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In this tribute article to D.G. Miller, we review some historical and recent contributions to understanding the myoelastic-aerodynamic (MEAD) theory of phonation and the related acoustic phenomena in subglottal and vocal tract. At the time of the formulation of MEAD by van den Berg in late 1950s, it was assumed that vocal fold oscillations are self-sustained thanks to increased subglottal pressure pushing the glottis to open and decreased subglottal pressure allowing the glottis to close. In vivo measurements of subglottal pressures during phonation invalidated these assumptions, however, and showed that at low fundamental frequencies subglottal pressure rather tends to reach a maximum value at the beginning of glottal closure and then exhibits damped oscillations. These events can be interpreted as transient acoustic resonance phenomena in the subglottal tract that are triggered by glottal closure. They are analogous to the transient acoustic phenomena seen in the vocal tract. Rather than subglottal pressure oscillations, a more efficient mechanism of transfer of aerodynamic energy to the vocal fold vibrations has been identified in the vertical phase differences (mucosal waves) making the glottal shape more convergent during glottis opening than during glottis closing. Along with other discoveries, these findings form the basis of our current understanding of MEAD., Competing Interests: Conflicts of interest The authors declare that they have no financial conflicts of interest to disclose., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

The electroglottographic (EGG) contact quotient (CQegg), an estimate of the relative duration of vocal fold contact per vibratory cycle, is the most commonly used quantitative analysis parameter in EGG. The purpose of this study is to quantify the CQegg's relation to the closed quotient, a measure more directly related to glottal width changes during vocal fold vibration and the respective sound generation events. Thirteen singers (six females) phonated in four extreme phonation types while independently varying the degree of breathiness and vocal register. EGG recordings were complemented by simultaneous videokymographic (VKG) endoscopy, which allows for calculation of the VKG closed quotient (CQvkg). The CQegg was computed with five different algorithms, all used in previous research. All CQegg algorithms produced CQegg values that clearly differed from the respective CQvkg, with standard deviations around 20% of cycle duration. The difference between CQvkg and CQegg was generally greater for phonations with lower CQvkg. The largest differences were found for low-quality EGG signals with a signal-to-noise ratio below 10 dB, typically stemming from phonations with incomplete glottal closure. Disregarding those low-quality signals, we found the best match between CQegg and CQvkg for a CQegg algorithm operating on the first derivative of the EGG signal. These results show that the terms "closed quotient" and "contact quotient" should not be used interchangeably. They relate to different physiological phenomena. Phonations with incomplete glottal closure having an EGG signal-to-noise ratio below 10 dB are not suited for CQegg analysis., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

In 1985, at a conference sponsored by the National Institutes of Health, Martin Rothenberg first described a form of nonlinear source-tract acoustic interaction mechanism by which some sopranos, singing in their high range, can use to reduce the total airflow, to allow holding the note longer, and simultaneously enrich the quality of the voice, without straining the voice. (M. Rothenberg, "Source-Tract Acoustic Interaction in the Soprano Voice and Implications for Vocal Efficiency," Fourth International Conference on Vocal Fold Physiology, New Haven, Connecticut, June 3-6, 1985.) In this paper, we describe additional evidence for this type of nonlinear source-tract interaction in some soprano singing and describe an analogous interaction phenomenon in communication engineering. We also present some implications for voice research and pedagogy., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Kymographic imaging is a modern method for displaying and evaluating vibratory behaviour of the vocal folds which is crucial for voice production. This review summarizes the state of the art of this method, and focuses on the progress in this area within the last 5 years., Recent Findings: Videokymography, using a special videocamera, offers high-speed (video)kymographic images in real time, which is advantageous in daily clinical practice. Two other methods use software to create kymograms retrospectively: digital kymography processes high-speed videolaryngoscopic recordings and offers numerous research possibilities, whereas strobovideokymography processes videostroboscopic recordings, and its use is limited to regular vibration patterns. Current studies reveal that high-speed kymographic images allow more reliable visual evaluation of vibrations than by watching video recordings. Image analysis procedures have been advanced to quantify the vibration properties of the vocal folds. New information has been obtained on asymmetry, mucosal waves, irregularities, phonation onset, and nonlinear dynamic phenomena in voice disorders, as well as in singing., Summary: High-speed kymography visualizes vibratory features which are not simply observable via traditional methods. It shows large potential in better understanding the functional origin of hoarseness and unsteady phonatory states. Further research in this area is envisioned.

