A Trigger Reduction Approach to Treatment of Paradoxical Vocal Fold Motion Disorder in the Pediatric Population Publication date: Available online 16 September 2019 Source: Journal of Voice Author(s): Craig Zalvan, Erick Yuen, Jan Geliebter, Raj Tiwari Abstract Objectives Paradoxical vocal fold motion disorder (PVFMD), or induced laryngeal obstruction (ILO), is a clinical phenomenon characterized by inappropriate adduction of the true vocal folds during inspiration. The resultant episodes of acute respiratory distress marked by exercise-induced cough, inspiratory stridor, throat tightness, and shortness of breath are often misattributed to asthma despite normal pulmonary function testing results. Although the pathogenesis of the disease remains unclear, the etiology is likely multifactorial with an inflammatory, neurological, and psychiatric basis. Our trigger reduction approach, consisting of a plant-based, Mediterranean-style diet to treat laryngopharyngeal reflux and sinus toilet, aims to dampen the peripheral neuronal hyperexcitability of the laryngopharyngeal tissues that is hypothesized to contribute to this disorder. The primary objective of the present study was to assess for therapeutic efficacy by analyzing pre- and post-treatment subjective scores using four validated indices: Voice Handicap Index (VHI), Reflux Symptom Index (RSI), Dyspnea Index (DI), and Cough Severity Index (CSI). Methods A retrospective chart review of all patients age ≤18 years seen by the senior author between 2012 and 2018 who reported laryngeal spasm (J35.5) as a presenting complaint with no underlying organic diagnosis that otherwise explained the symptom identified the study cohort. Patients were excluded if another cause of their laryngeal spasm was identified or their medical records were incomplete. Results Of 80 patients, 24 met the criteria. The most frequent presenting symptom was exercise-induced dyspnea (79%). Of the four measured indices, only a change in DI (P = 0.024) met statistical significance. Of 24 patients, 18 (75%) demonstrated a reduction in DI following our treatment protocol. Using reduction in DI as a continuous variable to assess response, the patient cohort experienced a 4.62 (95% confidence interval [CI]: 0.65–8.6) mean point reduction. Using the eight-point reduction (improvement) in DI as an accepted clinical response to treatment, 8 of 24 patients (33%) experienced a clinically relevant response. Changes in CSI (P = 0.059), RSI (P = 0.27), and VHI (P = 0.25) did not meet statistical significance. Of 24 patients, 8 (33%), 11 (46%), and 7 (29%) demonstrated a reduction in CSI, RSI, and VHI following our trigger reduction protocol, respectively. The patient cohort experienced a mean point reduction of 1.8 (95% CI: −0.1 to 3.7), 1.3 (95% CI: −1.1 to 3.7), and 1.3 (95% CI: −1.0 to 3.6) in CSI, RSI, and VHI, respectively. Conclusions Paradoxical vocal fold motion disorder is a multifactorial disease that poses diagnostic and therapeutic challenges. Early diagnosis and treatment are critical to ensure patient safety, satisfaction, and reduction in health care costs, as mistreatment with asthma pharmacotherapy, intubation, or tracheostomy may exacerbate their dyspnea and lead to preventable hospitalizations. Our results demonstrate that a trigger reduction approach consisting of a plant-based, Mediterranean-style diet and sinus toilet alone may not achieve a clinically meaningful response in the majority of patients. However, given their favorable safety profile, our therapeutic regimen, along with respiratory retraining therapy, may provide symptom relief for selected patients who would otherwise continue to suffer.

Vocal Fatigue in Prospective Vocal Professionals Publication date: Available online 14 September 2019 Source: Journal of Voice Author(s): Supraja Anand, Pasquale Bottalico, Camille Gray Abstract Objectives The goals of the study were to (a) examine vocal fatigue in speech-language pathology students through subjective and objective measures following a novel 30-minute vocal loading task (VLT) and (b) evaluate the effects of psychosocial factors on vocal fatigue. Methods Seventeen speech-language pathology students completed a 30-minute VLT using the LingWAVES software program. In addition to maintaining target intensity goals during reading a text, participants were also required to modify their pitch and voice quality. Vocal fatigue was measured subjectively using Vocal Fatigue Index and Borg vocal effort scale and objectively using variations of relative sound pressure level, fundamental frequency, pitch strength, smoothed cepstral peak prominence (CPPS), and acoustic voice quality index before, during, and after VLT. Participants provided information on their sleep quantity, stress, and depression through nonstandardized and standardized surveys. Results Results revealed that perceived effort and fatigue increased significantly after the 30-minute VLT. Acoustic measures of relative sound pressure level and fundamental frequency and increased systematically during and after the completion of task. All students were moderately stressed and measures related to pitch were highly related with perceived stress. Conclusions The results of this study provide support for altering multiple vocal parameters to induce measurable changes in vocal fatigue following a short-duration VLT.

