High-Resolution Manometry Contributions to the Physiology of Phonation

High-resolution manometry (HRM) is a motility diagnostic system that measures intraluminal pressure of the gastrointestinal tract using a series of closely spaced pressure sensors. The topographic plot generated by HRM software makes it possible to visualize phonation pressures at the pharynx, UES, and body of the esophagus in real time, indicating pressure intensity by color, which permits easy data interpretation. It has been largely used for swallowing study and dysphagia diagnosis. Due to the proximity of the pharyngoesophageal and laryngeal structures, this technology instigated voice researchers. Despite the few studies published so far, high-resolution manometry has yet proven to be an extremely useful tool in obtaining entire pharyngoesophageal segment pressure measurements during phonation. It also allows natural voice production not interfering with the mouth area. HRM data already brought light to subglottic pressure, vertical laryngeal excursion, cricopharyngeal muscle activation, air flow, muscle tension associated with vocalization and pressure variations associated with different phonatory stimuli.

La manometría de alta resolución (HRM, por sus siglas en inglés) es un sistema de diagnóstico de motilidad que mide la presión intraluminal del tracto gastrointestinal mediante una serie de sensores de presión dispuestos de manera cercana. El gráfico topográfico generado por el software de HRM permite visualizar las presiones de fonación en la faringe, el EEI y el cuerpo del esófago en tiempo real, indicando la intensidad de la presión mediante colores que facilitan la interpretación de los datos. Ha sido ampliamente utilizado para el estudio de la deglución y el diagnóstico de la disfagia. Debido a la proximidad de las estructuras faringoesofágicas y laríngeas, esta tecnología ha despertado el interés de los investigadores en voz. A pesar de los pocos estudios publicados hasta ahora, la manometría de alta resolución ha demostrado ser una herramienta extremadamente útil para obtener mediciones de presión de todo el segmento faringoesofágico durante la fonación. Además, permite la producción natural de la voz sin interferir en el área de la boca. Los datos de HRM ya han arrojado luz sobre la presión subglótica, la excursión laríngea vertical, la activación del músculo cricofaríngeo, el flujo de aire, la tensión muscular asociada con la vocalización y las variaciones de presión asociadas con diferentes estímulos fonatorios.

Etiology of Hoarseness of Voice Based on FOL

Background: Hoarseness (dysphonia) is the reason for about 1% of all consultations in primary care. Numerous conditions can cause hoarseness, ranging from simple inflammatory processes to more serious systemic, neurologic, or cancerous conditions involving the larynx. Evaluation of a patient with hoarseness includes a careful history, physical examination, and in many cases, laryngoscopy. This study aimed to analyze the etiology of hoarseness of voice based on a fiberoptic laryngoscope (FOL). Material & Methods: This cross-sectional study was conducted in the Department of ENT, in Bangabandhu Sheikh Mujib Medical College Hospital, Faridpur for 2 years; from January 2017 to December 2018. A total of 75 subjects fulfilling the inclusion criteria were enrolled as study subjects. Data were processed and analyzed using the software SPSS (Statistical Package for Social Sciences) version 11.5. Results: In this study, most of the patients (18, 24.0%) belonged to the age group of 41-50 years, followed by 16 (21.33%) patients in the 61-70 years of age group, and then 15 (20.0%) patients were in 21-30 years of age group. None was from 0-10 years and only 2 (2.66%) patients belonged to the 11-20 years age group. Concerning the sex of the patients, 62 (83.0%) patients were male and the rest 13 (17.0%) were female indicating male predominance. 40 (53.33%) respondents had a smoking habit, and the rest 35 (46.66%) patients did not have a smoking habit. Regarding occupation, most of the patients (24, 32.0%) were farmers, followed by 19 (25.33%) were businessmen, and 10 (13.33%) patients were service holders. Concerning the findings, most of the patients (20, 26.66%) had growth of larynx, followed by 11 (14.66%) patients had polyp/cyst, 10 (13.33%) patients had paresis, 8 (10.66%) patients had nodule, 6 (8.0%) patients had edema, 4 (5.33%) patients had chronic laryngitis, 3 (4.0%) patients had keratosis/leukoplakia and another 3 (4.0%) patients had a phonatory gap. Conclusion: Hoarseness of voice is a symptom, not a diagnosis, and therefore warrants a careful determination of the underlying cause in every case. Fiber optic laryngoscopy was an excellent tool for the diagnosis of hoarseness. Causes of hoarseness included growth in the larynx, polyp/cyst, nodules, edema, chronic laryngitis, keratosis/leukoplakia, and phonatory gaps in this study.

Valores de referência para dados eletroglotográficos de idosas / Reference values for electroglottographic data of elderly women

RESUMO Objetivo Apresentar valores de referência para os dados de frequência fundamental e quociente de fase fechada extraído da eletroglotografia em idosas e verificar se diferem com o resultado do exame laríngeo. Método Estudo observacional analítico transversal, realizado com 73 idosas na faixa etária de 60 a 84 anos. Foram realizadas avaliações eletroglotográficas e laríngeas. O material de voz coletado de cada participante foi a emissão sustentada da vogal /a/, emitida em frequência e intensidade habituais, no registro modal, de modo prolongado. As medidas eletroglotográficas extraídas foram: Frequência fundamental (F0) e quociente de contato (CQ) extraídos da eletroglotografia (EGG). Foi realizada análise descritiva dos dados por meio da análise das medidas de tendência central e de dispersão das variáveis contínuas. Para estabelecer se as variáveis contínuas do EGG diferem de acordo com o diagnóstico laríngeo, foram utilizados os testes t-Student (teste paramétrico) e Mann-Whitney (não paramétrico). Para todos os testes foi considerado o nível de significância de 5%. Resultados A maioria das participantes não possui alterações laríngeas, 27,4% têm presbilaringe. A média das medidas eletoglotográficas foram: 187,24 Hz de F0 e 48,49% de QC. Não houve significância estatística ao comparar o exame laríngeo segundo as medidas do EGG. Conclusão Mulheres idosas apresentam valores médios de F0 EGG de 187,24 Hz. O valor médio obtido no QC foi de 48,49%. As medidas eletroglotográficas de F0 e QC não se modificaram com a presença de presbilaringe em idosas.

