Pre- and post-operative voice therapy for benign vocal fold lesions: protocol for a non-randomised, multicentre feasibility trial with embedded process evaluation.

BACKGROUND: Management of benign vocal fold lesions (BVFLs) is variable with individuals receiving surgery, voice therapy, or a combination of these approaches. Some evidence suggests that the best outcomes may be achieved when patients are offered pre- and post-operative voice therapy in addition to phonosurgery, but what constitutes pre- and post-operative voice therapy is poorly described. The pre- and post-operative voice therapy (PAPOV) intervention has been developed and described according to the TIDieR checklist and Rehabilitation Treatment Specification System (RTSS) for voice. The PAPOV intervention is delivered by specialist speech and language therapists trained in the intervention and comprises 7 essential and 4 additional components, delivered in voice therapy sessions with patients who are having surgery on their vocal folds for removal of BVFLs. STUDY DESIGN: Non-randomised, multicentre feasibility trial with embedded process evaluation. METHOD: Forty patients from two sites who are due to undergo phonosurgery will be recruited to receive the PAPOV intervention. Measures of feasibility, including recruitment, retention, and adherence, will be assessed. The feasibility of gathering clinical and cost effectiveness data will be measured pre-treatment, then at 3 and 6 months post-operatively. An embedded process evaluation will be undertaken to explain feasibility findings. DISCUSSION: This study will assess the feasibility of delivering a described voice therapy intervention protocol to patients who are undergoing surgery for removal of BVFLs. Findings will be used to inform the development and implementation of a subsequent effectiveness trial, should this be feasible. TRIAL REGISTRATION: This trial has been prospectively registered on ISRCTN (date 4th January 2023), registration number 17438192, and can be viewed here: https://www.isrctn.com/ISRCTN17438192 .

A mixed-method feasibility study of the use of the Complete Vocal Technique (CVT), a pedagogic method to improve the voice and vocal function in singers and actors, in the treatment of patients with muscle tension dysphonia: a study protocol.

BACKGROUND: Muscle tension dysphonia (MTD) results from inefficient or ineffective voice production and is the cause of voice and throat complaints in up to 40% of patients presenting with hoarseness. Standard treatment is voice therapy (SLT-VT) delivered by specialist speech therapists in voice disorders (SLT-V). The Complete Vocal Technique (CVT) is a structured, pedagogic method which helps healthy singers and other performers optimise their vocal function enabling them to produce any sound required. The aim of this feasibility study is to investigate whether CVT administered by a trained, non-clinical CVT practitioner (CVT-P) can be applied to patients with MTD before progressing to a pilot randomised control study of CVT voice therapy (CVT-VT) versus SLT-VT. METHODS/DESIGN: In this feasibility study, we use a mixed-method, single-arm, prospective cohort design. The primary aim is to demonstrate whether CVT-VT can improve the voice and vocal function in patients with MTD in a pilot study using multidimensional assessment methods. Secondary aims are to assess whether (1) a CVT-VT study is feasible to perform; (2) is acceptable to patients, the CVT-P and SLT-VTs; and (3) whether CVT-VT differs from existing SLT-VT techniques. A minimum of 10 consecutive patients with a clinical diagnosis of primary MTD (types I-III) will be recruited over a 6-month period. Up to 6 video sessions of CVT-VT will be delivered by a CVT-P using a video link. The primary outcome will be a change in pre-/post-therapy scores of a self-reported patient questionnaire (Voice Handicap Index (VHI)). Secondary outcomes include changes in throat symptoms (Vocal Tract Discomfort Scale), acoustic/electroglottographic and auditory-perceptual measures of voice. Acceptability of the CVT-VT will be assessed prospectively, concurrently and retrospectively both quantitatively and qualitatively. Differences from SLT-VT will be assessed by performing a deductive thematic analysis of CVT-P transcripts of therapy sessions. CONCLUSION: This feasibility study will provide important data to support whether to proceed with a randomised controlled pilot study focusing on the effectiveness of the intervention compared to standard SLT-VT. Progression criteria will be based on demonstrating a positive outcome in treatment, successful delivery of the pilot study protocol, acceptability to all stakeholders and satisfactory recruitment rates. TRIAL REGISTRATION: ClinicalTrials.gov website ( NCT05365126 Unique Protocol ID: 19ET004). Registered on 06 May 2022.

