadores seropositivos. Un 90% acepta que la dirección de un colegio conozca si un alumno es VIH+. Un 78% está de acuerdo en tener compañeros de clase VIH+. Los encuestados no aceptan limitaciones laborales a los trabajadores sanitarios VIH+. Un 60% está totalmente en desacuerdo con que los sanitarios puedan rechazar el tratamiento de un paciente VIH+. Un 69% está de acuerdo con la obligatoriedad de la prueba VIH a los trabajadores sanitarios, y un 55% con que éstos puedan conocer la situación VIH de los pacientes. Conclusiones: En general, nuestra muestra se manifiesta en contra de limitaciones sociales o laborales a personas.

To review the recent literature since the 2009 Cochrane review regarding the effectiveness of voice therapy for patients with functional dysphonia.A range of articles report on the effects of voice therapy treatment for functional dysphonia, with a wide range of interventions described. Only one study is a randomized controlled trial. A number of excellent review articles have extended the knowledge base. In primary research, methodological issues persist: studies are small, and not adequately controlled. Studies show improved standards of outcome measurement and of description of the content of voice therapy.There is a continued need for larger, methodologically sound clinical effectiveness studies. Future studies need to be replicable and generalizable in order to inform and elucidate clinical practice.

Objective: The aim of the study was to assess the applicability of the Voice Handicap Index (VHI) in the screening diagnostics of voice dysfunction and in the evaluation of the level of handicap due to dysphonia. Patients andMethods: A total of 165 patients with voice disorders (vocal paresis, benign vocal fold masses, and functional dysphonia) and 65 healthy controls completed the VHI questionnaire. All the participants were subjected to maximum phonation time (MPT) assessment, the patients also to laryngovideostroboscopy. Results: The VHI scores for the patients and controls differed significantly (p < 0.001). A significant correlation (p < 0.05) was found when MPT and VHI were compared. The cutoff point, at which VHI sensitivity (for distinguishing between subjects with voice dysfunction and with vocal health) reached its maximal value (98%) at the highest level of specificity (95%), was assumed to be 12. Conclusions: The study revealed that the VHI is a reliable tool for identifying patients who experience vocal dysfunction and should be used in multidimensional diagnostics of voice disorders. The level of 12 points in the VHI test should be considered to be a threshold for rating the biopsychosocial impact of dysphonia.

Objective: This study focuses on the relation between objective voice quality and the self-perception of a voice handicap. Patients and Methods: The study group consisted of 86 German-speaking patients (51 women, 35 men) suffering from benign dysphonia. The test persons completed the German version of the Voice-Related Quality of Life (V-RQOL) Questionnaire without prior information about their diagnosis and underwent voice analysis with the Dysphonia Severity Index (DSI) being the parameter of this study. Results: No correlation between V-RQOL and DSI could be found (p > 0.05). On the V-RQOL, women scored worse than men, but not at a significant level. Patients with dysphonia of organic origin scored significantly worse than patients with functional dysphonia (p = 0.026). On the DSI, men’s values were significantly lower than women’s (p = 0.001). Organic dysphonia caused significantly lower DSI values than functional dysphonia (p = 0.011). Conclusion: Objective voice quality and the individual perception of voice quality by the patient are independent parameters. Both need to be assessed in clinical practice.

Locus of Control (LoC) refers to an individuals' perception of whether they are in control of life events. Health Locus of Control refers to whether someone feels they have influence over their health. Health Locus of Control has not been studied in any depth in voice-disordered patients. The objective of this study was to examine Health Locus of Control in three patient groups: (1) Spasmodic Dysphonia, (2) Functional Dysphonia and (3) a nondysphonic group with Nonlaryngeal Dystonia. LoC was measured and compared in a total of 57 patients using the Multidimensional Health Locus of Control Scales (diagnostic specific) Form C. Internal, Chance, and Powerful others LoC were measured and comparisons were made using one-way analysis of variance. Contrary to expectations Internal LoC was found to be significantly higher in the Functional Dysphonia group when compared to the other two groups. There was no significant difference between the groups in Chance or Powerful others LoC. The two organic groups, Spasmodic Dysphonia and Nonlaryngeal Dystonia, were more alike in Internal Health Locus of Control than the Functional Dysphonia group. The diagnostic nature of the groups was reflected in their LoC scores rather than their voice loss. These results contribute to the debate about the etiology of Spasmodic Dysphonia and will be of interest to those involved in the psychology of voice and those managing voice-disordered patients.