ABSTRACT Purpose To present reference values for fundamental frequency data and closed-phase quotient extracted from electroglottography in older women and verify if they differ from laryngeal examination results. Methods Observational analytical cross-sectional study in 73 older women, aged 60 to 84 years, using electroglottographic and laryngeal examinations. Each participant's voice sample had a sustained prolonged vowel /a/ emitted at the usual frequency and intensity, in the modal register. Fundamental frequency (F0) and vocal fold contact quotient (CQ) were extracted from the electroglottography. Data were descriptively analyzed with measures of central tendency and dispersion of continuous variables. To establish whether continuous electroglottography variables differed from the laryngeal diagnosis, Student's t-test (parametric test) and Mann-Whitney (non-parametric test) were performed. The significance level in all tests was set at 5%. Results Most participants did not have laryngeal changes, while 27.4% had presbylarynx. The mean electroglottographic measures were 187.24 Hz for F0 and 48.49% for CQ. There was no statistical significance between laryngeal examinations and EGG measures. Conclusion Older women have mean electroglottographic F0 values of 187.24 Hz and CQ of 48.49%. Electroglottographic F0 and CQ measures did not change with the presence of the presbylarynx in older women.

Tipos de fibras de los músculos intrínsecos laríngeos de seres humanos: una revisión de la literatura / Fiber types in human intrinsic laryngeal muscles: a literature review

El estudio de las fibras musculares permite comprender con mejor detalle la composición de los músculos y sus características funcionales. Además, facilita la aplicación de programas de entrenamiento y rehabilitación basados en las vías energéticas que regulan la contracción muscular. Su estudio generalmente va unido al análisis de las cadenas pesadas de miosina (MyHC), las que informan sobre las características y propiedades funcionales del músculo. El objetivo de este trabajo fue sintetizar la evidencia científica disponible sobre la distribución de fibras musculares y de isoformas de cadenas pesadas de miosina de los músculos intrínsecos de la laringe de seres humanos. Se realizó una revisión sistemática de la literatura mediante el análisis de artículos encontrados en las bases de datos PubMed, EBSCOHost y SciELO. Los hallazgos informan sobre la existencia de fibras tónicas lentas y tipo I, II, IIA y IIX/IIB. Además, se reconoce la presencia de las isoformas MyHC-I, MyHC-IIA, MyHC-IIX, MyHC-Fetal, MyHC-L y MyHC-IIB. En conclusión, los músculos intrínsecos de la laringe presentan una mezcla de fibras y de isoformas de MyHC lentas y rápidas,la que obedece a adaptaciones y cambios evolutivos que han permitido, por ejemplo, las características fonatorias que presenta la voz del ser humano.

The study of muscle fibers allows the composition of muscles and their functional characteristics to be understood in greaterdetail. In addition, it makes it possible to applytraining and rehabilitation programs based on the energypathways that regulatemuscle contraction. Studying muscle fibers is generally associated withthe analysis of myosin heavy chains (MHC) which provide information on the functional characteristics and properties of muscles. The objective of this study was to synthesize the available scientific evidence onthe distribution of muscle fibers and myosin heavy chain isoforms present in the intrinsic laryngeal muscles of human beings. A systematic reviewof the literature was carried outand articles found on PubMed, EBSCOHost,and SciELOwere analyzed.The findings showthe presenceof slow-tonic, type I, type II, type IIA, and type IIX/IIB fibers. Additionally,isoforms MHC-I, MHC-IIA, MHC-IIX, MHC-Fetal, MHC-L, and MHC-IIB canbe found. In conclusion, intrinsic laryngeal muscles are composed ofa combination of slow and fast fibers and MHC isoforms, derived from evolutionary adaptations and changes which have given way, among other things, to the phonetic characteristics ofthe human voice.

The aging larynx: An anatomical perspective

There has been a striking increase in the geriatric population worldwide over the last few decades. As the aging process continues to alter functioning of all body systems, the human voice is also significantly affected. The senile voice is characterized by its changes in pitch, hoarseness, tremulousness, and breathiness with reduced harmonics and intensity. Such phonatory changes in the elderly may hinder effective communication, thus bringing down their confidence levels and impairing their quality of life. These characteristic features that distinguish the senile voice from younger speakers are accompanied by age?related changes in the organ of phonation, the larynx. The summative morphological and structural changes occurring in the elderly larynx have been referred to as “Presbylarynx.” The present review article is an attempt by the authors to explore the various anatomical age-related changes occurring in the larynx that may be responsible for altered vocal function in the elderly. An improved understanding of the anatomical basis of the aged voice can give further directions into the management of vocal disorders and improved speech performance in the elderly.

Alterations of oral functions and dental malocclusions in adolescents: a cross-sectional population-based study / Alterações das funções orais e má oclusão em adolescentes: um estudo transversal de base populacional

Abstract This article aims to assess whether alterations of oral functions (AOF) are associated with malocclusion (MO)'s type and severity. Cross-sectional study of a representative sample of 332 adolescents aged 12 years in São Luís-MA, Northeastern Brazil. MO criteria included Angle's classification, Dental Aesthetic Index, and other morphological problems. The AOF were evaluated by breathing, phonation, chewing, and swallowing. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using logistic and multinomial regression analyses (α=5%). Mouth breathing was associated with defined (OR=3.84; 95%CI=1.45-10.12), disabling (OR=4.34; 95%CI=1.99-9.49), and class III (OR=4.15; 95%CI=1.19-14.54) MO. Phonation problems were associated with defined (OR=2.01; 95%CI=1.02-4.39), disabling (OR=3.04; 95%CI=1.55-5.96), and Class II (OR=2.02; 95%CI=1.28-3.18) MO. Chewing disorders were associated with posterior crossbite (PCB) (OR=2.32; 95%CI=1.12-4.82). Swallowing disorders were associated with Class III MO (OR=5.66; 95%CI=1.35-23.71), PCB (OR=6.13; 95%CI=2.76-13.62), and posterior open bite (OR=4.53; 95%CI=1.72-8.92). Breathing and phonation alterations are associated with MO in anterior arch segments, while chewing and swallowing disorders, in the posterior segments.

