Prospective case-controlled sound localisation study after cochlear implantation in adults with single-sided deafness and ipsilateral tinnitus.

OBJECTIVES: To analyse the sound localisation skills of subjects with profound single-sided deafness (SSD) and accompanied ipsilateral tinnitus who are using a cochlear implant (CI) for between 4 and 11 years. DESIGN: Sound localisation skills were tested using nine loudspeakers in a frontal semicircle ranging from -90° to +90°. Subjects were tested in the CION and the CIOFF conditions via 3 localisation stimuli: broadband noise (BB), low-pass noise (LP) and high-pass noise (HP). PARTICIPANTS: The test group consisted of 10 adult subjects with profound sensorineural SSD, ipsilateral tinnitus and a CI. Normative data of a control group of 30 normal hearing subjects were used for comparison. MAIN OUTCOME MEASURES: Sound location accuracy was analysed via the root-mean-square error (RMSE), the mean absolute error (MAE), the localisation bias ('b') and the bias-adjusted deviation ('db '). Subjective dynamic aspects of hearing were assessed via a reduced version of the Speech, Spatial and Qualities of Hearing Scale (SSQ5 ). RESULTS: For all 3 stimuli, the RMSE improved significantly in SSD subjects in the CION condition compared to the CIOFF condition. The localisation accuracy of subjects with SSD improved significantly for BB and HP stimuli. A significant bias-adjusted deviation 'db ' was found for the BB and HP stimuli. Subjects' mean SSQ5 scores were significantly higher in the CION condition at test date than in the CIOFF condition preoperatively. CONCLUSIONS: Subjects can better locate sound in the CION condition than in the CIOFF condition.

Life-threatening macroglossia after posterior fossa surgery: a surgical positioning problem?

A 55-year-old woman was operated in the lateral park bench position with significant neck flexion and oral packing. Macroglossia was noticed immediately postoperatively after endotracheal extubation. The patient was reintubated for 13 days and subsequently required a tracheostoma. After the placement of the tracheostoma and the removal of the endotracheal tube, the congestion of the tongue decreased markedly within 24 hours. Macroglossia is a rare complication following posterior fossa procedures with few cases reported so far. It can cause airway obstruction, which could be a life-threatening complication, and it therefore requires prompt treatment. The aetiology of postoperative macroglossia remains uncertain and has been attributed to arterial, venous and lymphatic compression, mechanical compression, or neurogenic causes. This article describes new insights into aetiology and also describes preventive measures and possible treatment.

Towards a consensus on a hearing preservation classification system.

CONCLUSION: The comprehensive Hearing Preservation classification system presented in this paper is suitable for use for all cochlear implant users with measurable pre-operative residual hearing. If adopted as a universal reporting standard, as it was designed to be, it should prove highly beneficial by enabling future studies to quickly and easily compare the results of previous studies and meta-analyze their data. OBJECTIVES: To develop a comprehensive Hearing Preservation classification system suitable for use for all cochlear implant users with measurable pre-operative residual hearing. METHODS: The HEARRING group discussed and reviewed a number of different propositions of a HP classification systems and reviewed critical appraisals to develop a qualitative system in accordance with the prerequisites. RESULTS: The Hearing Preservation Classification System proposed herein fulfills the following necessary criteria: 1) classification is independent from users' initial hearing, 2) it is appropriate for all cochlear implant users with measurable pre-operative residual hearing, 3) it covers the whole range of pure tone average from 0 to 120 dB; 4) it is easy to use and easy to understand.

Two-stage palatoplasty using a modified Furlow procedure.

A two-stage palatal repair using a modification of Furlow palatoplasty is presented. The authors investigate the speech outcome, fistula formation and maxillary growth. In a prospective, successive cohort study, 40 nonsyndromic patients with wide cleft palate were operated on between March 2001 and June 2006 by a single surgeon. 10 patients in the first cohort underwent a Furlow palatoplasty (control group). In 30 patients in the second cohort a unilateral myomucosal cheek flap was used in combination with a modified Furlow palatoplasty (study group). The hard palate was closed in both groups 9-12 months later. The Bzoch speech quality score was superior in the study group, and the hypernasality was significantly reduced in the study group. Overall fistula formation was 0%. At the time of hard palate reconstruction palatal cleft width was significantly reduced. Relative short-term follow up of maxillary growth was excellent. There were no postoperative haematomas, infections, or episodes of airway obstruction. This technique is particularly encouraging, because of better speech outcome, absence of raw surfaces on the soft palate, no fistula formation, and good maxillary growth. Further follow-up is necessary to determine the long-term effects on facial development.