Objective: We evaluated the efficacy of voice therapy according to Borragan's method associated to S. Magnani's vocal counselling in functional dysphonia in children. Patients and methods: We prospectively treated 16 patients with vocal fold nodules (10 males, 6 females). Age ranged from 6 to 11 years with a mean age of 9 years. We performed a full screening phoniatric evaluation. In addition psychological tests were carried out to investigate psychological background. Results: We lost three patients at follow-up; one patient received surgery, eight patients healed (43.75%), four improved (25%). There was no statistical difference in the analysis of electroacoustical parameters while MPT significatively raised after therapy. Conclusion: If patients have motivation voice therapy could improve functional dysphonia in children. It is also important psychological background. Further studies on bigger populations with long-term follow-up are needed. © 2006 Elsevier Ireland Ltd. All rights reserved.

Speaking fundamental frequency (SFF) and its perceptual correlate "habitual pitch" have been considered important and contentious parameters in voice assessment and treatment. In clinical circles, disagreement exists regarding the role of habitual pitch in the development, maintenance, and treatment of disordered voices. Despite these divergent opinions, few studies have objectively evaluated SFF changes associated with voice improvement after therapy. To determine whether consistent directional and magnitude changes in SFF occur after management, pretreatment and posttreatment audio recordings of 40 women with functional dysphonia were analyzed. All subjects were treated with manual circumlaryngeal therapy, a treatment approach that does not directly target pitch as a perceptual entity to be manipulated. Results indicated that, as a group, no significant change in mean SFF was observed after successful management. Although no consistent directional pattern was identified, 80% of the subjects experienced pitch changes greater than one semitone; this suggests that voice improvement is often accompanied by a shift in SFF. Clinical implications of the data are discussed.

Summary Functional (nonorganic) dysphonia is often characterized by vocal instability. The purpose of the prospective study was to examine whether there is a difference in vocal instability of functional dysphonic voices compared with healthy ones, this means whether electroglottographic perturbation values differ (1) between healthy and dysphonic voices and (2) between two subgroups of the dysphponic voices (hpertonic and hypotonic dysphonic voices). Twenty-three patients with hypertonic functional dysphonia, 9 with hypotonic functional dysphonia and 31 healthy nonsmokers, were each examined electroglottographically before (Ex 1), immediately after (Ex 2), and 1 hour after (Ex 3) voice loading. Perturbations of frequency, amplitude, quasi-open-quotient, and contact-index were calculated from the EGG signal. At all three times of examination, hypertonic dysphonic voices showed higher perturbations than healthy voices, and they had higher perturbations than hypotonic dysphonic voices before and 1 hour after voice loading. Hypotonic dysphonic voices showed higher perturbations than healthy voices only 1 hour after voice loading. Voice loading induced different reactions in dysphonic voices: Some voices showed increased perturbations, and others exhibited normal or even decreased perturbation immediately after voice loading. Examination of electroglottographic-derived perturbations immediately after voice loading seems not to be useful. Differentiation of hypertonic and hypotonic dysphonic voices was possible with an estimated sensitivity of 88.9% and a specificity of 87.0% by using the sum of the amplitude-perturbation and the quasi-open-quotient-perturbation measured before voice loading.

The main aim of this study was to describe the changes in acoustic analysis in diagnosing voice disorders in children. The secondary goal was the attempt at differentiation of organic and functional disorders by means of acoustic analysis. The study included 112 children in treated due to laryngeal papilloma, gastro-esophageal reflux, atopic disease and noduli vocales. The following values have been determined: basic frequency F(o), jitter, shimmer, F(o) tremor and the harmonics to noise ratio (HNR). The study results confirmed that the HNR value was the most sensitive indicator of changes in the voice organ.