Resumo O objetivo deste artigo é avaliar se alterações das funções orais (AFO) estão associadas ao tipo e gravidade da maloclusão (MO). Estudo transversal com amostra representativa de 332 adolescentes de 12 anos em São Luís-MA, Nordeste do Brasil. Critérios de MO incluíram Classificação de Angle, Índice de Estética Dental e outros problemas morfológicos. As AFO foram avaliadas por respiração, fonação, mastigação e deglutição. Odds ratios (OR) e intervalos de confiança de 95% (IC95%) foram calculados em análises de regressão logística e multinomial (α=5%). Respiração oral foi associada com MO definida (OR=3,84; IC95%=1,45-10,12), incapacitante (OR=4,34; IC95%=1,99-9,49) e classe III (OR=4,15; IC95%=1,19-14,54). Problemas de fonação foram associados às MO definidas (OR=2,01; IC95%=1,02-4,39), incapacitantes (OR=3,04; IC95%=1,55-5,96) e Classe II (OR=2,02; IC95%=1,28-3,18). Alterações na mastigação foram associadas à mordida cruzada posterior (MCP) (OR=2,32; IC95%=1,12-4,82). Deglutição atípica foi associada à MO Classe III (OR=5,66; IC95%=1,35-23,71), MCP (OR=6,13; IC95%=2,76-13,62) e mordida aberta posterior (OR=4,53; IC95%=1,72-8,92). Alterações de respiração e fonação estão associadas às MO nos segmentos anteriores do arco, enquanto as de mastigação e deglutição, nos segmentos posteriores.

Problemas del habla asociados a la disglosia labial y palatal / Speech disorders associated with labial and palatal cleft

RESUMEN Fundamento: según la Organización Mundial de la Salud, el paladar y labio fisurado son malformaciones del aparato estomatognático que producen problemas conocidos como disglosia labial y palatal. Estas afectan a una de las funciones del aparato estomatognático como es la fonación. Objetivo: analizar los problemas bucofonatorios asociados a la disglosia labial y palatal. Métodos: se realizó un estudio de tipo no experimental, descriptivo de corte trasversal. La población de estudio estuvo conformada por 62 pacientes de la Fundación Operación Sonrisa Ecuador, de los cuales se seleccionaron 42 mediante un muestreo no probabilístico intencional. La técnica que se utilizó fue la observación con sus instrumentos la historia clínica y el algoritmo de la escala del habla. Resultados: la escala del habla nasolabial, dentopalatina, test de esfuerzo y el total mostraron una correlación negativa escasa con los trastornos de la salud bucodental agrupados. Por otro lado, la escala del habla test de esfuerzo evidenció una asociación negativa débil con relación a los trastornos de salud bucodental agrupadas. La escala nasolabial provocado y velofaríngea no mostraron correlación en ningún nivel con respecto a los trastornos de la salud bucodental agrupados. Conclusiones: la mayor dificultad en la producción de los fonemas fue dentopalatina en /t/, /d/, /l/, /rr/, /ll/. Dentro de la escala del habla, la media del indicador test de esfuerzo mostró la evaluación más baja.

ABSTRACT Background: according to the World Health Organization, the cleft lip and cleft palate are oral disorders that produce speech problems. These ones affect one of the functions of the stomatognathic system such as phonation. Objective: to analyze the oral problems associated with labial and palatal cleft. Methods: a non-experimental, descriptive, transversal study was carried out. The population was constituted of seventy-two patients whose medical records which were filled out by professionals in different health areas of Operation Smile, forty-two of them were selected based on criteria through intentional non-probabilistic sampling. The observation was applied as technique and its instrument was the medical records and the speech algorithm. Results : the nose-labial speech scale, dent-palatine, stress test and the total showed a low negative correlation with the grouped oral pathologies. On the other hand, the stress test speech scale showed a weak negative association in relation to the grouped oral disorders. The provoked nasolabial scale and velopharyngeal did not correlate at any level with respect to the grouped oral pathologies. Conclusion: the greatest difficulty in the production of phonemes was dent-palatine in / t /, / d /, / l /, / rr /, / ll /. The speech scale showed that the average of the effort test indicator showed the lowest evaluation.

Respostas pressóricas faringeana, esofágica e do esfíncter esofagiano a tarefas vocais à luz da manometria de alta resolução / Pharyngeal, upper esophageal sphincteric and esophageal pressures responses related to vocal tasks at the light of high resolution manometry

ABSTRACT BACKGROUND: High-resolution manometry (HRM) represents a potential tool for measuring pharyngoesophageal phonation pressures. OBJECTIVE: This study aims to evaluate pharyngeal, esophageal upper sphincteric and esophageal pressures during different phonation tasks. METHODS: 12 (six males, mean age 27 years) professional singers underwent HRM and produced four different vocal tasks at low, medium and high vocal loudness: vowel /ae/, ascending five note scale, word /hey/ and word /go/. Pressures were measured at pharynx, upper esophageal sphincter (UES) and esophagus. Visual analysis of the HRM topographic plots were performed. RESULTS: Esophageal pressures are higher during vocalization than at rest. Pharyngeal and UES phonation pressures does not differ significantly from rest pressures. Visual analysis of the topographic plots showed an important UES pressure increasement during phonation. CONCLUSION: HRM is a valuable tool for measuring pharyngoesophageal pressures during phonation. Esophageal pressures are higher during phonation than at rest and tend to increase with vocal loudness increment. The topographic plot provides additional data about phonatory mechanism physiology, especially at the UES region.

