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A principal components analysis was performed on a set (10) of acoustic, aerodynamic, perceptual and laryngoscopic data obtained from 87 dysphonic patients. Two principal components were clearly identified: the first represents in some way the glottal air leakage, resulting in turbulent noise, particularly obvious in higher spectral frequencies, and giving the perceptual impression of breathiness; the second accounts rather for the degree of aperiodicity in vocal fold oscillation, reflected in jitter measurements and with a perceptual correlate of harshness or roughness. Morphological changes of vocal folds correlate more closely with this second principal component. Among acoustic parameters, harmonics-to-noise ratio in the formant zone and magnitude of the dominant cepstrum peak seem to integrate to some extent the effects of both principal components.

Introduction: Atopy and ear, nose and throat (ENT) diseases are frequently associated; however, no clinical tool has been proposed so far to discriminate which patients could be atopic and therefore deserving of a further immunoallergological evaluation. Objective: The aim of this study was to assess and validate a set of dichotomous responses suitable for predicting the presence of atopy in adult patients. Methods: An 11-item questionnaire, i.e., the Atopy Index Inventory (AII), comprised of 4 questions regarding the clinical history for allergic disease and 7 questions evaluating the presence of the most frequent clinical signs affecting allergic patients, was developed and administered to 226 adult subjects (124 atopic subjects and 102 healthy, not atopic subjects). The atopic condition was proven by an immunoallergological evaluation according to the diagnostic criteria of the EAACI guidelines. Internal consistency and clinical validity were tested. Results: In healthy subjects, the first 4 variables of the AII returned a 100% correct response (all answered “no”) and were defined as “decisive” responses. In the logistic regression analysis, when decisive items were negative, the atopic condition was confirmed when answering “yes” to at least 3 “probability” items (cut-off = 2.69). The difference in AII scores between allergic and healthy group was significant using the Mann-Whitney U test (p < 0.0001). The sensitivity and specificity of the AII were 0.97 and 0.91, respectively, with a true predictive value of 0.92 and a false predictive value of 0.97. The ROC curve showed an area of 0.94, with an OR of 0.88 (95% CI 0.87–0.97, p = 0.0001). The internal consistency as determined by the Cronbach α coefficient was 0.88. Conclusion: The AII has been proven to be a brief, simple and sufficiently accurate tool for screening ENT patients in search of atopic individuals and to allow their clinical management.

Objectives/Hypothesis. Oxandrolone (Ox) increases height gain but may also cause voice deepening in growth hormone (GH)-treated girls with Turner syndrome (TS). We assessed the effect of Ox on objective and subjective speaking voice frequency in GH-treated girls with TS. Study Design. A multicenter, randomized, placebo (Pl)-controlled, double-blind study was conducted. Methods. One hundred thirty-three patients were included and treated with GH (1.33 mg/m(2)/d) from baseline, combined with Pl or Ox in a low (0.03 mg/kg/d) or conventional (0.06 mg/kg/d) dose from the age of 8 years and estrogens from the age of 12 years. Yearly from starting Ox/Pl until 6 months after discontinuing GH + Ox/Pl, voices were recorded and questionnaires were completed. Results. At start, mean (+/- standard deviation [SD]) voice frequency SD score (SDS) was high for age (1.0 +/- 1.2, P < 0.001) but normal for height. Compared with GH + Pl, voices tended to lower on GH + Ox 0.03 (P = 0.09) and significantly lowered on GH + Ox 0.06 (P = 0.007). At the last measurement, voice frequency SDS was still relatively high in OH + PI group (0.6 +/- 0.7, P = 0.002) but similar to healthy girls in both OH + Ox groups. Voice frequency became lower than 2 SDS in one patient (3%) on OH + Ox 0.03 and three patients (11%) on GH + Ox 0.06. The percentage of patients reporting subjective voice deepening was similar between the dosage groups. Conclusions. Untreated girls with TS have relatively high-pitched voices. The addition of Ox to GH decreases voice frequency in a dose-dependent way. Although most voice frequencies remain within the normal range, they may occasionally become lower than -2 SDS, especially on OH + Ox 0.06 mg/kg/d.