OBJETIVOS:Identificar a relação entre o tipo de disfonia, o grau de desvio vocal autoavaliado e a presença de sintomas vocais em indivíduos adultos.MÉTODOS:Participaram do estudo 164 indivíduos de ambos os gêneros (58 homens e 106 mulheres, média de idade de 42,89 anos) com diagnóstico médico otorrinolaringológico de disfonia, divididos em três grupos, de acordo com o tipo de disfonia. Ao todo 87 indivíduos com disfonia funcional, 35 com disfonia organofuncional e 42 com disfonia orgânica responderam a versão validada para o Brasil da Voice Symptom Scale (VoiSS) (Escala de Sintomas Vocais - ESV), composta por 30 questões, com quatro escores: Limitação, Emocional, Físico e Total, e autoavaliaram suas vozes em excelente, muito boa, boa, razoável ou ruim.RESULTADOS:Houve diferenças na ESV de acordo com o tipo de disfonia para as médias dos resultados nos escores Limitação, Emocional e Total, o que não foi verificado no escore Físico. As médias dos resultados nos escores Limitação, Emocional e Total da ESV foram maiores nas disfonias orgânicas, seguidas pelas organofuncionais e pelas funcionais. Quanto pior a autoavaliação, maior o desvio nos escores Limitação, Emocional e Total da ESV.CONCLUSÕES:Indivíduos com disfonias orgânicas relataram maior percepção de sintomas vocais, seguidos pelos sujeitos com disfonias organofuncionais e com disfonias funcionais. De forma geral, os indivíduos disfônicos apresentaram sintomas vocais físicos independente do tipo da disfonia. Por fim, existem correlações diretas entre os escores Limitação, Emocional e Total da ESV com a autoavaliação vocal. PURPOSE:To identify the relationship among the type of dysphonia, vocal deviation self-assessed and the presence of voice symptoms in adults.METHODS:One hundred sixty-four subjects of both genders (58 males and 106 females, mean age 42.89 years) diagnosis of dysphonia, divided into three groups according to the type of dysphonia: 87 individuals with functional dysphonia, 35 individuals with organofunctional dysphonia and 42 individuals with organic dysphonia, answered the Brazilian validated version of Voice Symptom Scale (VoiSS) (Escala de Sintomas Vocais - ESV), that consists of 30 questions with four scores: Impairment, Emotional, Physical and Total, and self-assessed their voices as excellent, very good, good, fair or poor.RESULTS:According to the dysphonia type, there were differences in ESV Impairment, Emotional and Total mean scores, which was not found in the Physical score. The Impairment, Emotional and Total mean scores were higher in organic dysphonia, followed by organofunctional dysphonia and finally functional dysphonia. When the vocal self-assessment is poor, the higher are the deviations in the Impairment, Emotional and Total ESV scores.CONCLUSIONS:Individuals with organic dysphonia reported higher perception of voice symptoms, followed by subjects with organofunctional dysphonia and finally individuals with functional dysphonia. In general, individuals with dysphonia presented physical voice symptoms, regardless of the type of the dysphonia. Finally, there are direct correlations between Impairment, Emotional and Total ESV scores and the vocal self-assessment. Universidade Federal de São Paulo (UNIFESP) Department of Speech-Language Pathology and Audiology Sindicato dos Professores de São Paulo UNIFESP, Department of Speech-Language Pathology and Audiology SciELO