RESUMO CONTEXTO: A manometria de alta resolução (MAR) é uma ferramenta de grande potencial para mensuração das pressões faringoesofágicas durante a fonação. OBJETIVO: O estudo visa avaliar pressões faringianas, do esfíncter esofagiano superior e do esôfago durante manobras fonatórias. MÉTODOS: Doze (seis homens, idade média 27 anos) cantores profissionais foram submetidos à MAR e produziram quatro tarefas vocais em intensidade baixa, média e alta: vogal / ae /, escala ascendente de cinco notas, palavras /hey/ e /go/. Pressões aos níveis da faringe, esfíncter esofagiano superior e esôfago foram aferidas além de análise visual dos traçados. RESULTADOS: Pressões esofágicas foram maiores na vocalização que no repouso. Pressões da faringe e esfíncter esofagiano superior durante a fonação não foram diferentes que no repouso. Análise visual dos traçados mostrou importante incremento da pressão do esfíncter durante a fonação. CONCLUSÃO: MAR é uma ferramenta valiosa para mensurar as pressões faringoesofágicas durante a fonação. Pressões esofágicas são maiores durante a fonação que no repouso e tendem a aumentar com maior intensidade sonora. Análise visual dos traçados mostram dados adicionais sobre a fisiologia do mecanismo da fonação, especialmente na região do esfíncter esofagiano superior.

Craniofacial and neurological manifestations in patients with Guillain-Barré syndrome / Manifestaciones neurológicas craneofaciales en pacientes con síndrome de Guillain-Barré

Introducción: Among the broad range of symptoms of the Guillain-Barré Syndrome (GBS), patients can present craniofacial manifestations. Consequently, the participation of the dental surgeon in the evaluation of the stomatognathic system using a multidisciplinary approach model is very important. Objective: To identify the craniofacial and neurological manifestations of the Guillain-Barré Syndrome in patients from three hospitals in the district of Lambayeque, Peru, in 2019. Material and Methods: A descriptive, prospective, and cross-sectional study was carried out in 59 patients diagnosed with GBS by means of a clinical evaluation carried out by previously calibrated neurologists (k=0.911). Additionally, an oral evaluation of the oral hygiene index, the periodontal status, and the oral pH was carried out. Data were processed using frequency distribution tables. Results: 4 4.07% of the patients presented at least one functional alteration, such as unilateral limitation for facial expressions (25.42%), dysphagia (18.64%), alteration in phonation (11.86%), and loss of the sense of taste (6.78%), showing involvement of the corresponding cranial nerves. In addition, unfavorable conditions of oral hygiene and acid pH were observed in some cases, which proved adverse for the periodontal structures of the patients. Conclusion: The study found craniofacial manifestations of GBS, such as cases of unilateral facial palsy, dysphagia, difficulty in phonation, and loss of the sense of taste, due to the alteration of the cranial nerves that command these functions. In addition, poor oral hygiene, and the presence of acidic pH in some patients created an adverse environment for the integrity of the periodontal structures

Introducción: El Síndrome de Guillain-Barré (SGB) dentro de su amplia sintomatología puede presentar manifestaciones craneofaciales, por lo que resulta importante la participación del cirujano dentista en la evaluación del sistema estomatognático desde un modelo de abordaje multidisciplinario. Objetivo: Identificar las manifestaciones neurológicas craneofaciales del Síndrome de Guillain-Barré en pacientes de tres establecimientos de salud de Lambayeque, Perú en el año 2019. Materiales y Metodos: Se realizó un estudio descriptivo, prospectivo y transversal, con 59 pacientes diagnosticados con SGB, mediante una evaluación clínica realizada por médicos neurólogos previamente calibrados (k=0,911). Adicionalmente se realizó una evaluación bucodental del índice de higiene oral, del estado periodontal y del pH bucal, siendo procesados los datos mediante tablas de distribución de frecuencias. Resultados: El 44,07% de pacientes presentaron por lo menos una alteración funcional, identificando limitación unilateral para expresiones faciales (25.42%), disfagia (18.64%), alteración en la fonación (11.86%) y pérdida del sentido del gusto (6.78%), evidenciando compromiso de los pares craneales correspondientes. Además se observaron condiciones desfavorables de higiene oral y de pH ácido en algunos casos, que resultaron adversas para las estructuras periodontales de los pacientes. Conclusión: Fueron encontradas manifestaciones craneofaciales del SGB, identificando casos con parálisis facial unilateral, disfagia, dificultad para la fonación y pérdida del sentido del gusto, debido a la alteración de los pares craneales que comandan esas funciones. Además las condiciones desfavorables de higiene oral y la presencia de pH ácido en algunos casos, propiciaron un ambiente adverso para la integridad de las estructuras periodontales.

Orientaciones filosóficas en la intervención fonoaudiológica de voz. El desafío actual de dar el alta / Philosophical orientations in voice therapy. The current challenge of discharge

El presente artículo corresponde a una reflexión sobre las orientaciones filosóficas en la terapia vocal actual. Cuando existe alguna alteración o trastorno vocal, se habla comunmente de un desequilibrio entre los subsistemas involucrados en el proceso fonatorio, es decir, fuelle (sistema respiratorio), fuente (pliegues vocales) y filtro (tracto vocal). Si no hay un correcto balance, entonces el sistema no tiene un correcto funcionamiento y pueden aparecer síntomas como ronquera, sensación de cuerpo extraño, prurito, fatiga vocal o bien disfonía o incluso afonía. Como con-secuencia de estas dificultades, se generan compensaciones que durante el proceso de la intervención fonoaudiológica el profesional debe volver a "equilibrar". Para lograr este objetivo, se desarrollan y analizan las diversas herramientas que entregan las filosofías de pensamiento a lo largo de la historia de la rehabilitación vocal, don-de se encuentran la orientación higiénica, psicológica, sintomatológica, fisiológica y ecléctica. En este mismo sentido, el profesional debe buscar lo que percibe como más idóneo para cada paciente o grupo a intervenir, centrado en mejorar la calidad vocal y las necesidades actuales de estos, basándose en el contexto mundial actual, con el objetivo de lograr un buen proceso de entrenamiento o rehabilitación y final-mente lograr el alta.