Pre- and Postoperative Voice Therapy for Benign Vocal Fold Lesions: An International Electronic Delphi Consensus Study.

INTRODUCTION: Voice therapy management of benign vocal fold lesions (BVFLs) is variable and there are currently no clinical guidelines. Poor descriptions of voice therapy interventions lead to unwarranted variation in treatment. Triangulation of the current evidence identifies a number of potential best practice elements, but also a number of outstanding questions to be explored. The aim of this study was to refine and gain global consensus on "best practice" for a pre- and postoperative voice therapy intervention for adults with BVFLs. METHODS: An international sample of expert voice therapists (n = 42) were recruited to take part in this three-round electronic modified Delphi study. Participants were presented with statements concerning a pre- and postoperative voice therapy intervention. Statements were developed from previous research and based on the TIDieR checklist (eg, why, when, what, how?) Participants rated the extent to which they agreed or disagreed with a statement and gave comments to support their response. Consensus was defined as >75% of participants agreeing or strongly agreeing with a given statement. If consensus was not reached, participant comments were used to generate new statements and were rated in the next round. Stability of consensus between rounds was assessed. RESULTS: The 42 international experts achieved consensus on 33 statements relating to components of a best practice pre- and postoperative voice therapy intervention for patients with BVFLs. Consensus on statements ranged from 81% to 100%. These statements were explicitly mapped to the TIDieR checklist to ensure that all aspects of the intervention were considered and the questions of "why, what, how, when and individual tailoring" were addressed. CONCLUSIONS: This study has significantly enhanced our understanding of what should be in a best practice pre- and postoperative voice therapy intervention. It is important to now test these findings for acceptability and feasibility, prior to considering effectiveness research.

Extreme Vocals-A Retrospective Longitudinal study of Vocal Health in 20 Professional Singers Performing and Teaching Rough Vocal Effects.

BACKGROUND: Rough vocal effects, extreme, or extended vocal techniques to sound intentionally hoarse or rough are an integral part of many genres and styles, and research has recently demonstrated the involvement of supraglottic narrowing and vibrations to produce such sounds. The vocal health of singing with rough vocal effects is poorly documented, especially in a longitudinal manner, while much vocal pedagogy continuously treats the sounds as harming to or dangerous for the vocal mechanism. OBJECTIVE: To longitudinally investigate the vocal health of professional singers who perform the five rough-sounding vocal effects Distortion, Growl, Grunt, Rattle, and Creaking as part of their singing and teaching. METHODS: Twenty singers underwent nasoendoscopic examination, filled in SVHI questionnaires, and were assessed by GRBAS with a 14-year interval in a retrospective longitudinal study (from 2007 to 2021). Endoscopic materials were assessed by Reflux Finding Score and a hybrid version of the Stroboscopy Rating Scale. RESULTS: Singers presented at initiation of study with an average SVHI of 9.2 (±9), which decreased at time of follow up 14 years later to an average of 5.12 (±6). Laryngeal assessments (RFS and SRS) revealed low averages at initiation of study as well as at conclusion of the study with only small fluctuations in averages, with findings mainly relating to arytenoid asymmetry. CONCLUSION: The participating singers perform and teach rough vocal effects continually and present with healthy laryngeal mechanisms and within-normal SVHI and GRBAS scores. The findings suggest that controlled supraglottic narrowing and techniques to allow for supraglottic structures to engage in vibration as an additional noise source can be performed sustainable and in a healthy manner if performed with correct vocal technique.

Intra-tracheal multiplexed sensing of contact pressure and perfusion.

Incorrect endotracheal tube (ETT) cuff inflation pressure causes significant problems for intubated patients. The technical development and first in vivo use of a smart ETT for measurements at the cuff-trachea interface during mechanical ventilation are described. The intra-tracheal multiplexed sensing (iTraXS) ETT contains integrated optical fibre sensors to measure contact pressure and blood perfusion. The device is tested during mechanical ventilation in a porcine model (N=6). For contact pressure, signals were obtained in all 30 measurements. For perfusion, data could be obtained in all 33 measurements. In the 3 cases where the cuff was inflated to an artificially high-level, blood occlusion is observed.

Use of proton pump inhibitors to treat persistent throat symptoms: multicentre, double blind, randomised, placebo controlled trial.