While vocal fold adduction is an important parameter in speech, relatively little has been known on the adjustment of the vocal fold adduction in singing. This study investigates the possibility of separate adjustments of cartilaginous and membranous vocal fold adduction in singing. Six female and seven male subjects, singers and non-singers, were asked to imitate an instructor in producing four phonation types: "aBducted falsetto" (FaB), "aDducted falsetto" (FaD), "aBducted Chest" (CaB), and "aDducted Chest" (CaD). The phonations were evaluated using videostroboscopy, videokymography (VKG), electroglottography (EGG), and audio recordings. All the subjects showed less posterior (cartilaginous) vocal fold adduction in phonation types FaB and CaB than in FaD and CaD, and less membranous vocal fold adduction (smaller closed quotient) in FaB and FaD than in CaB and CaD. The findings indicate that the exercises enabled the singers to separately manipulate (a) cartilaginous adduction and (b) membranous medialization of the glottis though vocal fold bulging. Membranous adduction (monitored via videokymographic closed quotient) was influenced by both membranous medialization and cartilaginous adduction. Individual control over these types of vocal fold adjustments allows singers to create different vocal timbres.

We report novel direct quantitative comparisons between 3D profiling measurements and simulations of human vocal fold vibrations. Until now, in human vocal folds research, only imaging in a horizontal plane was possible. However, for the investigation of several diseases, depth information is needed, especially when the two folds act differently, e.g. in the case of tumour growth. Recently, with our novel depth-kymographic laryngoscope, we obtained calibrated data about the horizontal and vertical positions of the visible surface of the vibrating vocal folds. In order to find relations with physical parameters such as elasticity and damping constants, we numerically simulated the horizontal and vertical positions and movements of the human vocal folds while vibrating and investigated the effect of varying several parameters on the characteristics of the phonation: the masses and their dimensions, the respective forces and pressures, and the details of the vocal tract compartments. Direct one-to-one comparison with measured 3D positions presents-for the first time-a direct means of validation of these calculations. This may start a new field in vocal folds research.

We report the design of a novel laser line-triangulation laryngoscope for the quantitative visualization of the three-dimensional movements of human vocal folds during phonation. This is the first successful in vivo recording of the three-dimensional movements of human vocal folds in absolute values. Triangulation images of the vocal folds are recorded at the rate of 4000 fps with a resolution of 256x256 pixels. A special image-processing algorithm is developed to precisely follow the subpixel movements of the laser line image. Vibration profiles in both horizontal and vertical directions are calibrated and measured in absolute SI units with a resolution of +/-50 microm. We also present a movie showing the vocal folds dynamics in vertical cross section.

Background: A newly developed artificial voice source was clinically evaluated in laryngectomized women for voice quality improvements. The prosthesis was placed in a commercially available, tracheoesophageal shunt valve., Methods: In 17 subjects, voice-producing element (VPE) prototypes were compared with the subject's regular tracheo-esophageal shunt voice in a randomized cross-over trial. The evaluation was based on aeroacoustic measurements and perceptual analysis., Results: Considerably higher fundamental frequencies were attained with the use of the VPE. The sound pressure level also increased for most subjects. The required driving pressures of the lung and air flow rates were altered, allowing significantly longer phonation times in 1 breath. Accumulation of mucus did not interfere with the proper functioning of the device during these tests., Conclusion: A VPE with sound-generating membranes is suitable for providing a substitute voice source for laryngectomized patients, especially patients suggestive of a severely hypotonic or atonic pharyngoesophageal segment who can benefit from a more melodious and louder voice.

