Deep Learning-Based Analysis of Glottal Attack and Offset Times in Adductor Laryngeal Dystonia.

OBJECTIVE: Diagnosis of adductor laryngeal dystonia (AdLD) is challenging as it mimics voice features of other voice disorders. This could lead to misdiagnosis (or delayed diagnosis) and ineffective treatments of AdLD. This paper develops automated measurements of glottal attack time (GAT) and glottal offset time (GOT) from high-speed videoendoscopy (HSV) in connected speech as objective measures that can potentially facilitate the diagnosis of this disorder in the future. METHODS: HSV data were recorded from vocally normal adults and patients with AdLD during the reading of the "Rainbow Passage" and six CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice) sentences. A deep learning framework was designed and trained to segment the glottal area and detect the vocal fold edges in the HSV dataset. This automated framework allowed us to automatically measure and quantify the GATs and GOTs for the participants. Accordingly, a comparison was held between the obtained measurements among vocally normal speakers and those with AdLD. RESULTS: The automated framework was successfully developed and able to accurately segment the glottal area/edges. The precise automated measurements of GAT and GOT revealed minor, nonsignificant differences compared to the results of manual analysis-showing a strong correlation between the measures by the automated and manual methods. The results showed significant differences in the GAT values between the vocally normal subjects and AdLD patients, with larger variability in both the GAT and GOT measures in the AdLD group. CONCLUSIONS: The developed automated approach for GAT and GOT measurement can be valuable in clinical practice. These quantitative measurements can be used as meaningful biomarkers of the impaired vocal function in AdLD and help its differential diagnosis in the future.

Laryngeal Imaging Study of Glottal Attack/Offset Time in Adductor Spasmodic Dysphonia during Connected Speech.

Adductor spasmodic dysphonia (AdSD) disrupts laryngeal muscle control during speech and, therefore, affects the onset and offset of phonation. In this study, the goal is to use laryngeal high-speed videoendoscopy (HSV) to measure the glottal attack time (GAT) and glottal offset time (GOT) during connected speech for normophonic (vocally normal) and AdSD voices. A monochrome HSV system was used to record readings of six CAPE-V sentences and part of the "Rainbow Passage" from the participants. Three raters visually analyzed the HSV data using a playback software to measure the GAT and GOT. The results show that the GAT was greater in the AdSD group than in the normophonic group; however, the clinical significance of the amount of this difference needs to be studied further. More variability was observed in both GATs and GOTs of the disorder group. Additionally, the GAT and GOT time series were found to be nonstationary for the AdSD group while they were stationary for the normophonic voices. This study shows that the GAT and GOT measures can be potentially used as objective markers to characterize AdSD. The findings will potentially help in the development of standardized measures for voice evaluation and the accurate diagnosis of AdSD.

Spatial Segmentation for Laryngeal High-Speed Videoendoscopy in Connected Speech.

OBJECTIVE: This study proposes a new computational framework for automated spatial segmentation of the vocal fold edges in high-speed videoendoscopy (HSV) data during connected speech. This spatio-temporal analytic representation of the vocal folds enables the HSV-based measurement of the glottal area waveform and other vibratory characteristics in the context of running speech. METHODS: HSV data were obtained from a vocally normal adult during production of the "Rainbow Passage." An algorithm based on an active contour modeling approach was developed for the analysis of HSV data. The algorithm was applied on a series of HSV kymograms at different intersections of the vocal folds to detect the edges of the vibrating vocal folds across the frames. This edge detection method follows a set of deformation rules for the active contours to capture the edges of the vocal folds through an energy optimization procedure. The detected edges in the kymograms were then registered back to the HSV frames. Subsequently, the glottal area waveform was calculated based on the area of the glottis enclosed by the vocal fold edges in each frame. RESULTS: The developed algorithm successfully captured the edges of the vocal folds in the HSV kymograms. This method led to an automated measurement of the glottal area waveform from the HSV frames during vocalizations in connected speech. CONCLUSION: The proposed algorithm serves as an automated method for spatial segmentation of the vocal folds in HSV data in connected speech. This study is one of the initial steps toward developing HSV-based measures to study vocal fold vibratory characteristics and voice production mechanisms in norm and disorder in the context of connected speech.