Item reduction of the voice handicap index based on the original version and on European translations.

OBJECTIVE: Constructing an internationally applicable short-scale of the Voice Handicap Index (VHI). METHODS: Subjects were 1,052 patients with 5 different types of voice disorder groups from Belgium, France, Sweden, Germany, Italy, The Netherlands, Portugal, and the USA. Different 9- and 12-item subsets were selected from the 30 VHI items using (1) the first factor of an unrotated factor analysis (narrow range subsets) and (2) the first three factors after promax rotation (broad range subsets). Country-specific subsets were selected to test deviations from the international subsets. For all subsets, reliability was investigated using Cronbach's alphas and correlations with the total VHI. Validity was investigated using regression on voice disorder groups. All analyses were performed for the total and for all country-specific subject samples. RESULTS: Reliability was high for all item subsets. It was lower for the international compared to the country-specific subsets and for the broad range compared to the narrow range subsets. Validity was best for the broad range subsets. Validity was better for the international than for the country-specific subsets. For all statistics the 12-item subsets were not essentially better than the 9-item subsets. CONCLUSION: The international broad range 9-item subset forms a scale which approximates well the total VHI.

Validation of the voice handicap index by assessing equivalence of European translations.

OBJECTIVE: We aimed to assess the equivalence of translations of the Voice Handicap Index (VHI). PATIENTS AND METHODS: Confirmatory factor analysis was used to assess equivalence of the US version and several translations including (1) Dutch, (2) Flemish Dutch (Belgium), (3) UK English, (4) French, (5) German, (6) Italian, (7) Portuguese and (8) Swedish. VHI questionnaires were gathered from 1,281 subjects. Patients were classified into 11 voice lesion categories. Patients with incomplete response (4%) and patients within voice lesion categories with small numbers were excluded from further analyses, leaving a cohort of 1,052 patients from 8 countries. RESULTS: The internal consistency of the VHI proved to be good. Confirmatory factor analysis across countries revealed that a 3-factor fixed measurement model best fitted the data; the 3 subscales appeared to highly intercorrelated, especially in the US data. The underlying structure of the VHI was also equivalent regarding various voice lesions, but distinct groups were recognized with respect to the height of the VHI scores, indicating that various voice lesions lead to a diversity of voice problems in daily life. CONCLUSION: The US VHI and the translations appeared to be equivalent, which means that the results from studies from the various included countries can be compared.

Long-term outcome of hyperfunctional voice disorders based on a multiparameter approach.

SUMMARY: The purpose of this study is to determine the long-term voice outcome (6.1 years after a well-defined voice treatment program) of hyperfunctional voice disorders in 27 subjects. All patients showed a muscle tension pattern type I (MTP I). Perceptual ratings, aerodynamic and acoustical analyses, Voice Handicap Index (VHI) value, and a determination of the Dysphonia Severity Index (DSI) were performed. The laryngovideostroboscopic images indicated that 51% of the subjects still show pathological laryngological findings. The negative evolution of the DSI from -1 to -3.2 is in agreement with this finding. Analysis of the components of the DSI shows that the main responsible variable for this negative change is the lowest intensity (I-low) that increased with 8.1 dB, indicating that subjects generally speak too loud, which is a typical problem for vocal hyperfunction. The VHI-score indicates an unimportant psychosocial impact of the voice disorder. The more objective and laryngostroboscopic findings indicate a chronic situation for a substantial part of the subjects and even a worse situation for some of them. Whether the long-term voice outcome results can be changed with the insertion of several follow-up voice rehabilitation sessions over the years remains unanswered and is a subject for further research.

Evolution of vocal fold nodules from childhood to adolescence.