Do Voice Acoustic Parameters Differ Between Bilingual English-Spanish Speakers and Monolingual English Speakers During English Productions? Publication date: Available online 14 September 2019 Source: Journal of Voice Author(s): Lady Catherine Cantor-Cutiva, Pasquale Bottalico, Charles Nudelman, Jossemia Webster, Eric J. Hunter Summary Background In addition to language differences in fundamental frequency between bilinguals and monolinguals, studies have also included other acoustic parameters to analyze differences in voice production associated with the language spoken. Aim To identify differences in voice acoustic parameters during English productions between monolingual and bilingual English speakers. Method Exploratory cross-sectional study with two groups of subjects: monolingual English speakers (n = 40), and bilingual English-Spanish speakers (n = 13). Participants filled out a questionnaire and recorded one reading in English (second sentence of Rainbow passage “The rainbow is a division of white light into many beautiful colors”) under a “virtual-simulated” acoustic condition of No Noise and Medium Reverberation Time (0.8 seconds). Result Analysis by gender shows that monolingual speakers had higher fundamental frequency mode, and lower standard deviation of fundamental frequency compared to bilingual English-Spanish speakers. Bilingual male speakers had higher jitter and harmonics-to-noise ratio than monolingual speakers. On the contrary, female bilingual speakers had lower jitter and shimmer than monolingual speakers. Conclusions Speaking a second language may influence voice acoustic parameters, and therefore, should be considered when comparing acoustic speech metrics.

Upper Airway Thermoregulation During Singing Warm-Up Publication date: Available online 13 September 2019 Source: Journal of Voice Author(s): Mary J. Sandage, Shuoyang Wang, Guanqun Cao Abstract The primary aim of this research was to quantify the degree to which the upper airway temperature changes with singing warm-up. Based on prior upper airway thermoregulation research it was hypothesized that upper airway temperature would not significantly increase during singing warm up when compared to prewarm up and recovery phases. Ten participants completed a short singing warm-up of their choice until they felt sufficiently warmed up while upper airway temperature was measured at 1 second intervals via a transnasal thermistor placed against the posterior pharyngeal wall, just above the larynx. Descriptive statistics and statistical modeling were used for comparison of pre-warm-up, warm-up, and recovery phases of a short singing warm-up. Results indicated a physiologically-significant increase (≥0.5°C) of upper airway temperature during the singing warm-up when compared to the prewarm up average. Significant differences (P < 0.0001) were identified between all pairwise comparisons analyzed for the three phases of data collected (baseline, warm-up, and recovery). These findings support an upper airway tissue temperature increase in response to the singing warm-up. The extent to which these findings can be generalized to the intrinsic laryngeal muscles is still unknown given the technical difficulty of obtaining intramuscular laryngeal temperature measures.

Validation of the Dysphonia Severity Index in the Dr. Speech Program Publication date: Available online 13 September 2019 Source: Journal of Voice Author(s): HaKyung Kim, ShaoHua Gao, Bin Yi, RunJie Shi, Qin Wan, ZhaoMing Huang Abstract Purpose The Dysphonia Severity Index (DSI) is an objective multiparameter index of voice quality that measures and describes overall voice quality. Some studies have suggested that the reliability of devices for DSI measurement should be examined. We explored the feasibility of DSI measurements using the Dr. Speech (DRS) device, verified its effectiveness for clinical voice measurements and intradevice reliability, and examined the correlation between the DSI and self-evaluations of voice problems. Methods Seventy adult participants (including individuals with voice problems and healthy adults) underwent objective and subjective voice assessments. These data were then used to establish a DSIDRS model and test the intradevice (DRS device and Praat software) reliability. The clinical validation of the DSIDRS was conducted by measuring the DSI of six other participants and comparing the observed and predicted perceived voice quality as expressed by the G score (of the GRBAS scale). Moreover, the relationship between the DSI measurements and participants’ self-evaluations of voice problems was investigated by analyzing the correlation between the DSI and the Voice Handicap Index (VHI). Results The DSIDRS discriminated 80% of participants’ voice quality ratings. There were strong correlations between the DSI and variables measured by the DRS device and Praat software. Furthermore, there was no significant correlation between the DSIDRS and VHI. Conclusion The DRS device can perform DSI measurements. Objective voice measurements and perceptual voice ratings reflected different aspects of vocal function and its effects. These factors should be considered in clinical practice settings.