We designed and developed a laser line-triangulation endoscope compatible with any standard high-speed camera for a complete three-dimensional profiling of human vocal fold vibration dynamics. With this novel device we are able to measure absolute values of vertical and horizontal vibration amplitudes, length and width of vocal folds as well as the opening and closing velocities from a single in vivo measurement. We have studied, for the first time, the generation and propagation of mucosal waves by locating the position of its maximum vertical position and the propagation velocity. Precise knowledge about the absolute dimensions of human vocal folds and their vibration parameters has significant importance in clinical diagnosis and treatment as well as in fundamental research in voice. The new device can be used to investigate different kinds of pathological conditions including periodic or aperiodic vibrations. Consequently, the new device has significant importance in investigating vocal fold paralysis and in phonosurgical applications.

In cancer patients who have undergone total surgical removal of the larynx, ideally voice rehabilitation should be performed using a shunt valve (placed in a fistula of the tracheo-esophageal wall) and a tracheostoma valve (TSV) to enable hands-free tracheo-esophageal speech. A tracheostoma is created by suturing the trachea into the lower anterior part of the neck, and a TSV is a device that can be placed at the stoma. Unfortunately, many patients are unable to use a TSV, mainly due to fixation difficulties. To improve the fixation of the TSV, tracheostoma tissue connector (TS-TC) prototypes have been designed. Prototype 1 consisted of a titanium ring, inner diameter 30 mm, with a circular polypropylene mesh glued to it with silicone adhesive. Four holes had been drilled into the ring for the insertion of sub- and percutaneous screws. Prototype 2 consisted of a silicone rubber ring, inner diameter 30 mm, combined with polypropylene mesh and four titanium inserts that functioned as a base plate for the insertion of sub- and percutaneous screws. In adult female goats a tracheostoma was created and the prototypes were implanted. After 6 weeks of subcutaneous implantation, percutaneous screws were inserted. After twelve weeks, the experiment was terminated and the implants with the surrounding tissues were processed and examined histologically. The clinical appearance during weeks 7-12 varied from very poor to relatively good. Histologically, the implants showed a uniform inflammatory response. We found that all the tissue surrounding the screws showed signs of epithelial down growth. It was concluded that the two-stage implantation procedure of our prototype TS-TCs in this animal model was unsuccessful. Additional research efforts are necessary to improve tissue immobilization and to devise reliable fixation systems for TSVs., (Copyright 2007 Wiley Periodicals, Inc.)

A modern way of voice rehabilitation after total laryngectomy includes the use of shunt valves and tracheostoma valves. Problems of fixation to the surrounding tissue are a major drawback in the use of the shunt valve, heat and moisture exchange (HME) filters and, especially, the tracheostoma valve. To solve these problems different tissue connectors were developed. The main objective was to test the feasibility of these prototypes in a new animal model. Here we discuss the results, problems and complications of the selected Saanen goat model. In this prospective laboratory study, 19 healthy adult female Saanen goats (Capra hircus) were used and observed post-surgically for 12 weeks. Selection criteria such as comparable anatomy to humans and easy handling were used for animal model development. Also a literature search using the Medline and the ISI Web of Science databases was performed. The anatomy of the Saanen goat was investigated in a separate postmortem study. Surgery consisted of a laryngotracheal separation and implantation of a tracheo-oesophageal and tracheostoma tissue connector with fibrin tissue glue. Postoperative care consisted of frequent stoma care, monitoring appetite, weight, vital signs and administration of antibiotics, analgesics and mucolytic agents. All animals survived the surgical procedure. However, postoperative care was extensive, labour intensive and was accompanied by several complications. Eleven animals died spontaneously before the end of the experiment. The tracheostoma tissue connector caused signs of local infection in all cases. There was no evidence of infection around the tracheo-oesophageal tissue connector in 18 cases. It was concluded that the use of goats in this tracheostoma model was associated with major complications and should, therefore, only be used for short-term experiments with intensive care. Additional research is needed to see if clinical application of the tissue connectors is possible in the future.