Deep-Learning-Based Representation of Vocal Fold Dynamics in Adductor Spasmodic Dysphonia during Connected Speech in High-Speed Videoendoscopy.

OBJECTIVE: Adductor spasmodic dysphonia (AdSD) is a neurogenic dystonia, which causes spasms of the laryngeal muscles. This disorder mainly affects production of connected speech. To understand how AdSD affects vocal fold (VF) movements and hence, the speech signal, it is necessary to study VF kinematics during the running speech. This paper introduces an automated method for analysis of VF vibrations in AdSD using laryngeal high-speed videoendoscopy (HSV) in running speech. METHODS: A monochrome HSV system was used to obtain video recordings from vocally normal individuals and AdSD patients during production of the six CAPE-V sentences and the "Rainbow Passage." A deep neural network was designed based on the UNet architecture. The network was developed for glottal area segmentation in HSV data providing a tool for quantitative analysis of VF vibrations in both norm and AdSD. The network was trained and validated using the manually labeled HSV frames. After training the network, the segmentation quality was quantitatively evaluated against visual analysis results of a test dataset including segregated HSV frames and a short sequence of VF vibrations in consecutive frames. RESULTS: The developed convolutional network was successfully trained and demonstrated an accurate segmentation on the testing dataset with a mean Intersection over Union (IoU) of 0.81 and a mean Boundary-F1 score of 0.93. Moreover, the visual assessment of the automated technique showed an accurate detection of the glottal edges/area in the HSV data even with challenging image quality and excessive laryngeal maneuvers of AdSD patients during the running speech. CONCLUSION: The introduced automated approach provides an accurate representation of the glottal edges/area during connected speech in HSV data for norm and AdSD patients. This method facilitates the development of HSV-based measures to quantify VF dynamics in AdSD. Using HSV to automatically analyze VF vibrations in AdSD can allow for understanding AdSD vocal mechanisms and characteristics.

A Deep Learning Approach for Quantifying Vocal Fold Dynamics During Connected Speech Using Laryngeal High-Speed Videoendoscopy.

PURPOSE: Voice disorders are best assessed by examining vocal fold dynamics in connected speech. This can be achieved using flexible laryngeal high-speed videoendoscopy (HSV), which enables us to study vocal fold mechanics with high temporal details. Analysis of vocal fold vibration using HSV requires accurate segmentation of the vocal fold edges. This article presents an automated deep-learning scheme to segment the glottal area in HSV from which the glottal edges are derived during connected speech. METHOD: Using a custom-built HSV system, data were obtained from a vocally healthy participant reciting the "Rainbow Passage." A deep neural network was designed for glottal area segmentation in the HSV data. A recently introduced hybrid approach by the authors was utilized as an automated labeling tool to train the network on a set of HSV frames, where the glottis region was automatically annotated during vocal fold vibrations. The network was then tested against manually segmented frames using different metrics, intersection over union (IoU), and Boundary F1 (BF) score, and its performance was assessed on various phonatory events on the HSV sequence. RESULTS: The designed network was successfully trained using the hybrid approach, without the need for manual labeling, and tested on the manually labeled data. The performance metrics showed a mean IoU of 0.82 and a mean BF score of 0.96. In addition, the evaluation assessment of the network's performance demonstrated an accurate segmentation of the glottal edges/area even during complex nonstationary phonatory events and when vocal folds were not vibrating, thus overcoming the limitations of the previous hybrid approach that could only be applied to the vibrating vocal folds. CONCLUSIONS: The introduced automated scheme guarantees accurate glottis representation in challenging color HSV data with lower image quality and excessive laryngeal maneuvers during all instances of connected speech. This facilitates the future development of HSV-based measures to assess the running vibratory characteristics of the vocal folds in speakers with and without voice disorder. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19798864.

Detection of Vocal Fold Image Obstructions in High-Speed Videoendoscopy During Connected Speech in Adductor Spasmodic Dysphonia: A Convolutional Neural Networks Approach.