To describe teachers treated for dysphonia and vocal cord nodules by the public health system in Navarra (Spain), to describe associated factors and to identify the proportion of these cases registered as occupational diseases.Cases of dysphonia occurring in persons between the age of 18 and 65 years, registered between May 2010 and June 2011, and treated in a specific unit (Speech Unit) of Otorhinolaryngology Services were identified. Information on occupation, sex and clinical diagnosis was collected. For teachers, additional information was obtained on smoking habits, teaching level and prior training in speech disorders and their prevention. Cases declared as occupational diseases were identified from the official Register of Occupational Diseases of Navarra.135 teachers (18% of all dysphonia patients in the sample) were treated for dysphonia in the Speech Unit (87% women). Being female was 3-fold higher among teachers than other occupations (crude prevalence odds ratio = 3.5; 95% confidence interval, 95%CI, 2.1-5.9). Female teachers were also 6.5 years (95%CI, 1.7-11.4) younger than male teachers. No association was found between smoking and risk of vocal cord nodules or dysphonia. Only 20% of teachers treated had received training on speech disorders and their prevention. Nine out of 83 cases of vocal cord nodules diagnosed in professional voice users were officially declared as occupational diseases; in all cases, these were teachers.Dysphonia in teachers is a frequent reason for visiting a specialty clinic. Among these professionals, women showed a higher risk of suffering from vocal cord nodules. Most cases of vocal cord nodules in our sample were not reported as occupational diseases.Describir a los docentes que son atendidos por disfonía y los que son diagnosticados con nódulos de las cuerdas vocales en las consultas especializadas del Servicio Público de Salud de Navarra, identificar factores relacionados en la aparición de estas dolencias y valorar la declaración de los nódulos de las cuerdas vocales como enfermedad profesional. MÉTODOS: A partir de los registros de consultas externas de atención especializada de la Comunidad de Navarra (España) de mayo de 2010 hasta junio de 2011, se identificaron los casos de disfonía, con edades entre 18 y 65 años, entre los atendidos en las consultas de laringe del Servicio de Otorrinolaringología del Servicio Navarro de Salud y posteriormente derivados a la Unidad de Voz de dicho servicio. Se obtuvo información sobre ocupación, sexo y diagnóstico de los casos. En los docentes se disponía también de datos acerca de hábito tabáquico, nivel de enseñanza en el que trabajan y formación sobre trastornos foniátricos y su prevención, entre otros. La identificación de los casos que habían sido declarados como enfermedad profesional se llevó a cabo mediante búsqueda de sucesos coincidentes en el Registro de Enfermedades Profesionales en Navarra.135 docentes (18% del total de pacientes en la muestra) fueron atendidos por disfonía en la Unidad de Voz del Servicio de Otorrinolaringología del Servicio Navarro de Salud (87% mujeres). En pacientes con disfonía, ser mujer es 3 veces más frecuente en los docentes que en el resto de ocupaciones (odds ratio de prevalencia cruda ORp=3,5; intervalo de confianza al 95%, IC95% 2,1-5,9). Adicionalmente, los casos entre docentes mujeres tienen una media de edad inferior en 6,5 años (IC95% 1,7-11,4) que los casos entre docentes varones. Fumar no se asoció a mayor riesgo de padecer disfonía o nódulos. Un 20% de los docentes tenía formación sobre trastornos fonatorios y su prevención. De 83 casos de nódulos diagnosticados entre profesionales de la voz sólo nueve (11%) fueron declarados como enfermedad profesional, todos ellos en docentes.Las disfonías en los docentes son motivo frecuente de consulta en las clínicas especializadas. Entre estos profesionales, las mujeres presentan mayor riesgo de padecer nódulos que los hombres. La mayoría de los casos de nódulos identificados no se declaran como enfermedades profesionales.

Time consuming is an important aspect in assessing dysphonic patients. So, the English version of the Voice Handicap Index (VHI-30), a self-administered questionnaire consisting of 30 items used to evaluate patients' self-perception of voice problems, was reduced to 10 items (VHI-10) for clinical purposes. In 2010, an Italian version of VHI-30 was validated, now the aims of this study were to analyze the psychometric properties of an Italian version of VHI-10 and to evaluate its validity in a cohort of patients affected by organic or functional dysphonia.Cross-sectional study.The Italian version of the VHI-30 was submitted to 372 dysphonic participants and 120 healthy control subjects and was conducted again 2 weeks later. The 10 items constituting the VHI-10 were extracted from the VHI-30. For 73 dysphonic patients, the questionnaire was also administered after treatment.The scores of the control group were significantly lower with respect to all diagnostic subgroups (P0.001). The Cronbach's α, test-retest, and Pearson's correlation index demonstrated high reliability and validity of the Italian VHI-10. The ratio of the VHI-10 and VHI-30 scores was higher than 0.333 in all subgroups.This study demonstrated that the Italian VHI-10 is a robust tool that can adequately represent and replace the VHI-30. The reported results support the use of the VHI-10 for the Italian population in clinical settings owing to its validity and rapid and simple use.

Increased levels of fatigue and perfectionism were noted during evaluation of cognitive behavioral therapy for the treatment of functional dysphonia. The investigators thus aimed to explore levels of general fatigue and perfectionism in patients with functional dysphonia and controls.Case-control study.Teaching hospital, United Kingdom.Patients recruited through speech therapy were asked to recruit a friend as a control, of the same sex and within 5 years of their age. An 11-point fatigue questionnaire, previously validated on a normal population, was analyzed using both Likert (0123) and bimodal (0011) systems, with a score greater than 4 on the bimodal system implying substantial fatigue. A 35-point perfectionism questionnaire was also completed and analyzed for "healthy" and "unhealthy" perfectionist traits.There were 75 cases and 62 controls. The mean fatigue score in patients with functional dysphonia was 17.0 and 14.4 for the controls (Likert, P = .009). Under the bimodal scoring system, the mean fatigue scores in functional dysphonia (5.10) and controls (3.01) were also significantly different (P = .003). The mean perfectionism scores were 98.9 for patients with functional dysphonia and 91.2 for controls (P = 0.043).To the investigators' knowledge, this is the first substantial report that fatigue and perfectionism scores are significantly elevated in functional dysphonia. Functional dysphonia is shown to be analogous to other medically unexplained physical symptoms that are also marked by generic somatopsychic distress and for which multiple factors are implicated in their onset and maintenance. This has implications for both research and treatment.