SUMMARY: Bilateral (quasi) symmetrical lesions of the anterior third of the vocal folds, commonly called vocal fold nodules (VFNs) are the most frequent vocal fold lesions in childhood caused by vocal abuse and hyperfunction. This study evaluates their long-term genesis with or without surgery and voice therapy. A group of 91 postmutational adolescents (mean age, 16 years), in whom VFNs were diagnosed in childhood, were questioned to analyze the evolution of their complaints. Thirty four of them could be clinically reexamined by means of the European Laryngological Society-protocol, including a complete laryngological investigation and voice assessment. A total of 21% of the questioned group (n=91) had voice complaints persisting into postpubescence with a statistically significant difference (P

Relevance of subglottic pressure in normal and dysphonic subjects.

The purpose of this study was to determine the clinical value of subglottic pressure (SGP) in normal and dysphonic subjects. "The airway interrupted method" was used to measure the intra-oral pressure. Voice samples from 60 healthy subjects and 79 dysphonic patients were recorded under normal conditions of pitch and intensity. In normal subjects, age and gender have no significant impact on mean and peak SGP. The peak SGP measurements are significantly higher in dysphonic patients and could be included in the basic clinical set of objective voice parameters. No differences could be shown between pre- and postoperative assessments or between groups of dysphonic patients.

Effects of biofeedback in phonatory disorders and phonatory performance: a systematic literature review.

The purpose of this article was to systematically review the literature on the effects of biofeedback therapy in the domain of phonatory disorders and phonatory performance, using studies in peer-reviewed journals. An extensive definition of biofeedback is given and its place in voice treatment is defined. Eighteen group or case studies or reports considering the effects of electromyographic, laryngoscopic and acoustic biofeedback in dysphonic patients (hyperfunctional voice disorders, hypofunctional voice disorders, psychogenic voice disorder, laryngeal trauma, total laryngectomy, vocal cord dysfunction) and participants with normal voices are included and an analysis of procedure as well as research design and results is presented. The usefulness of biofeedback in phonatory disorders and performance was to be interpreted based on tendencies, since there is a lack of randomized controlled efficacy studies. In only 3 of 18 studies (16.7%) did biofeedback therapy fail to improve voice quality or not result in better results than other forms of therapy. Recommendations for improved methodologies are made, which include the use of acoustic voice quality parameters.

Good speech recognition and quality-of-life scores after cochlear implantation in patients with DFNA9.

OBJECTIVE: To compare audiometric and quality-of-life results in DFNA 9 patients who received a cochlear implant with cochlear implant patients with adult-onset progressive sensorineural hearing loss. STUDY DESIGN: Prospective comparative design; results were collected cross-sectionally. SETTING: Tertiary referral center. PATIENTS: Eleven DFNA 9 patients were included in the study as well as a comparative group of 39 post-lingually deafened cochlear implant subjects with adult-onset progressive sensorineural hearing loss. INTERVENTIONS: All patients received a cochlear implant. Subjects were implanted with either the Nucleus 24 M/RCS or Med-el Combi 40+ cochlear implant systems implementing the SPEAK, ACE, or CIS+ coding strategies. MEAN OUTCOME MEASURES: Speech recognition was determined by means of phonetically balanced monosyllabic word lists. The Hearing Handicap Inventory for Adults, the Glasgow Benefit Inventory, and the Scale for the Prediction of Hearing Disability in Sensorineural Hearing Loss were used to quantify the quality of life. RESULTS: The results show that the speech perception and the quality of life of the DFNA 9 patients do not differ significantly from the control group (p=0.179; p=0.56). CONCLUSION: In spite of the fact that DFNA 9 is a disease that is known to involve cochlear dendrites, cochlear implantation is a good option for treatment of deafness in DFNA 9.

Cleft palate speech and velopharyngeal dysfunction: the approach of the speech therapist.

Cleft palate and velopharyngeal dysfunction cause communication disorders in many different ways (articulation, resonance, voice and language). These problems are mainly present in childhood but remain a matter of concern for many years. Speech and language pathologists are involved in speech and language assessment and speech therapy procedures. This article gives an overview of the standard procedures of the speech pathologist in a cleft palate team and discusses the relationship between the team and private practices or school teams, as well as the practical aspects relating to reimbursement by the National Institute of Health and Invalidity (RIZIV).

Cochlear implantation: a bionic system to restore hearing in severely hearing impaired patients.