Objectives: Kymographic imaging through videokymography has been recognized as a convenient, novel way to display laryngeal behavior, yet little systematic research has been done to map the relevant features displayed in such images. Here we have aimed at specification of these features to enable systematic visual characterization and categorization of vocal fold vibratory patterns in voice disorders., Methods: A cross-sectional, descriptive design was used. We selected 45 subjects and extracted 100 videokymographic images from the archive of more than 7,000 videokymographic examinations of subjects with a wide range of voice disorders. The images showed a large variety of vocal fold vibratory behaviors during sustained phonations. We visually identified the prominent features that distinguished the vibration patterns across the images., Results: We divided the findings into 10 feature categories. They included refined traditional features (eg, mucosal waves), as well as additional features that are obscured in strobolaryngoscopy (eg, different types of irregularities, left-right frequency differences, shapes of lateral and medial peaks, cycle aberrations)., Conclusions: The variations in the identified features reveal different behavioral origins of voice disorders. The findings open new possibilities for objective documentation and for monitoring vocal fold behavior in clinical practice through kymographic imaging.

A stand-alone kymographic system for visualizing human vocal-fold vibration in real time is presented. By using a dual charge-coupled-device construction, the system not only provides kymographic images but also simultaneously presents structural images for navigating the endoscope to a desired position. With a temporal resolution of 7200 lines/s, the kymographic imaging produces a sufficient speed to investigate most types of vocal-fold vibrations. Moreover, by buffering the kymographic images during the vertical blanking periods, the system can retrieve an uninterrupted kymographic image sequence even though the television standard is used. The results from preliminary clinical evaluation present evidence that the real-time kymographic imaging substantially reduces the time required for functional evaluation of the vocal-fold vibrations.

For voice rehabilitation after total laryngectomy a shunt valve is usually placed in the tracheo-esophageal (TE) wall, thereby enabling the production of a TE voice. Some patients, however, are unable to produce a voice of sufficient quality. Furthermore, the TE voice is low pitched, which presents a problem especially for female laryngectomized patients. The voice quality after laryngectomy might be improved by introducing a voice-producing element (VPE) into the TE shunt valve. In this study a sound generator was developed that is suitable for application in such a VPE. This sound generator consists of two elastic membranes placed parallel inside a circular housing. A substitute voice source is created when the membranes start to vibrate via a constant flow of air passing between them. To determine the optimal membrane configuration for proper functioning under physiological conditions, up-scaled physical VPE models with different membrane geometries were evaluated using in vitro experimental tests. For certain membrane geometries the tests showed that a basic sound, containing multiple harmonics, could be successfully produced under physiological air pressure and airflow conditions. The fundamental frequency (60-95 Hz) and sound pressure level (57-78 dB, at 15 cm microphone distance) were regulated via changes in the driving pressure, thereby enabling the possibility of intonation in laryngectomized patients' speech. The obtained frequency range is considered appropriate for producing a substitute voice source for female patients. The geometry considerations in this study can be used for the development of a true scale VPE that can be evaluated clinically, to eventually replace the voice after laryngectomy.

Background: After total laryngectomy and voice rehabilitation using a tracheoesophageal shunt valve, patients often have valve-related complications such as leakage. To solve these problems, a tracheoesophageal tissue connector (TE-TC) was devised to serve as an interface between the patient's tissue (trachea and esophagus) and the shunt valve., Methods: The TE-TC is a permucosal connection constructed from a titanium ring (filled with a silicon rubber plug) combined with polypropylene or titanium mesh. After implantation in adult goats for 12 weeks the implants were submitted to histologic investigation., Results: Firm implant fixation was achieved. In nearly all (18/19), no signs of infection of the implant were seen; 11 of 19 animals died before the end of the experiment owing to complications not related to the implant., Conclusions: The TE-TC is a new device with potential in the solution for fixation-related problems in tracheoesophageal voice rehabilitation.