The present article corresponds to a reflection about the philosophical orientations in the current vocal therapy. When there are some vocal alterations or disorders, we usually talk about an imbalance between the sub-sysmtems involved in the fonatory process, which are bellows (respiratory system), source (vocal folds) and filter (vocal tract). When there is not a correct balance, the system does not work properly and as a consequence, it is possible to experiment symptoms such as hoarseness, foreign body sensation, pruritus, vocal fatigue, dysphonia or even aphonia. As a result of these difficulties, it is possible to generate compensations through the intervention of speech therapy. By virtue of this therapy the professional must 'balance'. In order to achieve this, it is necessary to develop and analyze the different tools that philoso-phical studies offer through the history of vocal rehabilitation. Some of these tools are hygienic orientation, psychological, symptomatological, physiological and eclec-tic. Thinking on that, the professional must search what it is most suitable for every patient or group of people that he/she will be working with. This must be focus on improving vocal quality and the actual necessities of the patient, based on the current global context. The final purpose of the professional is to achieve a good and healthy process of training and/or rehabilitation to accomplish medical discharge.

Objetivos de intervención en voz: Una propuesta para su análisis y redacción / Voice therapy goals: a proposal for analysis and writing

Este artículo de reflexión aborda aspectos que dan cuenta de la complejidad en el planteamiento de objetivos en torno a los marcos de abordaje vocal contemporáneos. Se plantea la complejidad de la selección y redacción de objetivos para la interven-ción en voz holística y ecléctica, y desde ella, la necesidad de incorporar el modelo CIF y las recomendaciones de la ASHA para el desarrollo de objetivos centrados en la persona, tanto a corto como a largo plazo. Se propone la utilización del método de análisis SMART y su aplicación específica para objetivos de intervención de la voz. Además, se abordan los aspectos formales que se deben considerar para una redacción precisa. Finalmente, se ejemplifica la propuesta mediante un caso clínico. Esta propuesta pretende ser de utilidad para fines terapéuticos y/o para el ámbito académico, tanto en la discusión de la formulación y diseño de planes terapéuticos como en el pensamiento reflexivo asociado al abordaje vocal.

This reflective article addresses aspects that deal with the complexity of objective setting in contemporary vocal approach frameworks. It addresses the complexity in selecting and writing objectives for holistic and eclectic voice therapy and the need to incorporate the ICF model and ASHA recommendations for the development of person-centered goals in both the short and long term. The use of the SMART analysis method is proposed and its specific application for voice therapy goal. Also, the formal aspects to be considered for precise wording are addressed. Finally, the proposal is exemplified through a clinical case. This proposal is intended to be useful for therapeutic and/or academic purposes, both in discussing the formula-tion and design of therapeutic plans and the reflective thinking associated with the vocal approach.

Maximum phonation time in the pulmonary function assessment / Tempo máximo de fonação para avaliação da função pulmonar

ABSTRACT Purpose: to evaluate the reliability of the maximum phonation time (MPT) and Vital Capacity intra and inter-examiner, by means of the single-breath counting test (CT) and the sustained /a/ phoneme, and the slow vital capacity (SVC). Methods: a reliability study carried out in three groups of healthy individuals, each group with 30 volunteers, allocated according to age. SVC was measured using a spirometer, while the MPT was assessed by the phoneme /a/ and CT. The data were analyzed using SPSS version 20.0. Initially, descriptive statistics were used and for data reliability, the intraclass correlation coefficient (ICC). Results: the Intraclass Correlation Coefficients (ICC) were considered excellent, with significant results above 0.92 for SVC and greater than 0.79 for CT and phoneme /a/. Regarding the inter-examiner evaluation, the ICCs were also significant for both SVC with values greater than 0.96, and for CT and the phoneme /a/ with values greater than 0.85. The error inherent in the technique was assessed using the standard error of the measurement for intra and inter-examiner analyses with values ranging from 1.79 to 3.29 for phoneme /a/, 3.20 to 6.58 for CT and 65, 05 to 206.73 for SVCml. Conclusion: phonation techniques with the phoneme /a/ and CT, as well as SVC, have an excellent reliability, due to intra and inter-examiner agreement measures.

RESUMO Objetivo: avaliar a concordância do tempo máximo de fonação (TMF) com a Capacidade Vital, intra e interexaminador, por meio da técnica de contagem numérica em uma única respiração (TC) e do fonema /a/ sustentado e da capacidade vital lenta (CVL). Métodos: trata-se de um estudo de concordância realizado em três grupos de indivíduos saudáveis, cada grupo com 30 voluntários, alocados de acordo a idade. A CVL foi mensurada por meio do espirômetro, enquanto o TMF foi avaliado pela emissão do fonema/a/ e da TC. Os dados foram analisados pelo programa SPSS versão 20.0. Inicialmente utilizou-se estatística descritiva e para concordância dos dados foi utilizado o coeficiente de correlação intraclasse (CCI). Resultados: os Coeficientes de Correlação Intraclasse (CCI) intraexaminadores foram considerados excelentes, com resultados significantes acima de 0,92 para a CVL e maiores que 0.79 para a TC e fonema/a/. Em relação à avaliação interexaminadores, os CCIs também foram significantes tanto para a CVL com valores maiores que 0,96 quanto para a TC e o fonema/a/ com valores maiores que 0,85. O erro inerente a técnica foi avaliada por meio do erro padrão da medida para as analises intra e interexaminadores com valores que variaram de 1,79 a 3,29 para fonema/a/, 3,20 a 6,58 para TC e 65,05 a 206,73 para CVLml. Conclusão: as técnicas de fonação com o fonema /a/ e TC, assim como a CVL, demonstraram uma excelente concordância intra e interexaminadores.