During a 2-year period, 17 patients with "functional dysphonia" were assessed and managed in a hospital setting. A single treatment approach, known as manual laryngeal musculoskeletal tension reduction, was employed. The effects of the therapy regimen were analyzed using perceptual and acoustical measures of vocal function. The results indicated a significant change in the direction of "normal" vocal function in the majority of patients within one treatment session. Perceptual measures of severity were consistently more likely to be rated as normal following treatment. Acoustic measures of voice confirmed significant improvements in jitter, shimmer, and signal-to-noise ratio (SNR). Results are discussed in terms of the clinical utility and effectiveness of this treatment approach for functional dysphonia.

Functional dysphonia is a term applied to voice disorders for which there is an absence of apparent structural change in the larynx. The aim of this work was to investigate how functional dysphonia may differ acoustically from other types of dysphonia. Fundamental frequency profiles for steady vowels were generated using a software program called GLIMPES (Glottal Imaging by Processing External Signals). The fundamental frequency variations were found to be unimodal in normal individuals. In contrast, the variations for dysphonic patients were sometimes bi-modal or multi-modal due to the presence of subharmonics or low-frequency modulations. The appearance of these patterns was generally related to the severity of the dysphonia rather than to its etiology.

Tape recordings before and after successful voice therapy from 174 subjects with non-organic voice disorders (functional dysphonia) were analysed by long-time averaged voice spectrograms (LTAS). In female as well as in male voices there was a statistically significant increase in level in the first formant region of the spectra. In the female voices there was also an increase in level in the region of the fundamental. The LTAS were compared to the results of a perceptual evaluation of the voice qualities by a small group of expert listeners. There was no significant change of the LTAS in voices with negligible amelioration after therapy. In the voices, where the change after therapy was perceptually rated to be considerable, the LTAS showed only an increase in intensity, but the general configuration of the spectral envelope remained unchanged. There was only a weakly positive correlation between the quality ratings and parameters of the spectra.

Summary Objectives The aim of this study was to look for visual subjective and objective parameters of vocal fold dynamics being capable of differentiating healthy from pathologic voices in daily clinical practice applying endoscopic high-speed digital imaging (HSI). Study Design and Methods Four hundred ninety-six datasets containing 80 healthy and 416 pathologic subjects (232 functional dysphonia (FD), 13 bilateral, and 171 unilateral vocal fold nerve paralysis) were analyzed retrospectively. Videos at 4000 Hz (256 × 256 pixel) were recorded during sustained phonation. Subjective parameters were visually evaluated and complemented by an analysis of objective parameters. Visual subjective parameters were mucosal wave, glottal closure type, glottal closure insufficiency (GI), asymmetries of the vocal folds, and phonovibrogram (PVG) symmetry. After image segmentation, objective parameters were computed: closed quotient, perturbation measures (PMs) of glottal area, and left-right asymmetry values. Results HSI evaluation enabled to distinguish healthy from pathologic voices. For visual subjective parameters, GI, symmetrical behavior, and PVG symmetry exhibited statistical significant differences. For 95% of the data, objective parameters could be computed. Among objective parameters, closed quotient, jitter, shimmer, harmonic-to-noise ratio, and signal-to-noise ratio for the glottal area function differentiated statistically significant normal from pathologic voices. Applying linear discriminant analysis by combining visual subjective and objective parameters, accurate classifications were made for 63.2% of the female and 87.5% of the male group for the three-class problem (healthy, FD, and unilateral vocal fold nerve paralysis). Conclusion Actual acoustically applied PMs can be transferred to clinical beneficial HSI analysis. Combining visual subjective and objective basic parameters succeeds in differentiating pathologic from healthy voices. The presented evaluation can easily be included into everyday clinical practice. However, further research is needed to broaden our understanding of the variability within and across healthy and pathologic vocal fold vibrations for diagnosing voice disorders and therapy control.

SIn a recent survey study it was found that female army instructors were significantly more likely to suffer from symptoms of vocal attrition than new female recruits, supporting the clinical impression that those who are engaged in a vocally taxing vocation are at higher risk for vocal attrition than those who are not. In the present study we found that instructors who reported having rapid, excessive or loud speech, or a combination of these, were significantly more likely to report symptoms of vocal attrition than instructors who reported not having these speech habits. Difference in prevalence of vocal attrition symptoms among recruits with and without these speech habits was statistically non-significant. The present findings confirm the clinical impression that idiosyncratic dysphonia can increase the risk of vocal attrition, especially in people who are engaged in a vocally demanding profession or vocation.Les resultats d'une enquete slatistique recente avaient permis de conclure que les in...