In previous studies, female patients in all age categories with a nonorganic dysphonia were found to report significantly more autonomic symptoms and complaints than healthy controls. After voice therapy, there was a highly significant reduction in the amount of autonomic symptoms and complaints (related or not related to voice). The present prospective study with a matched control group is designed to test the hypothesis that a specific kind of therapy is more efficient than the usual approaches in reducing these neurovegetative symptoms and complaints. Two matched groups of 34 patients diagnosed with nonorganic dysphonia and referred for voice therapy answered a questionnaire of 46 questions with 3 subsets and a consistency control. They received either "coordination therapy" (CTh)--a holistic approach addressing functional, personal and emotional aspects--or a conventional voice therapy (approximately 15 sessions). All patients again filled in a similar questionnaire after approximately 6 months. After therapy, there is in general a highly significant reduction in the amount of autonomic symptoms and complaints (related or not related to voice), to such an extent that patients report on average no more general neurovegetative symptoms and complaints than those of healthy controls. Symptoms and complaints of other nature (validity control) are not influenced. When compared with patients receiving conventional therapy, those who received CTh demonstrate a significantly higher reduction for the subset "neurovegetative symptoms/complaints related to voice and speech."

Summary In a previous study, female patients in all age categories with a nonorganic dysphonia were found to report significantly more autonomic symptoms and complaints than healthy controls. This could not be confirmed for the male subgroup. The present study is to corroborate and nuance this observation by investigating larger groups, and to determine if, after voice therapy, the number of autonomic symptoms and complaints—particularly those ones that have no obvious relation to voice function—decreases. It is a prospective study with a matched control group; 184 patients with nonorganic dysphonia and 126 normal controls answered a questionnaire of 46 questions with 3 subsets and a consistency control. One hundred and one patients received functional voice therapy and completed the questionnaire before and after treatment. A matched control group of 42 normal subjects also filled in the questionnaire two times, with an interval of about 6 months. Neurovegetative symptoms and complaints—voice related and not related—are reported in highly significant excess by patients (especially but not exclusively females) with habitual nonorganic voice disorder. After therapy, there is a highly significant reduction in the number of autonomic symptoms and complaints (related or not related to voice), to such an extent that patients report on average no more general neurovegetative symptoms and complaints than healthy controls (even less). The number of neurovegetative symptoms and complaints connected with voice function is also strongly reduced in patients after therapy, but remains in significant excess when compared with controls.

The effect of voice therapy in a group of chronically dysphonic patients with diverse diagnoses was studied according to the normal clinical procedure. The results were evaluated by perceptual rating, acoustic analysis, and the assessment of laryngostroboscopic recordings. Although the group effects for the differences between posttherapy and pretherapy data were clearly significant, the effects of voice therapy for the individual patients were divergent. For each of the three evaluation methods, a significant improvement was found for about 40% to 50% of the patients. The diversity of the therapy outcome among the patients could not be explained by the pretherapy status nor by age, gender, or diagnosis groups. In general, the perceptual ratings and the acoustic parameters from the baseline data were clearly correlated. However, these characterizations of the voice were only moderately correlated with the visual evaluation of the vocal fold vibrations. Relations among the three evaluation tools for the changes caused by voice therapy were very weak. The low correlation among the three methods suggests that a multidimensional evaluation of the voice is necessary to give a complete picture of the therapy outcome.

Left vagus nerve stimulation (VNS) by means of an implanted electrode has proven to reduce seizure frequency in epileptic patients with medically refractory seizures. This technique is now widely applied over the world. Voice changes appear to be one of the major side effects. The morphodynamic changes in the larynx and the acoustic impacts have been analyzed in detail in 7 implanted patients. Basic vagus stimulation is well tolerated. Extra stimulation induces an adductory spasm of either the ipsilateral vocal fold or the vestibular fold. The result, when the patient phonates, consists of a slight increase of F 0 as well as a moderate increase of random period perturbation, but there is no evidence for the occurrence of "bifurcations." Further, as the glottic closure remains sufficient, there is no increase in turbulent noise. The lack of increase in turbulent noise and the lack of "bifurcations" appears to clearly differentiate a spasmodic contraction of the vocal cord from a unilateral vocal fold paralysis.