CI replaces and functionally bypasses the inner haircells of the cochlea. Candidate selection is not merely based on non-aided auditory thresholds, but aided speech recognition tests in quite and in noise after a rehabilitation period may be decisive, besides a comprehensive selection process including general health, imaging, learning and cognitive skills, supportive aspect of the environment. The vast majority of severely or profoundly hearing impaired persons can benefit from CI. CI restores hearing of adults to a level allowing normal conversation, using the telephone and even understanding in a limited amount of background noise. Congenitally severely or profoundly hearing impaired children implanted before the age of 2 years, will outperform patients operated at a later age, allowing to follow mainstream education. CI is not just a technique, but the driving force behind an elaborate care-programme for the severely hearing impaired patient.

Vocal quality characteristics in children with cleft palate: a multiparameter approach.

The main purpose of the present study was to examine the vocal quality and to investigate the effects of gender on vocal quality in 28 children with a unilateral or bilateral cleft palate. In this study, the vocal quality was determined using videolaryngostroboscopic and perceptual evaluations, aerodynamic, voice range, acoustic, and dysphonia severity index (DSI) measurements. The DSI is based on the weighted combination of four voice measurements and ranges from +5 to -5 for, respectively, normal and severely dysphonic voices. Additional objectives were to compare the vocal quality characteristics of children with cleft palate with the available normative data and to investigate the impact of the cleft type on vocal quality. Gender-related vocal quality differences were found. The male cleft palate children showed an overall vocal quality of +0.62 with the presence of a perceptual slight grade of hoarseness and roughness. The female vocal quality had a DSI value of +2.4 reflecting a perceptually normal voice. Irrespective of the type of cleft, all subjects demonstrated a significantly lower DSI-value in comparison with the available normative data. The results of the present study have provided valuable insights into the vocal quality characteristics of cleft palate children.

Poor voice quality in future elite vocal performers and professional voice users.

The voice quality of 86 occupational voice users, i.e., students of a high school for audiovisual communication, was assessed by means of a multidimensional test battery containing: the GRBAS scale, videolaryngostroboscopy, maximum phonation time, jitter, lowest intensity, highest frequency, dysphonia severity index (DSI), and voice handicap index (VHI). In a questionnaire on daily habits the prevalence of smoking, eating habits, and vocal abuse were recorded. A comparison of the voice characteristics of the future occupational voice users with a control group revealed significant differences. The results of the VHI and the DSI of these students revealed significantly worse scores than the score of a control group characterized by no vocal complaints. Moreover, the questionnaire on daily habits showed that the future elite vocal performers and professional voice users take less precautions for the care of their voices. These findings support the importance of a good balanced vocal coaching.

Effect of cleft type on overall speech intelligibility and resonance.

The main purpose of this study was to measure and compare the effect of an unilateral cleft lip and palate (UCLP) and a bilateral cleft lip and palate (BCLP) on overall speech intelligibility, nasalance and nasality. An additional objective was to compare the nasalance and nasality patterns of cleft palate children with the available normative data for normal children. The subjects were 37 children with an UCLP (19/37) or a BCLP (18/37) with normal cognitive and motor functions and normal hearing levels. All subjects had a non-syndromic cleft, followed the same surgical protocol and did not undergo secondary pharyngeal surgery. To measure and compare the effect of cleft type, objective and subjective assessment techniques were used. For the objective assessment of nasal resonance the nasometer and the mirror-fogging test were used. Nasalance scores were obtained, while patients produced sounds, read three standard passages or repeated sentences focusing on specific consonants. A perceptual evaluation of speech, the Gutzmann (1913) test and the tests of Bzoch (1989) were used as subjective assessment techniques. The perceptual assessment of the overall speech intelligibility was based on the spontaneous speech and reading or repeating of the nasometric sentences. These samples were judged by three speech pathologists using a 4-category nominal scale. A subjective test (Morley, 1945) was used to evaluate the velopharyngeal mechanism. The findings of the present study show no statistically significant differences for nasalance values, nasality and overall speech intelligibility between the UCLP and BCLP children. Significant differences were found between the data of the normal group and the cleft palate children. These differences included nasalance values as well as nasality data and overall speech intelligibility.

Normative voice range profiles of male and female professional voice users.