Potential Risk Factors and Prevalence of Voice Symptoms in Students Starting Their Teacher Education Publication date: Available online 9 September 2019 Source: Journal of Voice Author(s): Ann-Christine Ohlsson, Gun Demitz-Helin, Ann-Christin Furu, Inger Hällgren, Suvi Karjalainen ABSTRACT The aim of the present study was to determine prevalence of voice problems and potential risk factors in teacher students at the start of their education. A total of 1494 students from seven teacher education schools participated in the study. The students answered a questionnaire about 11 risk factors, and one with six questions about voice symptoms, Screen6, and 30 statements in the Voice Handicap Index (VHI). Students reporting at least 2 weekly voice symptoms in Screen6 were assigned to the group with voice problems. Significance level was P < 0.05. Results: prevalence of risk factors was about the same in the seven groups of teacher students except the group with highest proportion of women that also showed the highest proportion of voice problems, 38%. Prevalence of voice problems in the total group was 17%. Comparison of students with or without voice problems showed that all factors except one were more prevalent among students with voice problems and women were overrepresented. Mean total VHI score was 22 in students with voice problems and eight in students without voice problems. Multiple regression analyses showed that frequent throat infections, hearing problems, previous speech therapy, or voice training were the potential risk factors that had the strongest association with voice symptoms as well as with total score in VHI. Conclusions: results from this study show that it is common that teacher students experience voice problems already at the start of their education and potential risk factors associated with voice problems are identified. Knowing that teaching is a high-risk profession for developing voice disorders, it is crucial that teacher students should receive compulsory preprofessional voice education including voice ergonomics and voice training.

Korean Voice Catastrophization Index (K-VCI): Validation of the Voice Catastrophization Index for Koreans Publication date: Available online 5 September 2019 Source: Journal of Voice Author(s): Yeon Woo Lee, Geun Hyo Kim, In Ho Bae, Hee June Park, Soon Bok Kwon Summary Objective The purpose of present study was to validate a Korean version of the Voice Catastrophization Index for assessing catastrophization in patients with voice problems in a Korean population. Methods Case group patients with voice problems (n = 80) and control group patients without voice problems (n = 25) participated in the study. They were asked to complete three questionnaires: Korean Voice Handicap Index, Korean Voice-Related Quality of Life, and Korean Voice Catastrophization Index (K-VCI). Some of case group with voice problems completed the same three questionnaires again to assess test-retest reliability. Clinicians implemented the Consensus Auditory-Perceptual Evaluation of Voice evaluation to rate the overall severity on voice quality. Results K-VCI scores for case group were significantly higher than those for control group. K-VCI scores were significantly correlated with Korean Voice Handicap Index, Korean Voice-Related Quality of Life, and overall severity. The K-VCI had significant test-retest reliability and its internal consistency was good to excellent (range of Cronbach alpha correlation coefficients: 0.789–0.930). The K-VCI was not affected by patient sex, age, symptom duration, or diagnosis types. K-VCI scores were highest among patients with primary muscle tension dysphonia. Conclusion We validated the K-VCI questionnaire for use in measuring the degree of catastrophization of voice problems in a Korean population. Future studies with a larger sample size will be necessary to further verify this and determine the clinical usefulness of the K-VCI.