Plasticity of voice quality is defined here as the degree of improvement in deviant voice quality that can be achieved immediately or quasi-immediately by changing basic voicing conditions, posture, articulation or resonance, breathing mechanics, laryngeal position, or auditory feedback. Thirty-two adult patients with various benign organic voice pathologies, and who had a (preoperative) functional voice therapy, were scored before therapy using a weighted multidimensional Index of Voice Plasticity (IVP). The hypothesis is that IVP could be a predictor of the final outcome of functional voice therapy, and therefore a correlation with a comparable quantification of the actual results of the therapy was investigated. The IVP shows a satisfactory correlation (Spearman's rho = 0.68) with the efficacy of (preoperative) voice therapy. The IVP also significantly differs between diagnostic categories. Although its predictive value remains limited, the Index of Voice Plasticity seems helpful in decision making for indication of (presurgical) voice therapy.

Practically nothing is known about the possible effect of a slightly louder phonation (as reflected by the sound pressure level) on commonly used acoustical parameters for evaluation of pathological voice quality. In this experiment, 87 patients with various kinds of voice pathology produced a /a:/ firstly at comfortable pitch and loudness, and secondly a little louder (average SPL increase: 2,6 dB). In case of normal vocal fold anatomy or superficial vocal fold pathology (epithelium or Reinke's space), louder voicing significantly reduces the perturbation parameters (jitter and shimmer), and thus also the noise to harmonics ratio. This is probably due to the increase of the oscillating mass by larger involvement of normal deeper layers of the vocal fold. In case of cancer or vocal fold paralysis, both involving the deeper layers of the vocal fold, louder voicing significantly enhances the irregularity of vocal fold vibration (jitter). When a tremor component is present in a voice (without known primary n...

Summary The hypothesis that relative humidity (RH) of air exerts an effect on voice has been widely accepted. The aim of this study has been to assess whether this can be demonstrated. Eight healthy subjects inhaled during ten minutes three different air conditions: dry, standard room, and humidified air. After inhalation, the subjects produced repeatedly a sustained /a/ of controlled pitch and loudness, which was analyzed for perturbation and noise-to-harmonic parameters. Perturbation measures increased after inhalation of dry air. No significant differences existed between standard and humidified air. No significant difference in the noise-to-harmonic ratio was found among the three conditions. We conclude that the human voice is very sensitive to decreases in RH of inhaled air, because even after a short provocation with dry air, a significant increase in perturbation measures was found.

From a clinical point of view, unilateral vocal fold paresis means that one of the vocal folds shows reduced mobility. Etiology may be mechanical or supranuclear, but in most cases it is a partial peripheral neurogenic lesion in the muscles innervated by one of the recurrent laryngeal nerves. On the one hand, a retrospective analysis was made of 71 cases with laryngoscopically reduced mobility of one vocal fold: 58 patients had electromyographic signs of partial denervation; 13 had normal electromyographic activity. Possible explanations are mechanical factors, paradoxical reinnervation, or central neurological pathology. On the other hand we reviewed 179 cases with an electromyographic diagnosis of unilateral partial peripheral neurogenic lesion in the muscles innervated by one of the recurrent laryngeal nerves: 119 patients showed a clinically immobile vocal fold, 2 a normally moving vocal fold and 58 a paretic vocal fold. A lot of immobile vocal folds are thus partial denervations. Insufficient amount of functional motor units and paradoxical reinnervation provide possible explanations.