OBJECTIVE: Adductor spasmodic dysphonia (AdSD) is a neurogenic voice disorder, affecting the intrinsic laryngeal muscle control. AdSD leads to involuntary laryngeal spasms and only reveals during connected speech. Laryngeal high-speed videoendoscopy (HSV) coupled with a flexible fiberoptic endoscope provides a unique opportunity to study voice production and visualize the vocal fold vibrations in AdSD during speech. The goal of this study is to automatically detect instances during which the image of the vocal folds is optically obstructed in HSV recordings obtained during connected speech. METHODS: HSV data were recorded from vocally normal adults and patients with AdSD during reading of the "Rainbow Passage", six CAPE-V sentences, and production of the vowel /i/. A convolutional neural network was developed and trained as a classifier to detect obstructed/unobstructed vocal folds in HSV frames. Manually labelled data were used for training, validating, and testing of the network. Moreover, a comprehensive robustness evaluation was conducted to compare the performance of the developed classifier and visual analysis of HSV data. RESULTS: The developed convolutional neural network was able to automatically detect the vocal fold obstructions in HSV data in vocally normal participants and AdSD patients. The trained network was tested successfully and showed an overall classification accuracy of 94.18% on the testing dataset. The robustness evaluation showed an average overall accuracy of 94.81% on a massive number of HSV frames demonstrating the high robustness of the introduced technique while keeping a high level of accuracy. CONCLUSIONS: The proposed approach can be used for efficient analysis of HSV data to study laryngeal maneuvers in patients with AdSD during connected speech. Additionally, this method will facilitate development of vocal fold vibratory measures for HSV frames with an unobstructed view of the vocal folds. Indicating parts of connected speech that provide an unobstructed view of the vocal folds can be used for developing optimal passages for precise HSV examination during connected speech and subject-specific clinical voice assessment protocols.

Human amniotic epithelial cell transplantation improves scar remodeling in a rabbit model of acute vocal fold injury: a pilot study.

OBJECTIVE: To gain insight into the molecular mechanisms underlying the early stages of vocal fold extracellular matrix (ECM) remodeling after a mid-membranous injury resulting from the use of human amniotic epithelial cells (hAEC), as a novel regenerative medicine cell-based therapy. METHODS: Vocal folds of six female, New Zealand White rabbits were bilaterally injured. Three rabbits had immediate bilateral direct injection of 1 × 106 hAEC in 100 µl of saline solution (hAEC) and three with 100 µl of saline solution (controls, CTR). Rabbits were euthanized 6 weeks after injury. Proteomic analyses (in-gel trypsin protein digestion, LC-MS/MS, protein identification using Proteome Discoverer and the Uniprot Oryctolagus cuniculus (Rabbit) proteome) and histological analyses were performed. RESULTS: hAEC treatment significantly increased the expression of ECM proteins, elastin microfibril interface-located protein 1 (EMILIN-1) and myocilin that are primarily involved in elastogenesis of blood vessels and granulation tissue. A reactome pathway analysis showed increased activity of the anchoring fibril formation by collagen I and laminin, providing mechanical stability and activation of cell signaling pathways regulating cell function. hAEC increased the abundance of keratin 1 indicating accelerated induction of the differentiation programming of the basal epithelial cells and, thereby, improved barrier function. Lastly, upregulation of Rab GDP dissociation inhibitor indicates that hAEC activate the vesicle endocytic and exocytic pathways, supporting the exosome-mediated activation of cell-matrix and cell-to-cell interactions. CONCLUSIONS: This pilot study suggests that injection of hAEC into an injured rabbit vocal fold favorably alters ECM composition creating a microenvironment that accelerates differentiation of regenerated epithelium and promotes stabilization of new blood vessels indicative of accelerated and improved repair.

A Tissue Engineered Construct for Laryngeal Regeneration: A Proof-of-Concept Device Design Study.