Objectives: Laryngopharyngeal reflux (LPR) may be a contributing factor in chronic hoarseness. The association of LPR with functional dysphonia (FD), the most common voice clinic diagnosis, is unknown. We attempted to determine whether patients with FD have a higher rate of laryngeal exposure to acidic stomach contents than do healthy volunteers. Methods: We recruited through the voice clinic 23 patients who had had persistent dysphonia for 3 months. Pregnancy, major structural laryngeal abnormality, and vocal fold paralysis were exclusion criteria. Eight healthy volunteers were recruited. The subjects gave informed consent to enter the study, which had the approval of our hospital ethics committee. The patients and control subjects underwent 24-hour dual-probe pH-metry. Results: Twenty-two patients and 6 control subjects completed the study. Overall, there seemed to be no statistical differences between patients and controls on all but 2 channel 1 pH-metry parameters. These were the longest reflux episode (seconds) in a supine position, and the fraction of time the pH was less than 4 in a supine position. Both of these time periods were longer in patients than in the controls (p Conclusions: Our study demonstrated an association between LPR and FD for 2 pH parameters. Larger studies are required to assess the potential relationship between nonorganic dysphonias and reflux. Furthermore, the presence of a multifactorial causation of FD, including “medical” and psychological causes, should be addressed in future studies.

The categorization of voice into quality type (ie, normal, breathy, hoarse, rough) is often a traditional part of the voice diagnostic. The goal of this study was to assess the contributions of various time and spectral-based acoustic measures to the categorization of voice type for a diverse sample of voices collected from both functionally dysphonic (breathy, hoarse, and rough) (n=83) and normal women (n=51). Before acoustic analyses, 12 judges rated all voice samples for voice quality type. Discriminant analysis, using the modal rating of voice type as the dependent variable, produced a 5-variable model (comprising time and spectral-based measures) that correctly classified voice type with 79.9% accuracy (74.6% classification accuracy on cross-validation). Voice type classification was achieved based on two significant discriminant functions, interpreted as reflecting measures related to "Phonatory Instability" and "F(0) Characteristics." A cepstrum-based measure (CPP/EXP ratio) consistently emerged as a significant factor in predicting voice type; however, variables such as shimmer (RMS dB) and a measure of low- vs. high-frequency spectral energy (the Discrete Fourier Transformation ratio) also added substantially to the accurate profiling and prediction of voice type. The results are interpreted and discussed with respect to the key acoustic characteristics that contributed to the identification of specific voice types, and the value of identifying a subset of time and spectral-based acoustic measures that appear sensitive to a perceptually diverse set of dysphonic voices.

Two vocal tract postures commonly identified as hallmarks of nonorganic dysphonia are anterior-posterior and medial compression of the supraglottis. However, insufficient data exist to support their diagnostic utility. The purpose of this study was to compare these two postures in patients with nonorganic dysphonia and normal controls using interval data derived from quantitative measures of videostroboscopic images obtained with an oral endoscope. Retrospectively, 40 patients with nonorganic dysphonia and 40 normal controls were selected. Relative anterior-posterior compression (LO(AP)) was calculated as the laryngeal outlet (LO) (the view of the true vocal folds during phonation) normalized to the anterior-posterior dimension in pixels. Relative ventricular fold medial compression (LO(w)) was calculated as the laryngeal outlet normalized to the medial dimension in pixels. Results were as follows: (1) LO(AP) was significantly greater for the dysphonic group, (2) the range of LO(AP) values between the two groups overlapped considerably, (3) no significant difference was found between groups for LO(w), (4) the correlation between LO(AP) and LO(w) within each subject yielded r values of 0.71 and 0.67 for the nonorganic dysphonia and normal control groups, respectively. It is concluded that medial compression of the ventricular folds can be a normal laryngeal posture, and that although anterior-posterior compression is present in greater degree in dysphonics, it is sufficiently common in normals to question its utility as a diagnostic sign of phonatory dysfunction.