The voice laboratory can be considered an essential tool for the assessment and treatment evaluation of voice patients and for clinical research on voice disorders. Whereas the medical examination focuses on the primary aetiologic diagnosis (cancer, infection, neurologic disease, reflux, and so forth), the voice laboratory provides a functional diagnosis and offers multidimensional information concerning the characteristics, limitations, and possibilities for change of disturbed voice production.

In this article, we investigate whether (1) the IINFVo (Impression, Intelligibility, Noise, Fluency and Voicing) perceptual rating scale and (2) the AMPEX (Auditory Model Based Pitch Extractor) acoustical analysis are suitable for evaluating adductor spasmodic dysphonia (AdSD). Voice recordings of 12 patients were analysed. The inter-rater and intra-rater consistency showed highly significant correlations for the IINFVo rating scale, with the exception of the parameter Noise. AMPEX reliably analyses vowels (correlation between PUVF (percentage of frames with unreliable F0/voicing 0.748), running speech (correlation between PVF (percentage of voiced frames)/voicing 0.699) and syllables. Correlations between IINFVo and AMPEX range from 0.608 to 0.818, except for noise. This study indicates that IINFVo and AMPEX could be robust and complementary assessment tools for the evaluation of AdSD. Both the tools provide us with the valuable information about voice quality, stability of F0 (fundamental frequency) and specific dimensions controlling the transitions between voiced and unvoiced segments.

Voice is multidimensional. Audio recording is the most important basic requisite for voice quality assessment. Once a high-quality complete recording has been attained, it can be stored and remains available. Existing research does not support the complete substitution of instrumental measures for auditory perceptual assessment. To be valuable, however, perceptual assessment should follow a standard procedure, as does the voice recording. A currently used scale for making perceptual judgments is the GRBAS scale. Videolaryngostroboscopy is the main clinical tool for diagnosing the etiology of voice disorders, but it can also be used to assess the quality of vocal fold vibration and thus evaluate the effectiveness of a treatment. The simplest aerodynamic parameter of voicing is the maximum phonation time (MPT), in seconds. It consists of the prolongation of an /a:/ for as long as possible after maximal inspiration and at a spontaneous, comfortable pitch and loudness. A reduction of possible bias (e.g., supportive respiratory capabilities compensating for poor membranous vocal fold closure) is possible by computing the ratio or quotient : Averaged phonation airflow or PQ = VC (ml)/MPT (s). Accu­rate estimation of subglottal pressure can be achieved by measuring the intraoral air pressure produced during the repeated pronunciation of /pVp/ syllables (i.e., a vowel between two ­plosive consonants). Among Voice Range Profile parameters, the highest and lowest frequencies and the softest intensity (decibels, or dBA, at 30 cm) seem most sensitive for changes in voice quality. Although subjective by definition, self-­evaluation is of great importance in clinical practice. Careful quantification is needed for self-evaluation to be compared and correlated with the objective as­­sessment provided by the voice, an important adjuvant technique, laboratory. The Voice Handicap Index is a largely diffused, validated protocol. Electromyography (EMG), an important adjuvant technique, is an electrophysiological investigation of neuromuscular function.

Objectives: The reliability of objective measurements on digital laryngeal images was investigated. Methods: The magnitude of the error of measurement of surface areas by visually tracing the outline was determined for three different areas: the area of the lesion and, during vibration, the glottal area on maximal opening of the vocal folds and the glottal area on maximal closing of the vocal folds. Results: The errors in these areas were 10% to 30%. The results suggest that the error is mainly due to the uncertainty of the real outline of areas with a vague boundary. Correction for differences in magnification between two images (posttherapy and pretherapy) is of importance in about 25% to 65% of cases, depending on the area measured. Conclusions: Only when the magnification ratio is small (less than about ±10% from 1.0) may a correction not be necessary.