To improve the voice quality of laryngectomised patients, a voice-producing element has been developed. Prior to in vivo testing we constructed and validated an in-vitro test set-up, consisting of a physical model of the subglottal tract and three physical models of the vocal tract, for the vowels /a/, /i/ and /u/ to evaluate the voice-producing element under physiologic acoustic conditions. To meet acoustic conditions described in the literature, we determined the appropriate dimensions of these physical models, using a numerical model of the pressure perturbation in rigid tubes. The numerical model showed that an acoustic equivalent of the subglottal tract could be obtained with a three-tube system and an end impedance. Vocal tract models could be constructed using two- and four-resonator tubes. The physical models were built and successfully validated according to the human acoustic properties. The developed in-vitro set-up can now be applied to test voice-producing elements or vocal fold models under physiologic acoustic conditions.

In order to identify factors that are associated with voice problems and voice-related absenteeism in teachers, 1,878 questionnaires were analysed. The questionnaires inquired about personal data, voice complaints, voice-related absenteeism from work and conditions that may lead to voice complaints and absenteeism. Different factors play a role in the development and consolidation of voice problems. Physical and psycho-emotional factors appear to be the most important risk factors. Remarkably, voice load and environment seem to be less important as risk factors in the development and consolidation of voice complaints. Teachers who experienced voice problems during their training reported more voice problems during their career. The results of this study stress the importance of a multifactorial approach in the diagnosis and treatment of voice problems, whereby physical and psycho-emotional aspects should be considered as sensitive to the risk of developing voice problems. Moreover, this study shows the crucial importance of adequate voice training during the teacher training programme.

In order to assess voice complaints and absence from work due to voice problems among teachers of primary and secondary education, as well as among a control group, 2,117 questionnaires were analysed. The total group consisted of 1,878 teachers and 239 controls. Female teachers more frequently reported voice complaints and absence from work due to voice problems than their male colleagues. No unequivocal relationship between age on the one hand and voice complaints and absence from work due to voice problems on the other hand was observed. Therefore, the percent of cases was corrected for gender but not for age. More than half of the teachers reported voice problems during their career and about one fifth had a history of absence from work due to voice problems. These numbers are relatively high compared to those of the controls with as well as to those without a vocally demanding profession. More than 20% of the teachers sought medical help or had been treated for a voice problem. Remarkably, more than 12% of the teachers had experienced voice problems during their training and this group reported significantly more voice complaints and absence from work due to voice problems in their career than the colleagues without voice problems during the training. The results of the Voice Handicap Index scores followed these trends. These findings point at voice problems during education as a risk factor for getting voice problems during the career. The results of this study clearly demonstrate that teaching is a high-risk profession for the development of voice problems, which is in accordance with other studies and support the contention that voice is a worldwide problem in the teaching profession. Furthermore, this study indicates the importance of voice care not only during training for the profession but also during the career.

With careers that depend to a large extent on the amplitude and sonorous beauty of their voices, opera singers must pay special attention to high notes, where the wide spacing of the harmonics of the voice source intensifies the critical importance of the tuning of the resonances of the vocal tract. This study uses spectrum analysis to examine a large number of recordings of a particularly challenging high note for tenors, the final sustained B4-flat of the aria 'Celeste Aida' from Verdi's opera Aida. The resonance strategy most frequently found uses a markedly displaced second formant to create a dominant resonance at the frequency of the third harmonic, about 1,400 Hz. Other strategies and combinations of strategies are examined as well. Arguments concerning the validity of drawing conclusions from the acoustic signals available in commercial recordings are considered, and it is concluded that such recordings can contain valuable information on resonance strategies for those who aspire to sing similar high notes., ((c) 2005 S. Karger AG, Basel)