OBJECTIVE: To assess the use of proton pump inhibitors (PPIs) to treat persistent throat symptoms. DESIGN: Pragmatic, double blind, placebo controlled, randomised trial. SETTING: Eight ear, nose, and throat outpatient clinics, United Kingdom. PARTICIPANTS: 346 patients aged 18 years or older with persistent throat symptoms who were randomised according to recruiting centre and baseline severity of symptoms (mild or severe): 172 to lansoprazole and 174 to placebo. INTERVENTION: Random blinded allocation (1:1) to either 30 mg lansoprazole twice daily or matched placebo twice daily for 16 weeks. MAIN OUTCOME MEASURES: Primary outcome was symptomatic response at 16 weeks measured using the total reflux symptom index (RSI) score. Secondary outcomes included symptom response at 12 months, quality of life, and throat appearances. RESULTS: Of 1427 patients initially screened for eligibility, 346 were recruited. The mean age of the study sample was 52.2 (SD 13.7) years, 196 (57%) were women, and 162 (47%) had severe symptoms at presentation; these characteristics were balanced across treatment arms. The primary analysis was performed on 220 patients who completed the primary outcome measure within a window of 14-20 weeks. Mean RSI scores were similar between treatment arms at baseline: lansoprazole 22.0 (95% confidence interval 20.4 to 23.6) and placebo 21.7 (20.5 to 23.0). Improvements (reduction in RSI score) were observed in both groups-score at 16 weeks: lansoprazole 17.4 (15.5 to19.4) and placebo 15.6 (13.8 to 17.3). No statistically significant difference was found between the treatment arms: estimated difference 1.9 points (95% confidence interval -0.3 to 4.2 points; P=0.096) adjusted for site and baseline symptom severity. Lansoprazole showed no benefits over placebo for any secondary outcome measure, including RSI scores at 12 months: lansoprazole 16.0 (13.6 to 18.4) and placebo 13.6 (11.7 to 15.5): estimated difference 2.4 points (-0.6 to 5.4 points). CONCLUSIONS: No evidence was found of benefit from PPI treatment in patients with persistent throat symptoms. RSI scores were similar between the lansoprazole and placebo groups after 16 weeks of treatment and at the 12 month follow-up. TRIAL REGISTRATION: ISRCTN Registry ISRCTN38578686 and EudraCT 2013-004249-17.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT.

BACKGROUND: Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors. OBJECTIVE: To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms. DESIGN: This was a double-blind, placebo-controlled, randomised Phase III trial. SETTING: This was a multicentre UK trial in eight UK ear, nose and throat departments. PARTICIPANTS: A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited. INTERVENTION: Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks. MAIN OUTCOME MEASURE: Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy). RESULTS: A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo. MAIN OUTCOMES: A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity. SECONDARY OUTCOMES: Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months. LIMITATIONS: Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics. CONCLUSIONS: Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole. TRIAL REGISTRATION: Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

BACKGROUND: One of the commonest reasons for patients attending hospital throat or voice clinics is persistent throat symptoms, which include a feeling of a lump in the throat, a cough or a hoarse voice. Over time, more of these patients are being treated with proton pump inhibitors to suppress stomach acid in the belief that stomach acid entering the throat causes the symptoms, but there is little evidence that these medications work. STUDY AIM: The aim of this study is to explore whether or not having a 16-week course of proton pump inhibitors has any impact on throat symptoms. We also tested the usefulness of three different questionnaires in measuring throat symptoms, explored side effects and whether or not patients adhere to treatment, and measured patients' quality of life. METHODS: Patients with persistent (lasting for more than 6 weeks) throat symptoms who agreed to participate were randomised to receive either the proton pump inhibitor lansoprazole or a placebo. Participants took lansoprazole or placebo for 16 weeks. Symptoms and quality of life were measured before patients were randomised and at 4 and 12 months after randomisation. RESULTS: The total number of participants was 346. The mean Reflux Symptom Index outcome score (higher scores meaning worse symptoms) was 22 before the 4-month course of capsules, 16 after 4 months and 15 after 12 months. Participant-reported throat symptoms and quality of life in all participants improved over the 12 months of the study. There was no difference in the symptom improvement experienced by proton pump inhibitor and placebo participants. CONCLUSIONS: This study shows that proton pump inhibitors do not benefit patients with persistent throat symptoms. Future research should focus on other available therapies.

Assessing and Quantifying Air Added to the Voice by Means of Laryngostroboscopic Imaging, EGG, and Acoustics in Vocally Trained Subjects.