OBJECTIVES/HYPOTHESIS: Develop a patient-specific tissue engineered construct for laryngeal reconstruction following a partial laryngectomy. STUDY DESIGN: Bench and animal research. METHODS: A construct made from a porous polyethylene scaffold shaped in a canine-specific configuration and seeded with autologous canine adipose-derived stem cells in fibrin glue was implanted in a canine following a partial laryngectomy. After 1 year, the construct was first evaluated in vivo with high-speed imaging and acoustic-aerodynamic measures. It was then explanted and evaluated histologically. RESULTS: The canine study at 1 year revealed the construct provided voicing (barking) with acoustic and aerodynamic measures within normal ranges. The canine was able to eat and breathe normally without long-term support. The construct was integrated with epithelialization of all areas except the medial portion of the vocal fold structure. No anti-infective agents were needed after the standard perioperative medications were completed. CONCLUSION: This study provided a successful first step toward developing a patient-specific composite construct for patients undergoing partial laryngectomies. LEVEL OF EVIDENCE: NA Laryngoscope, 132:S1-S11, 2022.

Quantitative Analysis of Vocal Fold Vibration using High-Speed Videoendoscopy in Children with and without Bilateral Lesions.

OBJECTIVE: To provide data on the measurable vocal fold vibratory differences in children with and without vocal fold lesions using high-speed videoendoscopy. DESIGN: Prospective study, 24 participants (8 healthy; 16 with lesions) between the ages of 5 and 10. METHODS: Rigid high-speed videoendoscopy at the rate of 8,000 frames per second was used to examine participants. Four objective vocal fold phase linearity measures were obtained to establish anterior-posterior contact and separation vibratory patterns. RESULTS: All objective measures showed a difference between nonlesion and bilateral vocal fold lesion groups. Contact-separation patterns in all nonlesion girls and young pre-pubertal boys exhibited an anterior-to-posterior contact and posterior-to-anterior separation; while older boys differed. The objective measures of open quotient, left-right relative phase asymmetry and speed index, showed linear anterior-posterior patterns within the nonlesion group; while the bilateral vocal fold lesion group displayed nonlinear patterns. Patterns in the posterior region of the vocal fold were similar in both groups; while patterns in the anterior region differed. CONCLUSIONS: This study suggests lesions have an effect on the anterior aspect of vocal fold vibratory patterns specifically anterior to the lesions. Age-related differences for males are also evidenced, prompting further investigation of laryngeal development in males and females from childhood to adulthood. This study could serve as a basis for the development of objective clinical measurements of vocal fold vibration in presence of lesions. Further findings could help redefine the theoretical framework of pediatric voice.

A Hybrid Machine-Learning-Based Method for Analytic Representation of the Vocal Fold Edges during Connected Speech.

Investigating the phonatory processes in connected speech from high-speed videoendoscopy (HSV) demands the accurate detection of the vocal fold edges during vibration. The present paper proposes a new spatio-temporal technique to automatically segment vocal fold edges in HSV data during running speech. The HSV data were recorded from a vocally normal adult during a reading of the "Rainbow Passage." The introduced technique was based on an unsupervised machine-learning (ML) approach combined with an active contour modeling (ACM) technique (also known as a hybrid approach). The hybrid method was implemented to capture the edges of vocal folds on different HSV kymograms, extracted at various cross-sections of vocal folds during vibration. The k-means clustering method, an ML approach, was first applied to cluster the kymograms to identify the clustered glottal area and consequently provided an initialized contour for the ACM. The ACM algorithm was then used to precisely detect the glottal edges of the vibrating vocal folds. The developed algorithm was able to accurately track the vocal fold edges across frames with low computational cost and high robustness against image noise. This algorithm offers a fully automated tool for analyzing the vibratory features of vocal folds in connected speech.

The Value of Dynamic Voice CT Scan for Complex Airway Patients Undergoing Voice Surgery.