Tracheal research covers two main areas of interest: tracheal reconstruction and tracheal fixation. Tracheal reconstructions are aimed at rearranging or replacing parts of the tracheal tissue using implantation and transplantation techniques. The indications for tracheal reconstruction are numerous: obstructing tracheal tumors, trauma, post-intubation tissue reactions, etc. Although in the past years much progress has been made, none of the new developed techniques have resulted in clinical application at large scale. Tissue engineering is believed to be the technique to provide a solution for reconstruction of tracheal defects. Although developing functional tracheal tissue from different cultured cell types is still a challenge. Tracheal fixation research is relatively new in the field and concentrates on solving fixation-related problems for laryngectomized patients. In prosthetic voice rehabilitation tracheo-esophageal silicon rubber speech valves and tracheostoma valves are used. This is often accompanied by many complications. The animal models used for tracheal research vary widely and in most publications proper scientific arguments for animal selection are never mentioned. It showed that the choice on animal models is a multi-factorial process in which non-scientific arguments tend to play a key role. The aim of this study is to provide biomaterials scientists with information about tracheal research and the animal models used.

Although subglottal pressures in conversational speech are relatively easily measured and thus known, the higher values that sometimes occur in singing (especially in tenors) have received little attention in the literature. Still more unusual is the opportunity to measure a large-scale change over decades in the application of pressure in singing production. This study compares measurements of subglottal pressure in a tenor/singing teacher (JS) at two points in his career: in his early thirties, when he was a subject in HS's dissertation study on the efficiency of voice production; and recently, in his fifties, in connection with JS's forthcoming book on the history of the pedagogy of Bel Canto. Although a single case study, its points of special interest include the high values initially measured (up to 100 cm H2O) and the reduction of this figure by more than 50% in the maximal values of the recent measurements. The study compares these values with those of other singers in the same laboratory (both with esophageal balloon and directly, with a catheter passed through the glottis) and in the literature, as well as discusses in detail the problems pertaining to the measurement (repeatability, correcting for lung volume, etc.). As a sophisticated subject, JS makes some pertinent observations about the changes in his use of subglottal pressure.

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.

The purpose of this retrospective study was to compare the preoperative and intraoperative diagnosis of benign vocal fold lesions for consistency. The diagnosis was made in 221 consecutive patients with benign vocal fold lesions for which a microlaryngoscopy was carried out in a general ENT-clinic. The preoperative diagnosis was obtained by both white halogen and stroboscopic light. The intraoperative diagnosis was obtained by direct microscopic visualization and palpation of the vocal folds. In 36% of the patients, the preoperative diagnosis was changed intraoperatively. In 31% of the patients, a lesion was missed at the preoperative examination and a lesion was diagnosed only during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively, and in 82% of the patients intraoperatively. Specially intracordal lesions constituted a diagnostic pitfall. Because the preoperative and intraoperative diagnosis often differed, both the patients and the ENT-surgeon must keep an open mind about what may need to be done at surgery.

Rapid subglottal pressure changes related to the glottal cycles influence the aerodynamics of phonation. Various methods to measure these have been developed, but are not practical for routine phoniatric use. For that reason, a noninvasive measurement tool is necessary. This article presents a technique that uses a microphone positioned at the skin of the jugular fossa to record the signal which arises in the subglottal spaces and is transmitted through the soft tissue to the surface of the skin. Using the program Glottal Segmentation of Voice and Speech, jugular microphone recordings from two healthy subjects were compared with simultaneously recorded direct intratracheal measurements during the same phonation. A systematic error arising from the transmission properties of the microphone and the soft tissue leads to phase and amplitude deviations. These must be taken into account and require correction. This correction procedure leads to high correlations and a good agreement between the two signals. Even without this correction the jugular microphone measurements proved to be useful as a diagnostic and a therapeutic tool in cases where chest resonance specific processes appear affected. In addition, they offer material for research purposes. Although based on a small number of subjects, the new method shows a good validity; testing on a larger number of subjects will probably strengthen the validity.