OBJECTIVE: To assess and quantify singers' strategies for adding air to phonation to sound "breathy" in a healthy manner STUDY DESIGN: Case-control study with 20 professional singers. METHODS: Twenty singers were recorded performing sustained vowels in the Complete Vocal Technique Neutral vocal mode with and without audible air added to the voice by means of laryngostroboscopic imaging using a videonasoendoscopic camera system, electroglottography, long-term average spectrum, as well as acoustic signals and audio perception. Singers completed Voice Handicap Index and Reflux Symptom Index questionnaires prior to examination. RESULTS: Air added to the voice resulted in an expected glottal gap along the length of the vocal folds, with little to no further difference in the supraglottic area, as compared with the Neutral phonation. Air added resulted in lowered Qx, mean Sound Pressure Level, and Cepstral Peak Prominence, but higher Harmonics-to-Noise Ratio, Jitter, and Shimmer, with decreased energy at the fundamental frequency. Adding audible air to the phonation did not exhibit similar effects on acoustics for males and females. Also, for females, H1-H2 difference decreased with air added, while it increased for males. CONCLUSION: Singers produce an audible airy phonation similar yet significantly different to the breathy phonation reported for both healthy and pathological speakers.

Extreme Vocal Effects Distortion, Growl, Grunt, Rattle, and Creaking as Measured by Electroglottography and Acoustics in 32 Healthy Professional Singers.

Vocal effects - also called extreme or extended vocal techniques - with the intention to sound hoarse or rough are widely used as part of many genres and styles of singing, yet scarcely documented in research. Physiological studies detail the involvement of supraglottic structures for the production of vocal effects, yet the acoustic impact of such involvement has not been documented systematically across phonation types. PURPOSE: To report acoustic measurements and electroglottography-specific measurements for the five rough-sounding vocal effects Distortion, Growl, Grunt, Rattle, and Creaking across phonation types to demonstrate differences between notes with and without vocal effects added. METHODS: Thirty-two professional singers and singing teachers produced sustained vowels in each of the four vocal modes with alternations of adding and removing the vocal effects. The singers were recorded with a microphone at a constant distance as well as with EGG. RESULTS: The vocal effects Distortion, Growl, Grunt, Rattle, and Creaking impact the acoustic spectra in separate and systematic ways across genders and phonation types. Each vocal effect impacted the spectrum in specific and particular frequency regions between 0 and 3.5 KHz as well as in higher partials after 12 kHz with statistical significance. EGG-waveforms were un-impacted by most of the vocal effects produced using supraglottic sound sources, whereas Grunt and Creaking conditions did impact EGG-waveform signals, though not consistently between participants. EGG measures confirmed sustained and unchanged Qx and Fx for most conditions, with statically significant changes in noise measurements Harmonic-to-Noise Ratio, Normalised Noise Energy, Relative Average Perturbation, and Cepstral Peak Prominence, despite Sound Pressure Level differing significantly only for a few specific conditions. Singers scored an average of 5,95 on Voice Handicap Index questionnaires and were all reportedly healthy. CONCLUSIONS: Vocal effects added to phonation produce specific increases and specific decreases in particular frequency regions in a systematic way and can be produced in a healthy and sustainable manner, as measured by Voice Handicap Index. Vocal effects can be added to different phonation types with differing acoustic output and singers were able to sustain and control involvement of the supraglottic sound source(s) independently of phonation type.

Deconstructing Timbre into 5 Physiological Parameters: Vocal Mode, Amount of Metal, Degree of Density, Size of Larynx, and Sound Coloring.