The effects of voice therapy in a group of chronically dysphonic patients are determined using two quality-of-life (QOL) instruments: the Voice Handicap Index (VHI), and a simple three-item outcome scale (three visual analogue scales). Both instruments measure changes in the quality of the voice itself and in the extent of impairment resulting from the dysphonia as experienced by the patient in social and occupational settings. Statistical tests conducted on pre- and post-treatment data indicated significant improvements on both instruments for the group as a whole. At the individual level, however, the effects were diverse. For roughly 50% of the subjects, a significant improvement could be established. The positive changes as measured with the three-item scale were greater than those measured with the VHI. The results suggest that the two QOL instruments measure slightly different aspects of the subjective perception of the therapy effects. In order to obtain a general evaluation of the patient's handicap, it may suffice to ask some simple questions.

In a group of chronically dysphonic patients, a voice range profile, or phonetogram, was recorded before and after receiving voice therapy and again 3 months later. The voice range profiles took a wide variety of shapes. Therefore, only measures that did not depend on a smooth contour could be used to describe changes before and after therapy. The main effect of voice therapy was an enlargement on the side of low frequency and low intensity.

The present study was designed to test the hypothesis that there is a relation between nonorganic habitual dysphonia and subjective experience of dysfunction of the autonomic nervous system (neurovegetative lability). Eighty-three patients (65 women and 18 men) with a nonorganic voice disorder and a matched control group answered a questionnaire of 46 questions. One question replicated in different terms and six nonrelevant questions point out that the inquiry forms were answered in a consistent way. It appears that female patients in all age categories with a nonorganic habitual dysphonia report significantly more autonomic symptoms and complaints than healthy controls. This hypothesis cannot be confirmed for the male subgroup.

Objective In this pilot study, the reliabilities of the perceptual ratings of four types of speech samples by six judges, with and without expertise in evaluating cleft palate speech, were studied. Design Pre- and postoperative tape recordings of 15 patients with cleft lip and palate who had undergone a superiorly based pharyngeal flap operation were selected. Five speech-language pathologists and one oral and maxillofacial surgeon perceptually rated the following variables on separate 100-mm visual analog scales: hypernasality, audible nasal emission, intelligibility, mis-articulations associated with velopharyngeal insufficiency, voice quality, and the presence or absence of hyponasality. These six variables were rated in four types of speech samples: reading of three sentences, repeating after the speech pathologist of three sentences, 10 sentences containing the aforementioned material, and the same 10 sentences in paired comparison. All speech samples were rerated after 3 months by the same judges. Results Judges differed largely in the range they used in their rating. Intrajudge reliability of .56 to .78 was found for ratings of hypernasality. No significant differences in intrajudge reliability were found for the ratings with the different types of speech samples. The intrajudge reliability of a judge with expertise was not necessarily higher than of a judge without this expertise. Conclusions The improvement in speech is most reliably assessed with speech samples in paired comparison. A speech-language pathologist with expertise in evaluating cleft palate speech does not guarantee a high intrajudge reliability of the rating.

Summary The box-counting method for determining the fractal dimension (D fj )was applied to the fundamental frequency (F 0 ) perturbations in normal and pathological voices in order to assess its clinical value. The upper limit of these D fj values was similar for both groups, but the distribution for pathological voices extended to lower values than for the normal voices. However, these lower values were most probably the result of one or a few outlying frequency points due to incorrect determination of the vocal period. The D fj of normal voices were within the range of values found for randomly varying F 0 values. It was concluded, that the vocal perturbations in pathological voices are also more or less randomly distributed. So, the D fj , at that least determined with the box-counting method, do not contain clinically relevant information in addition to the traditional measures for the extent of the vocal period perturbations. An exception is special perturbation types like diplophonia. The result of the computation is very sensitive for voice breaks and vibrato and depends on the number of periods.