An approach is given to extract parameters affecting phonation based upon digital high-speed recordings of vocal fold vibrations and a biomechanical model. The main parameters which affect oscillation are vibrating masses, vocal fold tension, and subglottal air pressure. By combining digital high-speed observations with the two-mass-model by Ishizaka and Flanagan (1972) as modified by Steinecke and Herzel (1995), an inversion procedure has been developed which allows the identification and quantization of laryngeal asymmetries. The problem is regarded as an optimization procedure with a nonconvex objective function. For this kind of problem, the choice of appropriate initial values is important. This optimization procedure is based on spectral features of vocal fold movements. The applicability of the inversion procedure is first demonstrated in simulated vocal fold curves. Then, inversion results are presented for a healthy voice and a hoarse voice as a case of functional dysphonia caused by laryngeal asymmetry.

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

OBJECTIVES: To assess the overall efficacy of voice therapy for dysphonia. DESIGN: Single blind randomised controlled trial. SETTING: Outpatient clinic in a teaching hospital. Participants: 204 outpatients aged 17-87 with a primary symptom of persistent hoarseness for at least two months. INTERVENTIONS: After baseline assessments, patients were randomised to six weeks of either voice therapy or no treatment. Assessments were repeated at six weeks on the 145 (71%) patients who continued to this stage and at 12-14 weeks on the 133 (65%) patients who completed the study. The assessments at the three time points for the 70 patients who completed treatment and the 63 patients in the group given no treatment were compared. MAIN OUTCOME MEASURES: Ratings of laryngeal features, Buffalo voice profile, amplitude and pitch perturbation, voice profile questionnaire, hospital anxiety and depression scale, clinical interview schedule, SF-36. RESULTS: Voice therapy improved voice quality as assessed by rating by patients (P=0.001) and rating by observer (P

Abnormal psychological factors have been implicated in the development of functional dysphonia (FD). This investigation describes the personality and psychological characteristics of 25 female subjects who had received the diagnosis of FD. In all subjects symptoms were resolved after voice therapy. While vocally asymptomatic, these remitted subjects with FD completed the Minnesota Multiphasic Personality Inventory (MMPI), an objective personality questionnaire. When compared with a medical outpatient control group, the results showed that subjects with FD scored significantly higher on 7 of 10 clinical scales, suggesting an elevated degree of emotional maladjustment. A stepwise logistic discriminant analysis identified 2 clinical scales that provided valuable discriminatory power between the two groups. Scale 1 (Hs-hypochondriasis), which measures the number and type of reported somatic complaints, and scale 7 (Pt-psychasthenia), a measure of diffuse anxiety, discriminated the groups with 88% sensitivity and 89% specificity. The results suggested that in spite of symptom improvement after voice therapy, the subjects with FD continued to exhibit poor levels of adaptive functioning, which may represent trait-like vulnerability. The clinical implications of these results for voice practitioners are discussed.

Manual circumlaryngeal therapy (manual laryngeal musculoskeletal tension reduction) was used to treat 25 consecutive functional dysphonia patients. Pre- and post-treatment audio recordings of connected speech and sustained vowel samples were submitted to auditory-perceptual and acoustical analysis to assess the immediate and long-term effects of a single treatment session. To complement audio recordings, subjects were interviewed in follow-up regarding the stability of treatment effects. Pre- and post-treatment comparisons demonstrated significant voice improvements. No significant differences were observed between post-treatment measures, suggesting that vocal gains were maintained. Interviews revealed 68% of subjects reported occasional partial recurrences, typically less than 4 days in duration, which resolved spontaneously. These results replicate and extend previous research suggesting the utility of manual circumlaryngeal therapy for functional voice disorders.

Ten patients who were referred to a speech pathologist for functional voice disorders were treated with voice therapy using the accent method. The vocal folds were normal except in three females who had moderate bilateral nodules. The voices were analyzed acoustically before and after treatment. Of the parameters tested, pitch perturbation quotient, amplitude perturbation quotient, normalized noise energy for 1-4 kHz, and fundamental frequency showed significant improvement.

In the past, there has been no consistent, objective method of following patients undergoing botulinum toxin injections for treatment of laryngeal dystonia. Herein, the application of translaryngeal resistance measurements to 15 dysphonic patients is described. Laryngeal resistance is calculated from analysis of translaryngeal pressure and airflow during the utterance /pi/, and found to fall predictably after successful toxin injection. In our series of patients, laryngeal resistance dropped by 69.1% after initial toxin injection. The changes in resistance over time correlate with subjective impressions of voice quality. Translaryngeal resistance measurements can be used objectively to follow patients longitudinally after injection and to collect objective data for analysis. No previously described measurements have met all these criteria. Laryngeal resistance measurement is an ideal method of documenting the results of botulinum toxin injection for the treatment of focal laryngeal dystonia.