Timbre has been related to adjustment at the source as well as adjustments in resonance, including laryngeal height and hypopharynx area and volume. However, it is often presented in vocal pedagogy as solely related to resonance. Very little data is available on the laryngeal adjustments at both source and resonance involved in achieving various timbres across a variety of phonation types. PURPOSE: To systematically assess the independent laryngeal adjustments at the source and independent laryngeal adjustments in the vocal tract necessary to obtain the lightest and darkest timbral extremes for four different phonation types. METHODS: Twenty-one professional singers produced a sustained vowel "EH" as in "stay" in each of the four phonation types ("UH" as in "hungry" for one type), varying the sound coloring to the lightest and darkest of their ability without altering pitch, vowel, or loudness. The singers were observed using laryngostroboscopy and electroglottography. A systematic assessment protocol covering 31 laryngeal gestures was developed based on previous research for objectively classifying changes in laryngeal setups. RESULTS: Darkening and lightening the sound color involved altering the size of the vocal tract space related to lowering/raising the larynx, widening/closing the piriform sinuses, increasing/decreasing the distance between stylopharyngeus and palatopharyngeus, increasing/decreasing anterior-posterior narrowing (and the resulting view of the vocal folds), medialising/retracting ventricular folds, and altering supraglottic funnel depth. The phonation types did not show equal ability to be colored. Female singers exhibited less coloring variation compared to the males. Classical singing exhibited both lightening and darkening colouring features. CONCLUSIONS: The singers were able to produce a variety of different timbral expressions within each of the investigated four phonation types by coloring the sustained note darker or lighter using laryngeal adjustments. Timbre is deconstructed as a perceptual artefact defined by (1) the choice of vocal mode, (2) the amount of metallic character, (3) the degree of density in the note, (4) the chosen sound color, and (5) the natural size of the larynx and vocal tract.

Laryngostroboscopic Exploration of Rough Vocal Effects in Singing and their Statistical Recognizability: An Anatomical and Physiological Description and Visual Recognizability Study of Distortion, Growl, Rattle, and Grunt using laryngostroboscopic Imaging and Panel Assessment.

OBJECTIVES: To study vocal effects in singing from the pedagogical method complete vocal technique as related to specific and discrete supraglottic structures and activities by means of laryngostroboscopic imaging and panel testing. STUDY DESIGN: This is a case-control study with a double-panel assessment. METHODS: Twenty singers were recorded performing four of the rough vocal effects from the method Complete Vocal Technique. Two studies were performed: (1) Laryngostroboscopic examination using a videonasoendoscopic camera system and the Laryngostrobe program; (2) two blind-panel assessments with (a) voice clinicians and (b) singing teachers to investigate the recognizability of the vocal effects in supraglottic structures. RESULTS: The four investigated vocal effects could be related to particular and discrete vibratory pattern of supraglottic structures; Distortion as vibrations of the ventricular folds, Growl as vibrations of the arytenoid cartilages against the epiglottis, Rattle as the vibration of the arytenoid cartilages against one another, and Grunt as the vibrations of the whole supraglottic structure from level 1-4 at low frequencies with a large amplitude in the vibration of the vocal folds, with particular movement of the aryepiglottic folds. The two panels recognized the vocal effects with 91%/96% accuracy for Distortion, 91%/74% accuracy for Rattle, 90%/66% accuracy for Grunt, and 83%/99% accuracy for Growl, with an overall accuracy of 91%/84%. CONCLUSION: Vocal effects can be performed, identified, and recognized as particular vibratory patterns of supraglottic structures with no visible pathology in subjects performing the effects.

Presbylaryngis: a state-of-the-art review.

PURPOSE OF REVIEW: Presbylaryngis is the term used to describe changes in the larynx with ageing. It represents an increasingly common complaint as global populations continue to grow and get older. Presbylaryngis has a significantly negative impact on patients' quality of life and their ability to participate in society. This article will review the relevant literature on the incidence, pathophysiology, clinical evaluation, and treatment modalities for presbylaryngis. RECENT FINDINGS: The recently developed Ageing Voice Index (AVI) constitutes the first validated instrument for voice complaints specifically for the elderly. The evidence suggests that the bedrock of treating presbylaryngis centres on voice therapy. Thus, voice therapy should represent the primary treatment offered with surgery reserved for those failing to adequately respond. However, the comparative effectiveness of the different surgical interventions, namely injection laryngoplasty and thyroplasty, remains undetermined highlighting the need for larger, prospective, comparative studies. SUMMARY: Presbylaryngis is characterized by specific changes at the microscopic level resulting in age-related vocal fold atrophy. However, its presence alone does not always result in symptomatic dysphonia and equally, presbyphonia is often multifactorial involving the lower respiratory tract in addition to the larynx. Thus, the role of a multidisciplinary voice clinic for presbylaryngis cannot be overstated.

Investigating Laryngeal "Tilt" on Same-pitch Phonation-Preliminary Findings of Vocal Mode Metal and Density Parameters as Alternatives to Cricothyroid-Thyroarytenoid "Mix".