Objective. To study the effects of high and low relative air humidity (RH) on the visco-elastic properties of the vocal fold cover. Materials and methods. The vocal fold mucosa of sheep larynges was microdissected. The mucosal specimens were attached on one side to an oscillator and on the other side to a force transducer. A sinusoidal oscillation (stress) was applied to the specimen and the transduced force (strain) was recorded in two different conditions of a continuous passing airflow: either dry air (RH = 0%) or humid air (RH = 100%). Of the recorded stress and strain curves the gain and phase-shift between the curves were computed and from these parameters stiffness and viscosity were calculated. In both air conditions the deep surface of the specimen was in contact with a saline bath. Results. Stiffness and viscosity both increased significantly more in dry air than in humid air. This increased stiffness and viscosity returned to baseline values after rehydration. Conclusion. We conclude that these findings indicate that changes in the RH of the airflow passing over the vocal cords influences the visco-elastic properties of the vocal cord cover.

Spasmodic dysphonia voices form, in the same way as substitution voices, a particular category of dysphonia that seems not suited for a standardized basic multidimensional assessment protocol, like the one proposed by the European Laryngological Society. Thirty-three exhaustive analyses were performed on voices of 19 patients diagnosed with adductor spasmodic dysphonia (SD), before and after treatment with Botulinum toxin. The speech material consisted of 40 short sentences phonetically selected for constant voicing. Seven perceptual parameters (traditional and dedicated) were blindly rated by a panel of experienced clinicians. Nine acoustic measures (mainly based on voicing evidence and periodicity) were achieved by a special analysis program suited for strongly irregular signals and validated with synthesized deviant voices. Patients also filled in a VHI-questionnaire. Significant improvement is shown by all three approaches. The traditional GRB perceptual parameters appear to be adequate for these patients. Conversely, the special acoustic analysis program is successful in objectivating the improved regularity of vocal fold vibration: the basic jitter remains the most valuable parameter, when reliably quantified. The VHI is well suited for the voice-related quality of life. Nevertheless, when considering pre-therapy and post-therapy changes, the current study illustrates a complete lack of correlation between the perceptual, acoustic, and self-assessment dimensions. Assessment of SD-voices needs to be tridimensional.

The acoustic distance between the voices of subjects of European and African origin was investigated. The subjects were 33 adult males divided in two groups. Group One consisted of 17 men of African origin, and Group Two included 16 men of European origin, all without vocal pathology at the time of the investigation. Sustained phonation of the vowel /a/ as well as humming were acoustically analyzed by the Real-time Frequency Analyzer (Bruel and Kjaer, type 2123). The F0, intensity of F0, intensity of harmonics 1-7, jitter and noise level intensity were investigated for both phonation tasks. The results of descriptive analysis (one-way variance) showed statistically significant difference between the two groups of subjects at lower frequencies around 300-450 Hz. However, the findings of multivariate statistics (factor congruence analysis) showed significant differences between subject samples in their factor structures. The topic deserves further studies.

This research aimed at establishing acoustic characteristics of breathy and nasal voices, in order to use these results in voice aes-thetics of voice professionals. Thirty-six trained judges evaluated degree of breathness, nasality and pleasantness of 104 male and 103 female voices. The voices were evaluated in a normal and in a rever-sed sound-order. These results were put into correlation with acous-tic variables of LTAS and then ANOVA procedure was applied and Scheo-ffe test for establishment of the significence differences. It was established that female voices showing the highest degree of breat-hness had statistically significantly 3.5 to5 kHz and in the range from 5 to 10 kHz ; and male voices had lower energy from 2.5 to 3.5 kHz and had higher energy from 5 - 10 kHz in relation to non-breathy voices. Female voices showing the highest degree of nasality have significantly higher energy from 70 to 400 Hz in a reversed sound or-der evaluation and lower energy in the part of spectrum from 1 to 1.2 kHz and from 2.5 to 5 kHz (2.5 to 3 and 3.5 to 5 kHz) in a normal so-und order, and male voices have lower energy from 330 to 550 Hz and higher energy from 850 Hz to 3 kHz in a normal sound order (significantly higher energy from 0.55 to 1 kHz, in a reversed sound order evaluation) in relation to the non-nasal voices. Also, male na-sal voices have non significantly lower energy from 3 to 10 kHz. It can also be said that nasality, more than breathness is connected with unpleasant voices.