The study offers an automatical quantitative method to obtain vibration properties of human vocal folds via videokymography. The presented method is based on image processing, which combines an active contour model with a genetic algorithm to improve detecting precision and processing speed, can accurately extract the vibration wave in videokymograms and quantify the vibration properties in terms of eight typical parameters automatically. To verify the precision of the proposed algorithm, an indirect simulation setup of vocal folds has been performed. The verification result shows that the relative error of the entire simulation system is less than 5%. Applying the method to analyzing hundreds of videokymograms from 12 subjects, the result indicates that the vibration characteristics of vocal folds can be recognized more exactly, and diseases of the vocal folds can be diagnosed quantitatively., (Copyright 2003 S. Karger AG, Basel)

Surgical removal of the larynx results in radically reduced production of voice and speech. To improve voice quality a voice-producing element (VPE) is developed, based on the lip principle, called after the lips of a musician while playing a brass instrument. To optimize the VPE, a numerical model is developed. In this model, the finite element method is used to describe the mechanical behavior of the VPE. The flow is described by two-dimensional incompressible Navier-Stokes equations. The interaction between VPE and airflow is modeled by placing the grid of the VPE model in the grid of the aerodynamical model, and requiring continuity of forces and velocities. By applying and increasing pressure to the numerical model, pulses comparable to glottal volume velocity waveforms are obtained. By variation of geometric parameters their influence can be determined. To validate this numerical model, an in vitro test with a prototype of the VPE is performed. Experimental and numerical results show an acceptable agreement.

In 76 teachers with persisting voice problems, the maintaining factors and coping strategies were examined. Physical, functional, psychological and socioeconomic factors were assessed. A parallel was drawn to a psychological cascade model designed for patients with chronic back pain. The majority of the patients were found to be in a deadlocked situation (phase 1 of the cascade model), for which the combination of externalization and unawareness of the situation is the main risk factor. Subjective rating of the voice problem was assessed by the Voice Handicap Index (VHI) and a visual analogue scale (VAS). Patients in phase 1 of the cascade model showed higher VHI and VAS scores compared with the other patients. For a high VHI score, the combination of socioeconomic factors and being in phase 1 was the most important risk factor. Socioeconomic factors were the most important risk factors for a high VAS score. We introduce the term 'chronicity', which means that the problems are maintained, the patient finds himself in a deadlocked situation, and is sliding down into a chronic disease. 'Chronicity' is essentially different from 'chronic', which refers only to the duration of the disease. We consider maintaining factors and (inadequate) coping factors, which consist of emotional/psychological, physical and socioeconomic aspects, as indicators for chronicity., (Copyright 2003 S. Karger AG, Basel)

Rehabilitation of laryngectomees has been furthered by the introduction of heat and moisture exchange (HME) filters, placed over a tracheostoma or on a tracheostoma valve (TSV). The airflow resistance of HME filters is an important factor with regard to the comfort of the patient. The goal of this study was to determine the airflow resistance (defined as the pressure drop over the device divided by the squared airflow through the device) of 4 commercially available HME filters with and without a TSV. The pressure drop over and the airflow through the devices were measured in vitro. Distinct differences among the devices were found. The mean airflow resistance of the HME filters ranged from 135 to 346 Pa x s2/L2, that of TSVs was between 66 and 297 Pa x s2/L2, and that of the combination was between 263 and 454 Pa x s2/L2. The Stom-Vent 2 HME filter and the Adeva Window TSV with an Adeva filter had the lowest airflow resistance of the devices measured in this study.