OBJECTIVES: The objective of this work was to study the parameters "metal" and "density" and their combinatory conditions in relation to the vocal modes Overdrive, Edge, and Curbing from the pedagogical method Complete Vocal Technique by means of laryngostroboscopic imaging, high-speed videoendoscopy, electroglottography (EGG), long-time-average spectrum (LTAS), and acoustics. STUDY DESIGN: This is a three-subject exploratory study. METHODS: Three singers were recorded performing various metal and density conditions of Overdrive, Edge, and Curbing from the Complete Vocal Technique method by means of laryngostroboscopic imaging using a videonasoendoscopic camera system and the Laryngostrobe program, high-speed videoendoscopy, EGG, LTAS, and acoustic signals using SpeechStudio. RESULTS: A laryngeal tilt was discovered as related to the condition of "reduced density" on same-pitch phonation, with observations of the thyroid cartilage tilting forward, stretching of the mucosa covering the cricoid-arytenoid complex and the posterior cricoid, and an upward posterior, slightly superior, contraction of the middle constrictor muscle in the pharyngeal wall. A resulting associated reduced contact quotient was observed on EGG, as well as a lowered mean sound pressure level. On LTAS, the laryngeal tilt was associated with a decrease of spectral energy in areas between the 7th and the 20th harmonic. The subjects of the study were able to perform the tilt without changing pitch or volume. CONCLUSIONS: Singers can perform laryngeal tilt during same-pitch phonation in the vocal modes Overdrive, Edge, and Curbing. The parameters of density and metal establish a more precise and anatomically grounded terminology than "mix register."

Curbing-The Metallic Mode In-between: An empirical study qualifying and categorizing restrained sounds known as Curbing based on audio perception, laryngostroboscopic imaging, acoustics, LTAS, and EGG.

OBJECTIVES: This study aims to study the categorization Curbing from the pedagogical method Complete Vocal Technique as a reduced metallic mode compared with the full metallic modes Overdrive and Edge by means of audio perception, laryngostroboscopic imaging, acoustics, long-term average spectrum (LTAS), and electroglottography (EGG). METHODS: Twenty singers were recorded singing sustained vowels in a restrained character known as Curbing. Two studies were performed: (1) laryngostroboscopic examination using a videonasoendoscopic camera system and the Laryngostrobe program; and (2) simultaneous recording of EGG and acoustic signals using Speech Studio. Images were analyzed based on consensus agreement. Statistical analysis of acoustic, LTAS, and EGG parameters was undertaken using Student paired t tests. RESULTS: The reduced metallic singing mode Curbing has an identifiable laryngeal gesture. Curbing has a more open setting than Overdrive and Edge, with high visibility of the vocal folds, and the false folds giving a rectangular appearance. LTAS showed statistically significant differences between Curbing and the full metallic modes, with less energy across all spectra, yielding a high second and a low third harmonic. Statistically significant differences were identified on Max Qx, Average Qx, Shimmer+, Shimmer-, Shimmer dB, normalized noise energy, cepstral peak prominence, harmonics-to-noise ratio, and mean sound pressure level (P ≤ 0.05). CONCLUSION: Curbing as a voice production strategy is statistically significantly different from Overdrive and Edge, and can be categorized based on audio perception. This study demonstrates consistently different laryngeal gestures between Curbing and Overdrive and Edge, with high corresponding differences in LTAS, EGG and acoustic measures.

Non-recurrent laryngeal nerve with a coexisting contralateral nerve demonstrating extralaryngeal branching.

Non-recurrence and extralaryngeal branching are 2 of the more frequently encountered anomalies of the recurrent laryngeal nerve. If not anticipated intraoperatively, these abnormalities can put the nerve at risk, with subsequent vocal cord palsy. It is therefore important to report on and understand these abnormalities. We present a unique case of a non-recurrent laryngeal nerve with a coexisting contralateral nerve demonstrating extralaryngeal branching. This case allows us to demonstrate the importance of arteria lusoria in head and neck surgery, and to conclude that non-recurrence and extralaryngeal branching can occur separately within individual nerves in the same patient. The case also highlights the importance of a systematic intraoperative approach to the identification of every recurrent laryngeal nerve, especially in bilateral procedures having already exposed an anomalous nerve on one side.

Overdrive and Edge as Refiners of "Belting"?: An Empirical Study Qualifying and Categorizing "Belting" Based on Audio Perception, Laryngostroboscopic Imaging, Acoustics, LTAS, and EGG.