Parámetros vocales para definir la severidad de una disfonía / Vocal parameters to determine severity of voice disorders

Introducción: la severidad de una disfonía da cuenta del grado de alteración que tiene una voz en relación con todos los procesos fisiológicos involucrados con la producción del sonido. Es importante determinar el nivel de severidad a fin de establecer un programa con el conjunto de ejercicios que permitan una rehabilitación apropiada. Objetivo: comprender si el comportamiento de los diferentes parámetros aerodinámicos, electroglotográficos, acústicos y de autorreporte vocal permite o no determinar la severidad de una disfonía. Método: se evaluaron 55 sujetos con diferentes tipos de disfonía según pará-metros aerodinámicos, electroglotográficos, acústicos y de autorreporte vocal. La muestra fue dividida en 3 grupos de acuerdo con el grado de gravedad de la patología. Se aplicó un análisis de varianza para comparar el comportamiento de las variables dependientes en relación con los niveles de severidad de la disfonía. Con el fin de determinar las diferencias entre estos niveles, se aplicó la prueba Post hoc (Tukey) a las variables significativas. Resultados: es posible determinar el nivel de severidad de una disfonía a partir de parámetros acústicos como el CPP, HNR y el cociente de pendiente espectral 1/5-5/8Khz. También se puede hacer por medio de cuestionarios de autorreporte vocal como el VOISS, el VHI y el VTDS

Introduction: the severity of dysphonia shows the degree of alteration that a voice has in relation to all the physiological processes involved in the production of sound. It is essential to determine the level of severity to establish a program with the set of exercises required for a proper rehabilitation. Objective: to understand if the behavior of the different aerodynamic, electroglot-tographic, acoustic, and vocal self-report parameters allows, or not, to determine the severity of dysphonia. Method: 55 subjects with different types of dysphonia were evaluated according to aerodynamic, electroglottographic, acoustic, and vocal self-report parameters. The sample was divided into three groups in relation to the severity degree of the patho-logy. An analysis of variance was applied to compare the behavior of dependent variables with the severity levels of dysphonia. The Post hoc test (Tukey) was applied to the significant variables to determine the differences between the severity levels. Results: it is possible to determine the level of severity of dysphonia from acoustic parameters such as CPP, HNR, and the ratio of spectral slope 1 / 5-5 / 8Khz. It is also possible to use voice self-report questionnaires such as the VOISS, the VHI, and the VTDS

Fisiología del ejercicio en la práctica de la vocología colombiana: una necesidad / Exercise physiology in Colombian vocology practice: a necessity

En los últimos años, la vocología ha prestado un interés particular a la investigación y aplicación clínica de principios ­basados en la ciencia­ que permitan maximizar el aprendizaje y el control motor asociados al funcionamiento de la voz. El proceso de producción vocal ocurre gracias a la acción coordinada de los subsistemas de respiración, fonación y resonancia. Estos, a su vez, deben su operatividad a la activación de diversos músculos que parecen comportarse de forma similar a aquellos que componen las extremidades. Teniendo esto en cuenta, los principios del ejercicio que han demostrado efectividad para mejorar la fuerza y resistencia de la musculatura de las extremidades podrían aplicarse al entrenamiento de la voz. En primer lugar, en este documento se presentan algunos aspectos funcionales del tejido muscular, describiendo las fibras musculares tipo I y II y puntualizando en la distribución de dichas fibras en la musculatura que hace parte de los subsistemas de la función vocal. En segundo lugar, se exponen las adaptaciones fisiológicas derivadas del ejercicio (acondiciona-miento) así como de la degeneración propia de la inactividad (desacondicionamiento). Posteriormente, se hace una explicación del enfoque de ejercitación de resistencia progresiva junto a los cinco principios que lo definen, concentrada en su aplicación a la vocología. Finalmente, se argumenta la necesidad de incluir la ciencia del ejercicio en la práctica e investigación en vocología en el contexto colombiano a la luz de algunos reportes nacionales disponibles hasta la fecha.

In recent years, vocology has focused especially in research and clinical application of evidence-based principles that enhance motor learning and motor control related to voice function. The process of voice production occurs due to coordinated action of respiration, phonation and resonance subsystems. Likewise, the function of these subsystems is a result of the activation of a variety of muscles that seem to behave similarly to skeletal limb muscles. Taking this into account, exercise principles that improve strength and endurance of skeletal limb muscles may also be applied to im-prove performance of voice production. First, this article focuses on functional aspects of muscle tissue; muscle fiber types I and II are described and, in the same way, the distribution of these fibers in voice production muscles is pointed out. Second, phy-siological adaptations to training (conditioning) as well as detraining from inactivity (deconditioning) are portrayed. Afterwards, progressive resistance training is explai-ned next to its principles and its application to vocology. Finally, the paper argues the necessity of including exercise science into practice and research of vocology in Colombian context, based on some national reports available to date

Aerodynamic measurement-Maximum Phonation Time in young patients with benign vocal fold lesions and with normal voice: a comparative analysis

Background: Clinicians use Maximum Phonatory Time (MPT) as one of tool to verify the glottic efficiency objectively. Impairment of vocal fold mucosa integrity due to lesions results in alteration in MPT. The aim of current study was to compare MPT in young adults with vocal fold lesions and age and sex matched normal subjects.Methods: This study was conducted in the Department of ENT & Head and Neck surgery of Government Medical College Srinagar on 41 adult patients with benign vocal fold lesions and 41 healthy subjects matched for age and sex for a period of 2 years from April 2017- April 2019. The aerodynamic measure was measured as maximum phonation time in seconds and the results were analysed statistically. Both patients and controls were explained the procedure. Results: Mean MPT in seconds in males with vocal fold lesion was 14.42 seconds with SD of 5.62 seconds and in females was 10.81 seconds with SD of 3.44 seconds. Coefficients of variation (CV) was 0.35 and 0.21 respectively. In control group it was 18.15 seconds with SD of 5.88 in males and in females it was 15.72 seconds with a SD of 6.21. Mean difference between patients and controls in males and females was 3.8 and 4.9 respectively. P-Value in males and females was 0.053 and 0.003 respectively.Conclusion: Vocal cord lesions decrease MPT in both sexes even in young adults.