INTRODUCTION: Dynamic voice computerized tomography (DVCT) is a novel technique that provides additional information to characterize laryngeal function for patients with complex airway history that may alter surgical decisions. The goal of this study was to evaluate the impact of DVCT on decision making for reconstructive voice surgery for a cohort of post-airway reconstruction dysphonia patients. METHODS: Retrospective chart review at a pediatric tertiary care center for patients with history of complex airway surgery and subsequent reconstructive voice surgery for dysphonia between 2010 and 2016. The study group had a DVCT prior to surgery while the control group underwent surgery without a DVCT. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and pediatric Voice Handicap Index (pVHI) scores were evaluated by the voice clinic team (otolaryngologist, speech therapist) before and after voice surgery. RESULTS: Twenty-one patients were analyzed (14 female, 67%) with a mean age (SD) of 14 (4.5) years old. Ninety percent (17/21) had a prior tracheostomy and a mean (SD) of 2.6 (1.3) airway surgeries. Twelve patients (57%) underwent DVCT prior to reconstructive voice surgery. CAPE-V baseline scores were similar between study and controls (means [SE] = 49 [4.6] and 57 [6.0], P = .72). However, scores significantly improved for the study group after voice surgery (mean [SE] = 31 (4.7), P < .0001) while controls did not improve (58 [5.7], P = .99). Baseline VHI scores were similar between both groups: mean (SE) = 54 (5.4) versus 52 (6.2), respectively, P = .99. Postsurgically, VHI scores were also similar between both groups (means [SE]: 46 [7.1] vs 47 [4.5], P = .99). Reconstructive voice surgery for study patients included posterior cricoid reduction (46%), vocal fold medialization/augmentation (46%), and laryngeal reinnervation (7.7%) while all controls underwent a single treatment (vocal fold medialization/augmentation). CONCLUSION: Patients with preoperative DVCT were more likely to have improvement. DVCT appeared to have altered surgical decision making and has allowed tailoring of reconstructive surgery to specific patients' needs. DVCT could represent an important tool prior to reconstructive surgery to guide the choice of surgical procedures for complex airway patients.

Utility of Laryngeal High-speed Videoendoscopy in Clinical Voice Assessment.

OBJECTIVE: This study aimed to assess the utility of laryngeal high-speed videoendoscopy (HSV) as a clinical tool. DESIGN: This is a prospective study of 151 patients. METHODS: A total of 151 adult patients (52 male, 99 female) underwent both videoendoscopy with stroboscopy (videostroboscopy) and HSV examination as part of a routine clinical voice assessment. At the time of the examination, ratings for videostroboscopy were reported in the clinical report. Next, the clinicians reviewed the HSV examination and indicated the changes in ratings of HSV relative to videostroboscopy. Finally, the clinical reports were reviewed by a clinician not involved in data collection or clinical care of the patients and noted differences between videostroboscopy and HSV clinical ratings, and resulting diagnoses were identified and grouped. RESULTS: Ratings of all vibratory features showed change between videostroboscopy and HSV. Mucosal wave and amplitude of vibration showed the largest percentage change, respectively, in 74% and 53% of the reports. They were followed by the features of glottal closure (36%), phase closure (32%), glottal edge (25%), and phase symmetry (21%). Ratings of supraglottic compression and vocal fold vertical level showed the least change between videostroboscopy and HSV. Changes in initial diagnosis owing to the inclusion of HSV were indicated in 7% of the cases. CONCLUSIONS: HSV may be an important laryngeal imaging technique for functional assessment of the pathophysiology of certain voice disorders. HSV could enable important refinements in the diagnosis and management of vocal fold pathology.

Temporal Segmentation for Laryngeal High-Speed Videoendoscopy in Connected Speech.

OBJECTIVE: This study proposes a gradient-based method for temporal segmentation of laryngeal high-speed videoendoscopy (HSV) data obtained during connected speech. METHODS: A custom-developed HSV system coupled with a flexible fiberoptic nasolaryngoscope was used to record one vocally normal female participant during reading of the "Rainbow Passage." A gradient-based algorithm was developed to generate a motion window. When applied to the HSV data, the motion window acted as a filter tracking the location of the vibrating vocal folds. The glottal area waveform was estimated using a statistical-based image-processing approach. The vocal fold vibratory frequency was computed by an autocorrelation-based extraction of the fundamental frequency (f0) from the glottal area waveform. Temporal segmentation was then performed based on the f0 contour and automatic detection of the epiglottic obstructions. Additionally, visual temporal segmentation was performed by viewing the HSV images frame by frame to determine the time points of the vocalization onsets and offsets, and the epiglottic obstructions of the glottis. RESULTS: The time points resulting from the automatic and visual temporal segmentation methods were cross-validated. The f0-contour patterns of rise and fall resulting from the automatic algorithm were found to be in agreement with the visual inspection of the vibratory frequency change in the HSV data. CONCLUSIONS: This study demonstrated the feasibility of automatic temporal segmentation of HSV imaging of connected speech, which allows for mapping the video content into onsets, offsets, and epiglottic obstructions for each vocalization. Automated analysis of HSV imaging of connected speech has significant clinical potential for advancing instrumental voice assessment protocols.