Normative voice range profiles (VRP) are calculated for a group of male and female teachers, based on 43 and 46 recordings, respectively. All individuals had healthy voices. These normative VRPs contain 95% prediction intervals for both frequency and intensity. They are based on a series of mathematical transformations of the original individual VRPs in order to maintain in the normative VRPs the typical oval VRP shape, including the dip between modal and falsetto register. The normative VRPs presented are directly applicable in the clinical practice of otolaryngologists and speech-language pathologists.

Aerodynamic and acoustic characteristics of voice in Prader-Willi syndrome.

Prader-Willi syndrome (PWS) is a multisystem disorder caused by DNA abnormalities involving chromosome 15. Major characteristics are infant hypotonia, hypogonadism, mental retardation, a short stature, atypical facial appearance, and the onset of obesity due to insatiable hunger in early childhood. Also, speech and language abnormalities have been reported including voice disorders. These have seldom been studied in detail, however. This paper reports the results of an acoustic and aerodynamic investigation of the voice in 22 individuals with PWS. Two age groups were distinguished, a group of children [chronological age (CA) 6 years, 7 months through 11 years, 7 months; total intelligence quotient (TIQ) 40-88] and a group of adolescents and adults (CA 17 years, 1 month through 29 years, 5 months; TIQ 41-94). Both aerodynamic and acoustic parameters were obtained and compared with normative data from the Belgian Study Group on Voice Disorders. It was found that voice difficulties do commonly occur in individuals with PWS including impairment of frequency levels, voice quality, and poor aerodynamic capabilities.

Nasometric values for normal nasal resonance in the speech of young Flemish adults.

OBJECTIVE: The purpose of this study was to obtain normative nasalance scores for adult subjects speaking the Flemish language. Additional objectives of the study were to determine if speaker sex played a role in differences in nasalance scores and if significantly different nasalance scores existed for Flemish compared with other languages or dialects. DESIGN: Nasalance scores were obtained while young Flemish adults read three standard nasalance passages. These passages were an oronasal passage (a text that contained the same approximate percentage of nasal consonants as found in the standard Dutch speech), an oral passage (a text that excluded nasal consonants), and a nasal passage (a reading text loaded with nasal consonants). PARTICIPANTS: Subjects included 58 healthy young Flemish adults with normal oral and velopharyngeal structure and function, normal hearing levels, normal voice characteristics, and normal resonance and articulation skills. METHODS: The Nasometer (model 6200) was used to obtain nasalance scores for the three reading passages. These three reading passages were designed specifically for use with the nasometer. The nasalance data were analyzed for sex dependence, using Student's t test for each reading passage. This same test was used for comparison of our data with data of other languages. RESULTS: Normative nasalance data were obtained for the oronasal text (33.8%), the oral text (10.9%), and the nasal text (55.8%). Female speakers exhibited significantly higher nasalance scores than male speakers on the passages containing nasal consonants (normal text, p = .001; nasal text, p = .042). Furthermore, statistically significant cross-linguistic nasality differences were observed. The English and Spanish languages were found to have more nasalance than the Flemish language. For the North Dutch and Flemish languages, this cross-linguistic phenomenon was absent. CONCLUSION: These normative nasalance scores for normal young adults speaking the Flemish language provide important reference information for Flemish cleft palate teams. Sex-related differences and cross-linguistic differences were shown.

The dysphonia severity index: an objective measure of vocal quality based on a multiparameter approach.

The vocal quality of a patient is modeled by means of a Dysphonia Severity Index (DSI), which is designed to establish an objective and quantitative correlate of the perceived vocal quality. The DSI is based on the weighted combination of the following selected set of voice measurements: highest frequency (F(0)-High in Hz), lowest intensity (I-Low in dB), maximum phonation time (MPT in s), and jitter (%). The DSI is derived from a multivariate analysis of 387 subjects with the goal of describing, purely based on objective measures, the perceived voice quality. It is constructed as DSI = 0.13 x MPT + 0.0053 x F(0)-High - 0.26 x I-Low - 1.18 x Jitter (%) + 12.4. The DSI for perceptually normal voices equals +5 and for severely dysphonic voices -5. The more negative the patient's index, the worse is his or her vocal quality. As such, the DSI is especially useful to evaluate therapeutic evolution of dysphonic patients. Additionally, there is a high correlation between the DSI and the Voice Handicap Index score.