Terapia breve intensiva com fonação em tubo de vidro imerso em água: estudo de casos masculinos / Intensive short-term therapy with phonation into a glass tube immersed in water: male case studies

RESUMO Trata-se de um estudo de casos de três homens com 25, 39 e 40 anos de idade, avaliados antes e após dez sessões consecutivas de fonação em tubo de vidro imerso em água. O objetivo foi descrever os resultados vocais da terapia breve intensiva com fonação em tubo de vidro imerso em água, em três homens sem afecções laríngeas e com queixas vocais. Em dois sujeitos, a maioria das medidas de fonte glótica melhorou, mas sem entrar na normalidade. Nos três sujeitos, a maioria das medidas de pressão sonora aumentou acima da normalidade; a maioria dos tempos máximos de fonação aumentou, mas sem entrar na normalidade; a diferença entre a média das vogais e a contagem de números permaneceu fora da normalidade; os resultados das relações s/z e ė/e permaneceram ou entraram na normalidade. Os resultados dos questionários de autoavaliação (Perfil de Participação em Atividades Vocais, Escala de Desconforto do Trato Vocal e Autoavaliação do Grau de Quantidade de Fala e Volume de Voz) mostraram que os escores se mantiveram ou pouco mudaram após a terapia. Todos os sujeitos mostraram Pré-contemplação, primeiro estágio, na Escala URICA-Voz. Nos três homens, após terapia breve intensiva com fonação em tubo de vidro imerso em água, houve discreta melhora na maioria das medidas vocais, mas ainda permaneceram alteradas e, na escala URICA-Voz, o grupo se classificou em Pré-Contemplação.

ABSTRACT This is a case study of three men aged 25, 39, and 40 years old, evaluated before and after ten consecutive phonation sessions into a glass tube immersed in water. The objective of this study was to describe the vocal results of intensive short-term therapy with phonation into a glass tube immerse in water in three men without laryngeal disorders and vocal complaints. In two subjects, most glottic source measurements improved, but without becoming normal. In all three subjects, most sound pressure measurements increased above normal; most of the maximum phonation times have increased, but without becoming normal; the difference between vowel average and number count remained outside the normal range; the results of s/z and ė/e ratios remained or entered the normal range. The results of the self-assessment questionnaires (Voice Activity and Participation Profile, Vocal Tract Discomfort Scale, and Talkativeness and Vocal Loudness Self-Assessment Scale) showed that the scores remained or little changed after therapy. All subjects showed pre-contemplation, first stage, on the URICA-Voice Scale. In the three men, after intensive short-term therapy with phonation into a glass tube immerse in water, there was a slight improvement in most vocal measures, but they still remained altered and, on the URICA-Voice scale, the group was classified as Pre-Contemplation.

Accuracy of single-breath counting test to determine slow vital capacity in hospitalized patients / Acurácia do teste de contagem em uma única respiração para determinar a capacidade vital lenta em pacientes hospitalizados

ABSTRACT Purpose: to identify the accuracy of the single-breath counting test to determine slow vital capacity in hospitalized patients and to evaluate the repeatability of the same examiner. Methods: a diagnostic study and the choice of techniques were randomly assigned. The area under the curve (receiver operating characteristic) was calculated from the slow vital capacity (20ml/kg) to evaluate the best psychometric characteristics of single-breath counting Test for this cutoff point. Repeatability observed by the same examiner was assessed using the Intraclass Correlation Coefficient. Results: 516 patients hospitalized for various diseases were analyzed. In the curve analysis (receiver operating characteristic/slow vital capacity=20ml/Kg), the value of 21 in single-breath counting test with a sensitivity of 94.44% and specificity of 76.62% (area under the curve =0.93, p<0.005) was found. The intraclass correlation coefficient value for the single-breath counting test was 0.976 with p>0.005. Conclusion: the single-breath counting test was a valid and repetitive technique, and may be an important screening option for assessment of lung function in the absence of specific equipment. This technique opens perspectives to replace slow vital capacity measurement in hospitals, which lack spirometric equipment, or in patients who may have a contagious disease, which has a risk of contamination and spread of disease from one patient to another.

RESUMO Objetivo: identificar a acurácia do teste de contagem em uma única respiração para determinar a capacidade vital lenta em pacientes hospitalizados e avaliar sua repetibilidade entre o mesmo examinador. Métodos: estudo de diagnóstico em que a escolha das técnicas foi aleatoriamente atribuída. A área sob a curva (característica de operação do receptor) foi calculada a partir da capacidade vital lenta (20ml/kg) para avaliar as melhores características psicométricas do teste de contagem em uma única respiração para este ponto de corte. A repetibilidade observada pelo mesmo examinador foi avaliada usando o coeficiente de correlação intraclasse. Resultados: foram analisados (característica de operação do receptor/capacidade vital lenta=20ml/Kg), foi encontrado o valor de 21 em teste de contagem em uma única respiração com uma sensibilidade de 94,44% e especificidade de 76,62% (área abaixo da curva=0,93, p<0,005). O valor do coeficiente de correlação intraclasse para o teste de contagem foi 0,976 com p>0,005. Conclusão: o teste de contagem em uma única respiração foi uma técnica válida, repetitiva e pode ser uma importante opção de rastreamento para avaliação da função pulmonar na ausência de equipamentos específicos. Essa técnica abre perspectivas no que se refere à substituição da medição da capacidade vital lenta em hospitais que não possuem equipamento espirométrico ou em pacientes que apresentam uma doença contagiosa com risco de contaminação e propagação de doença de um paciente para outro.

Obturadores de paladar en el sistema respiratorio-fono-articular. Caso clínico / Palatal obturators in the respiratory-phono-articular system. Clinical case

RESUMEN Los maxilares son los huesos que proveen soporte a la base del cráneo y son esenciales en la caja de resonancia para la producción de la voz, así como el sostén de los músculos del paladar blando por lo que los defectos creados en estas estructuras anatómicas tras la resección de neoplasias o traumatismos, dan como consecuencia la pérdida de algunas funciones como la fonación, deglución, masticación, respiración, estética y la pérdida de la autoestima. El paladar blando es un elemento esencial en los movimientos de la válvula velofaríngea que regula y dirige la transmisión de la energía del sonido y la presión de aire en las cavidades oral y nasal durante el habla, las resecciones de esta estructura involucran un reto en la rehabilitación.