Vertical Phase Difference and Glottal Efficiency in Musical Theater and Opera Singers.

OBJECTIVE: The objectives of this study were to (1) determine the relationship between vertical phase difference (VPD) and glottal efficiency (GE) in singers and (2) to compare VPD and GE between musical theater and opera singing styles. METHODS: Five opera and three musical theater singers (Mean age = 25.3, 100% male) performed a series of vocal tasks at two pitches (low pitch C#3, 133 ± 5 Hz; high pitch C#4, 277 ± 5 Hz) for three levels of loudness (soft, baseline, and loud), while undergoing flexible distal chip videostroboscopy. Aerodynamic and acoustic information for each vocal task was recorded using the Phonatory Aerodynamic System. VPD was qualitatively measured via visual-perceptual judgments of repeated comparison tests, where a blinded rater was asked to select the video in which the subject demonstrated the greatest VPD. Aerodynamic data were analyzed for differences in GE. RESULTS: Qualitative visual-perceptual analysis indicated that increased magnitude of VPD was correlated with tasks involving increased loudness or higher pitch. GE was similarly correlated with increased loudness or higher pitch. GE was minimally correlated with subglottal pressure at high pitch. CONCLUSION: This prospective study reveals novel human subject evidence that VPD may correlate with GE. Future studies will further explore the implications of VPD with respect to GE, subglottal pressure, and laryngeal mechanics.

Feasibility of Clinical Endoscopy and Stroboscopy in Children With Bilateral Vocal Fold Lesions.

Purpose: The purpose of this study was to examine the utility of flexible and rigid endoscopy and stroboscopy for the identification of anatomical and physiological features in children with bilateral vocal fold lesions. The secondary purpose was to describe the age distribution of patients who could tolerate use of the different types of endoscopes. Method: This cross-sectional clinic-based study included 38 children (ages 5 to 12 years) diagnosed with bilateral vocal fold lesions via videoendoscopy. Vocal fold vibratory characteristics (e.g., mucosal wave) were rated by 4 clinicians by consensus. Results: Bilateral vocal fold lesions could be well described anatomically after visualization with both flexible and rigid endoscopes and were most commonly described as symmetrical and broad based. However, the clinicians' confidence in the accuracy of stroboscopy for rating vocal fold vibratory characteristics was limited for both flexible and rigid stroboscopes. Conclusions: Videoendoscopy was adequate for viewing and characterizing anatomical structures of bilateral vocal fold lesions in pediatric patients; however, vibratory characteristics were often not fully visualized with videostroboscopy. In view of the importance of visualizing vocal fold vibration in the differential diagnosis and treatment of vocal fold lesions, other imaging modalities, such as high-speed videoendoscopy, may provide more accurate descriptions of vocal fold vibratory characteristics in this population.

Comparison of Videostroboscopy and High-speed Videoendoscopy in Evaluation of Supraglottic Phonation.

OBJECTIVES: To compare clinicians' ratings of videolaryngoscopy (VLS) and high-speed videoendoscopy (HSV) and assess confidence of ratings with VLS and HSV in patients with supraglottic phonation. METHODS: The VLS and HSV video samples were taken from 11 adolescents post airway reconstruction who use supraglottic tissues for voice. The 22 recordings were randomized and presented to 4 clinicians: 2 speech-language pathologists and 2 pediatric otolaryngologists. Additionally, a 5-point Likert scale was used to rate level of confidence of ratings. RESULTS: Clinicians were more likely to rate regularity on HSV versus VLS videos (P = .003). Presence of mucosal wave was rated similarly on both imaging modalities; however, HSV was more likely to identify location (P = .002). Supraglottic phase symmetry (P = .014) and number of vibratory tissues used for phonation were rated more often with HSV versus VLS. Clinicians were more confident with HSV ratings compared to VLS ratings for determining vibration source, vibration pattern, and ability to make treatment decisions (P < .0001). CONCLUSIONS: The HSV improves the ability to rate tissue vibratory characteristics when compared with VLS in children with supraglottic phonation. This information may allow better understanding of the underlying mechanisms of voice production in these individuals, leading to improved therapeutic and surgical recommendations.