OBJECTIVES: We aimed to study the categorizations "Overdrive" and "Edge" from the pedagogical method Complete Vocal Technique as refiners of the often ill-defined concept of "belting" by means of audio perception, laryngostroboscopic imaging, acoustics, long-term average spectrum (LTAS), and electroglottography (EGG). STUDY DESIGN: This is a case-control study. METHODS: Twenty singers were recorded singing sustained vowels in a "belting" quality refined by audio perception as "Overdrive" and "Edge." Two studies were performed: (1) a laryngostroboscopic examination using a videonasoendoscopic camera system (Olympus) and the Laryngostrobe program (Laryngograph); (2) a simultaneous recording of the EGG and acoustic signals using Speech Studio (Laryngograph). The images were analyzed based on consensus agreement. Statistical analysis of the acoustic, LTAS, and EGG parameters was undertaken using the Student paired t test. RESULTS: The two modes of singing determined by audio perception have visibly different laryngeal gestures: Edge has a more constricted setting than that of Overdrive, where the ventricular folds seem to cover more of the vocal folds, the aryepiglottic folds show a sharper edge in Edge, and the cuneiform cartilages are rolled in anteromedially. LTAS analysis shows a statistical difference, particularly after the ninth harmonic, with a coinciding first formant. The combined group showed statistical differences in shimmer, harmonics-to-noise ratio, normalized noise energy, and mean sound pressure level (P ≤ 0.05). CONCLUSION: "Belting" sounds can be categorized using audio perception into two modes of singing: "Overdrive" and "Edge." This study demonstrates consistent visibly different laryngeal gestures between these modes and with some correspondingly significant differences in LTAS, EGG, and acoustic measures.

Zenker's diverticulum complicating achalasia: a 'cup-and-spill' oesophagus.

A 72-year-old woman presented with long-standing gastro-oesophageal reflux, regurgitation of swallowed food and worsening cervical dysphagia. Fluoroscopic barium oesophagography revealed a posterolateral pharyngeal pouch (Zenker's diverticulum (ZD)) complicating a 'cup and spill' oesophageal deformity with a smoothly tapered segment at the gastro-oesophageal junction. CT and high-resolution manometry confirmed that the underlying abnormality was a massively dilated oesophagus with aperistalsis and pan-oesophageal pressurisation, consistent with a diagnosis of oesophageal achalasia (type II). She underwent endoscopic stapled diverticulotomy, with good symptomatic relief. We discuss the aetiology of ZD, its management and the association here with oesophageal achalasia.

Extramedullary relapse of multiple myeloma in the thyroid cartilage.

Multiple myeloma involving the thyroid cartilage is a very uncommon disease entity. Only 10 cases have been reported in the international literature to date and as such it constitutes a rare and challenging diagnosis to make. We report the case of a 63-year-old man with a background of malignant melanoma and multiple myeloma both of which were in remission at the time of presentation. The patient presented with hoarseness and a large neck mass that turned out to be an extramedullary deposit of his previously treated multiple myeloma indicating disease relapse. The differential diagnosis of a mass in the thyroid cartilage is discussed. Despite its rarity, this diagnosis should be considered even in patients with no history of multiple myeloma, as it can arise de-novo in the thyroid cartilage (extramedullary plasmacytoma). The importance of the multidisciplinary team (MDT) approach as well as recent advances in treatment are also discussed.

Surgical versus non-surgical interventions for vocal cord nodules.

BACKGROUND: This is an update of a Cochrane review first published in The Cochrane Library in Issue 2, 2001 and previously updated in 2007 and 2009.Vocal cord nodules are bilateral, benign, callous-like growths of the mid-portion of the membranous vocal folds. They are of variable size and are characterised histologically by thickening of the epithelium with a variable degree of inflammation in the underlying superficial lamina propria. They characteristically produce hoarseness, discomfort and an unstable voice when speaking or singing. OBJECTIVES: To assess the effectiveness of surgery versus non-surgical interventions for vocal cord nodules. SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 9 April 2012. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing any surgical intervention for vocal cord nodules with non-surgical treatment or no treatment. DATA COLLECTION AND ANALYSIS: No suitable trials were identified. MAIN RESULTS: No studies fulfilled the inclusion criteria. AUTHORS' CONCLUSIONS: There is a need for high-quality randomised controlled trials to evaluate the effectiveness of surgical and non-surgical treatment of vocal cord nodules.