Using Pitch Height and Pitch Strength to Characterize Type 1, 2, and 3 Voice Signals Publication date: Available online 5 September 2019 Source: Journal of Voice Author(s): Supraja Anand, Lisa M. Kopf, Rahul Shrivastav, David A. Eddins ABSTRACT Objective Classifying dysphonic voices as type 1, 2, and 3 signals based on their periodicity enables researchers to determine the validity of acoustic measures derived from them. Existing methods of signal typing are commonly performed by listening to the voice sample and visualizing them on narrow-band spectrograms that require training, time, and are subjective in nature. The current study investigated pitch-based metrics (pitch height and pitch strength) as correlates to characterizing voice signal types. The computational estimates were validated with perceptual judgments of pitch height and pitch strength. Methods Pitch height and pitch strength were estimated from Auditory-Sawtooth Waveform Inspired Pitch Estimator Prime algorithm for 30 dysphonic voice segments (10 per type). Ten listeners evaluated pitch height through a single-variable matching task and pitch strength through an anchored magnitude estimation task. One way analyses of variance were used to determine the effects of signal type on pitch height and pitch strength estimates. Relationship between computational and perceptual estimates was evaluated using correlation coefficients and their significance. Results There was a significant difference between signal types in both computational and perceptual pitch strength estimates. Periodic type 1 signals had greater pitch strength compared to type 2 and 3 signals. Auditory-Sawtooth Waveform Inspired Pitch Estimator Prime produced robust computational estimates of pitch height even in type 3 signals when compared to other acoustic software. Listeners were able to reliably judge pitch height in type 2 and 3 signals despite their lack of a clear fundamental frequency. Conclusions Pitch height and pitch strength can be measured in all dysphonic voices irrespective of signal periodicity.

Does Dysphagia Improve Following Laryngeal Reinnervation for Treatment of Hoarseness in Unilateral Vocal Fold Paralysis? Publication date: Available online 3 September 2019 Source: Journal of Voice Author(s): Zahide C. Buyukatalay, Simon Brisebois, Seher Sirin, Albert L. Merati Abstract Purpose There are many reports of the efficacy of laryngeal reinnervation on voice, but there is a paucity of literature regarding its impact on swallowing function. The goal of this study was to explore the impact of laryngeal reinnervation on swallowing outcomes among unilateral vocal fold paralysis (UVFP) patients. Methods We reviewed 22 UVFP cases treated with laryngeal reinnervation at our institution. Ten patients had complete datasets, including Eating Assessment Tool (EAT-10) scores and appropriate follow-up. Wilcoxon signed-rank test was used to compare pre- and postoperative scores. Results Over the study period, 10 cases (mean age 45.7 ± 13.3 years; 6/10 men) with UVFP underwent ansa cervicalis to recurrent laryngeal nerve anastomosis (6/10) or nerve-muscle pedicle procedure (4/10). The median time between injury and surgical reinnervation was 12.4 months (range 2.7–88.5 months). Based on EAT-10 scores 6/10 patients were found to have dysphagia. Of these, four improved their score after surgery, one remained stable, and one deteriorated. The median EAT-10 score of these patients improved from 13 to 7 after surgery, but this difference was not statistically significant (P = 0.138). Conclusion Laryngeal reinnervation procedure has the potential for restoring a near normal voice in UVFP. Laryngeal reinnervation of the vocal fold may be associated with a tendency toward improvement in the EAT-10 score in patients after surgery for hoarseness in the setting of UVFP.

Acoustic and Aerodynamic Comparisons of Voice Qualities Produced After Voice Training Publication date: Available online 3 September 2019 Source: Journal of Voice Author(s): Nicholas A. Barone, Christy L. Ludlow, Cari M. Tellis Summary Characteristics of true vocal fold vibration such as the proportion of closed phase of vibration to open phase, longitudinal tension, and the amount of medial compression are used to define four conditions during Estill Voice Training. However, it is unknown whether trainees achieve these phonatory differences after training. Acoustic and aerodynamic measures were used to determine differences in Slack, Thick, Thin, and Stiff conditions. Twenty-four female speech-language pathology graduate students received training perceiving and producing these four conditions and volunteered to participate 3–5 months later. After a 20-minute refresher training, participants were recorded using the Phonatory Aerodynamic System with electroglottography and Computerized Speech Lab. Four Estill Voice Training experts independently categorized the voice quality productions. Aerodynamic and acoustic measures of productions classified by at least three of four experts as having the intended quality determined if measures differentiated among voice qualities and supported the hypothesized physiological concepts used in training at Bonferroni corrected P ≤ 0.0063. Results showed that Slack had low fundamental frequency (fo), low sound pressure level (SPL), and high vibratory instability; Thick had high subglottal pressure (Psg), high SPL, and high vibratory stability; Stiff had high airflow while Thin had lower Psg than Thick. Seven measures differentiated the four qualities with 88.1% accuracy while only Psg, airflow, and jitter were required to differentiate Thick, Stiff, and Thin with 88.7% accuracy. As acoustic and aerodynamic measures differentiated among voice qualities and supported the theoretical physiological characteristics used in training, they could be used to track accuracy during training.