This study isolates the voice problems of 99 (40 male, 59 female) children choir singers (age range: 8-14), by applying and validating a simple method for classifying the singing voice. The prevalence of dysphonia was 20.2%. A singing range of fewer than 18 semitones is considered to suggest dysphonia (sensitivity of 80% and specificity of 95%). The validity of the method and its ease of application are discussed. We conclude that voice classification is necessary for all children who sing and that phoniatric examination of dysphonic children is imperative, with special attention given to those whose voices are changing.

According to the laryngeal clinical findings, figures making up a scale were assigned to vocally trained and vocally untrained persons suffering from different types of functional dysphonia. The different types of dysphonia--from the manifested hypofunctional to the extreme hyperfunctional dysphonia--were classified by means of this scale. Besides, the subjects' phonetograms were measured and approximated by three ellipses, what rendered possible the definition of phonetogram parameters. The combining of selected phonetogram parameters to linear combinations served the purpose of a phonetographic evaluation. The linear combinations were to bring phonetographic and clinical evaluations into correspondence as accurately as possible. It was necessary to use different kinds of linear combinations for male and female singers and nonsingers. As a result of the reclassification of 71 and the new classification of 89 patients, it was possible to graduate the types of functional dysphonia by means of computer-aided phonetogram evaluation with a clinically acceptable error rate. This method proved to be an important supplement to the conventional diagnostics of functional dysphonia.

It is apparent that voice disorders frequently labelled "functional" are associated with laryngeal muscle misuse. This use of the word "functional" is, however, intrinsically ambiguous, and so we propose an alternative term based on descriptive features of dysfunction: "muscle misuse voice disorders". Persistent phonation with an abnormal laryngeal posture can lead to organic changes such as nodules or polyps, particularly in females with posterior glottic chink. We hypothesized that the chink was related to an overall increase in laryngeal muscle tension, and more directly due to inadequate relaxation of the posterior crico-arytenoid muscle during phonation. We employed the term "muscular tension dysphonia" (MTD) to note this condition, but it may be that the term "laryngeal isometric" is superior since there are other misuses of the larynx that obviously are manifestations of abnormalities of muscular tension. With this in mind we have evolved a new classification based on the laryngeal isometric, glottic and supraglottic lateral contraction states, antero-posterior contraction states, conversion aphonia, psychogenic bowing, and adolescent transitional dysphonia.

SThirty patients diagnosed as suffering from non-organic dysphonia were assigned to one of three treatment groups: direct therapy, indirect and no treatment for a period of 8 weeks. Therapeutic outcome was evaluated by independent judges, patient self-evaluation, electrolaryngograph ratings and measures of fundamental frequency. The direct treatment group showed the most significant improvement in the return to normal voice functioning followed by the indirect treatment group. One patient in the control group showed improvement without any intervention. This study provides evidence in support of the effectiveness of both direct and indirect therapy in the treatment of non-organic dysphonia and raises questions concerning individual patient responses to these approaches.Trente patients diagnostiques comme souffrant de dysphonie non-organique ont ete repartis en trois groupes de trailement pendant une periode de huit semaines: therapie directe, therapie indirecte et absence de soins. L'effel du trai...

A psychogenic voice disorder co-occurred or evolved with the symptoms and signs of unilateral superior laryngeal nerve paresis. We speculated that the former was a manifestation of a musculoskeletal tension or conversion reaction disorder, whereas the latter was a sequela to a self-limiting inflammatory process. Voice therapy proved effective for alleviating the psychogenic dysphonia after the signs of the neuropathy had resolved, whereas psychotherapy offered strategies for stress management. A multidisciplinary approach to this patient provided for differential diagnosis and efficacious treatment.

The records of 109 patients, presenting with functional voice disorder during the years 1977–1981, have been reviewed. The mean age was 45 years and the F: M ratio is 2: 1. Excess voice use was not obviously an aetiological factor. Sixty-one of the 109 patients (56 per cent) were cured by speech therapy, in that their voices returned to their pre-morbid state, and a further 28 (26 per cent) were improved by therapy; seven patients (6 per cent) did not improve and 13 (12 per cent) were lost to follow-up. Of the patients that were ‘cured’, 54 per cent were discharged after three months' treatment and 72 per cent after six months' treatment. Eight per cent required treatment for more than a year.