Assessment of Vibratory Characteristics in Children Following Airway Reconstruction Using Flexible and Rigid Endoscopy and Stroboscopy.

IMPORTANCE: Up to half of children have substantial dysphonia after airway reconstruction. Visual assessment of vocal function is valuable. Feasibility of flexible and rigid endoscopy has been reported; however, the clinical utility of stroboscopy has not been examined. Rating of vibratory characteristics, such as mucosal wave and amplitude of vibration, is essential for the development of interventions to improve voice outcomes. OBJECTIVE: To examine (1) clinicians' ratings of anatomical and physiological features in children following airway reconstruction on initial voice evaluation using videolaryngostroboscopy and (2) the relationship of age to the type of endoscopy used. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 32 patients aged 3 to 21 years evaluated for post­airway reconstruction dysphonia between July 2011 and July 2012 at a quaternary care children's hospital. INTERVENTIONS: Clinical voice evaluation protocol including rigid and/or flexible endoscopy with stroboscopy. MAIN OUTCOMES AND MEASURES: Demographic and voice quality characteristics were collected. The ability to complete endoscopy and ratings of anatomical and/or physiological features were assessed by a consensus of 4 clinicians. A t test was used to determine whether age was a significant factor in successful completion of videolaryngostroboscopy. RESULTS: Of 31 children who underwent flexible videolaryngostroboscopy, 22 (71%) examinations were completed with a distal chip endoscope and 9 (29%) with a fiberoptic. Significant differences were found in age between children who completed the distal chip vs. fiberoptic examination (mean [SD], 7.3 [2.7] vs. 5.5 [6.2] years; P = .05). Rigid endoscopy was attempted for 14 (44%) of 32 patients; 9 examinations (64%) were successful. Significant differences were found in age between patients for whom a rigid endoscopy could be successfully completed vs. those for whom it was not (mean [SD], 12.9 [3.4] vs. 6.2 [2.1] years; P < .001). Eighteen (56%) were glottic phonators, 8 (25%) supraglottic, and 6 (19%) aphonic. Vibratory characteristics were visible in 10 of 37 examinations (27%); 6 (16%) had ratable characteristics. CONCLUSIONS AND RELEVANCE: Endoscopy can be successfully completed in most children who have undergone airway reconstruction, most often using a distal chip endoscope.We found that vibratory characteristics were often not assessed adequately using videolaryngostroboscopy. Further work identifying imaging modalities that better display vibratory characteristics, such as high-speed videoendoscopy, may provide new insight into vocal function and lead to a more thorough evaluation.

Teachers' perceptions of adolescent females with voice disorders.

PURPOSE: The purpose of this study was to explore teachers' attitudes toward, and perceptions of personality traits of, female adolescents who presented with voice disorders. METHOD: For this comparative study consisting of a 25-item web-based semantic differential survey, teachers rated voice recordings of 4 female adolescents (considered normophonic, mildly, moderately, and severely dysphonic, respectively) on 18 personality traits and 6 teacher attitude parameters. A flyer with a link to the survey was distributed via e-mail to teachers at 8 middle and high schools in Ohio. RESULTS: Thirty-two teachers completed the survey. Results revealed differences in teachers' perceptions of female adolescents with a normal voice compared to those with voice disorders. CONCLUSION: Adolescent female students with voice disorders may be at risk for academic, social, and vocational difficulties. These results highlight and support the need to inform teachers, speech-language pathologists, students, and families about the potential for subtle biases and negative perceptions of students with voice disorders by teachers. Furthermore, teaching self-advocacy to students who have voice disorders may help them obtain an optimal education experience.