ABSTRACT The maxillaries are the bones that provide support to the base of the skull and are essential in the sounding board for the voice production as well as the support of the muscles of the soft palate so that defects in these anatomical structures created after resection of tumors or trauma, they result in the loss of some features like phonation, swallowing, chewing, breathing, aesthetics and loss of self esteem. The soft palate is an essential element in velopharyngeal movements regulating valve and directs the transmission of sound energy and the air pressure in the oral and nasal cavities during speech, resections that this structure involves a challenge rehabilitation.

Maximum phonation times and vital capacity in dysphonic women / Tempos máximos de fonação e capacidade vital de mulheres disfônicas

ABSTRACT Objective: to verify the correlation between vital capacity and maximum phonation times of /ė/ (unvoiced) and /s/, as well as compare and relate them with the professional voice use and age in women with functional or organic-functional dysphonia. Methods: a retrospective research with 524 records of dysphonic patients from a school clinic, including young adult women with a speech-language diagnosis of functional or organic-functional dysphonia based on medical reports. Neurological and psychiatric alterations, previous speech therapy treatment, symptoms of flu or allergies on the day of evaluation, pulmonary disease, organic dysphonia diagnosis, and hearing loss, were excluded. The sample resulted in 14 women with functional dysphonia and 21 with organic-functional dysphonia. Data on professional voice use, as well as results for vital capacity and maximum phonation times were collected. The data were statistically analyzed at a 5% significance level. Results: There was a positive correlation for both groups of dysphonic patients between the maximum phonation times of /ė/ and of /s/, as well as the maximum phonation times of /ė/, /s/, and vital capacity. Higher values for vital capacity and maximum times of /s/ and /ė/ for voice professionals were seen. The maximum phonation times of /ė/ were lower than those of /s/. Conclusion: as the maximum phonation times of /ė/ increased, the maximum phonation times of /s/ and the vital capacity also augmented in both groups, demonstrating the interrelation among these variables; there was no relation with the other variables studied.

RESUMO Objetivo: verificar a correlação entre capacidade vital, tempos máximos de fonação de /ė/ (sem sonorização) e /s/ e comparar e relacionar com o uso profissional da voz e a idade em mulheres com disfonia funcional ou organofuncional. Métodos: pesquisa retrospectiva com 524 registros de disfônicos de uma clínica-escola. Foram incluídas: mulheres adultas jovens, diagnóstico fonoaudiológico de disfonia funcional ou organofuncional, com base no laudo médico. Foram excluídas: alterações neurológicas, psiquiátricas, tratamento fonoaudiológico prévio, quadro gripal ou alérgico no dia das avaliações, doença pulmonar, diagnóstico de disfonia orgânica, perda auditiva. A amostra resultou em 14 mulheres com disfonia funcional e 21 com disfonia organofuncional. Coletaram-se dados sobre e uso profissional da voz e resultados da capacidade vital e dos tempos máximos de fonação. Os dados foram analisados estatisticamente com nível de significância de 5%. Resultados: correlação positiva para ambos os grupos de disfônicas entre: tempo máximo de fonação de /ė/ e tempo máximo de fonação de /s/; e entre tempo máximo de fonação de /ė/, /s/ e capacidade vital. Maiores valores de capacidade vital, tempo máximo de /s/ e /ė/ nas profissionais da voz. Os valores de tempo máximo de fonação de /ė/ foram menores do que /s/. Conclusão: à medida que o tempo máximo de fonação de /ė/ aumentou, o tempo máximo de fonação de /s/ e a capacidade vital também aumentaram em ambos os grupos, evidenciando a inter-relação entre essas variáveis; não havendo relação com as demais variáveis estudadas.

Estado de los parámetros de habla en usuarios con enfermedad pulmonar obstructiva crónica (EPOC), reporte de una serie de casos / State of speech parameters in subjects with chronic obstructive pulmonary disease (COPD): a case-series report

Objetivo: Caracterizar los parámetros de habla en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Materiales y métodos: Serie de casos prospectiva. En todos los pacientes se realizó una evaluación de los siguientes parámetros del habla: tiempo máximo fonatorio, control motor oral, articulación, lectura, diadococinesias verbales y habla automática. Todos ellos fueron descritos a través de media, mediana y desviación estándar con el software SPSS versión 23. Resultados: Al estudio ingresaron 20 sujetos (7 hombres y 13 mujeres), edad promedio 64,4±9,1 años. En cuanto a los parámetros de habla se observó una reducción en tiempo máximo de fonación (TMF) en /s/ 6,58±6,76; /a/7,29±5,08; /i/8,24±5,72, lo mismo ocurrió en las tareas de repetición /pa/12,60±3,36; /ta/13,40±3,4, /ka/12±4,11 y número de palabras por minuto 109±26,25. Conclusiones: Los resultados de este estudio sugieren que los pacientes con EPOC presentan un deterioro en los parámetros del habla, lo que representa una posibilidad de ampliar investigaciones en esta línea y con ello considerar el habla en atención clínica integral

Objective: To characterize the speech parameters in patients with chronic obstructive pulmonary disease (COPD). Materials and methods: A prospective case-series study. All patients underwent an evaluation of the following speech parameters: maximum phonation time, oral-motor control, articulation, reading, verbal diadochokinesia, and automatic speech. The mean, median and standard deviation of these parameters were determined using SPSS software version 23. Results: Twenty (20) subjects (7 males and 13 females) whose average age was 64.4 ± 9.1 years entered the study. The speech parameters showed a reduction in the maximum phonation time (MPT) in /s/ 6.58 ± 6.76, /a/ 7.29 ±5.08, /i/ 8.24 ± 5.72. The same happened in the repetition tasks: /pa/ 12.60 ± 3.36, /ta/ 13.40 ± 3.4, /ka/ 12 ±4.11, and the number of words per minute accounted for 109 ± 26.25. Conclusions: The study results suggest that patients with COPD show an impairment in speech parameters. This represents an opportunity to increase research on this topic and thus consider the speech in the comprehensive clinical care.