Clinical Utility and Validation of the Acoustic Voice Quality and Acoustic Breathiness Indexes for Voice Disorder Assessment in English Speakers.

BACKGROUND: While several acoustic voice metrics are available for clinical voice assessment, there remains a significant need for reliable and ecologically valid tools. The Acoustic Voice Quality Index version 03.01 (AVQI-3) and Acoustic Breathiness Index (ABI) hold potential due to their comprehensive assessment approach, incorporating diverse voice aspects. However, these tools still need to be validated in English-speaking populations. METHODS: This study assessed the discriminatory accuracy and validity of AVQI-3 and ABI in 197 participants, including 148 with voice disorders. Voice samples were collected, followed by AVQI-3 and ABI calculations. Additionally, auditory-perceptual assessments were conducted by a panel of speech-language pathologists. RESULTS: AVQI-3 and ABI effectively identified disordered voice quality, evidenced by high accuracy (AUCs: 0.84, 0.89), sensitivity, and specificity (thresholds: AVQI-3 = 1.17, ABI = 2.35). Strong positive correlations were observed with subjective voice quality assessments (rs = 0.72, rs = 0.77, p < 0.001). CONCLUSIONS: The study highlights AVQI-3 and ABI as promising instruments for clinically assessing voice disorders in U.S. English speakers, underscoring their utility in clinical practice and voice research.

Flexible Versus Rigid Laryngoscopy: A Prospective, Blinded Comparison of Image Quality.

OBJECTIVE: To compare flexible distal-chip laryngoscopy (FDL) and rigid telescopic laryngoscopy (RTL) in image quality and diagnostic ability. STUDY DESIGN: Prospective cohort study; blinded comparison. METHODS: Eighteen normal adult subjects were recruited to undergo both FDL and RTL and normalized videos were recorded. Three blinded laryngologists compared the videos for color fidelity, illumination, resolution, and vascularity, and indicated superiority with FDL, RTL, or no difference. Raters also reported if an abnormality was seen and in which video it was better visualized. Videos for two subjects were repeated to assess intra-rater reliability, making 20 video comparisons across 3 raters for a total of 60 ratings. Differences in responses were analyzed via Mann-Whitney U and Pearson Χ2. Inter-rater reliability was assessed via Fleiss' kappa, and intra-rater reliability was assessed via percent agreement. RESULTS: RTL was rated superior in all categories of image quality (47 vs 5 vs 8, P < 0.01; 47 vs 7 vs 6, P < 0.01; 51 vs 5 vs 4, P<0.01; 44 vs 9 vs 7, P < 0.01, respectively). An abnormality was seen 33 times with both modalities and 6 times with RTL only. When seen with both modalities, visualization was superior in RTL compared with FDL (29 vs 4, P <0.01). CONCLUSIONS: There was significant superiority of RTL in all categories of image quality, with slight inter-rater agreement for color fidelity, resolution, and vascularity. RTL was also significantly better for visualization of abnormalities. These findings suggest superior image quality in RTL compared with FDL, but further research is required to determine if this difference is clinically significant.

Voice Biofeedback via Bone Conduction Headphones: Effects on Acoustic Voice Parameters and Self-Reported Vocal Effort in Individuals With Voice Disorders.

PURPOSE: This study explores sidetone amplification (amplified playback of one's own voice) provided via bone conduction in participants with voice disorders. The effects of bone conduction feedback on acoustic voice parameters and vocal effort ratings are examined. METHODS: Speech samples of 47 participants with voice disorders were recorded in three auditory feedback conditions: two with sidetone amplification delivered via bone conduction and one condition with no alteration of the feedback. After each task, the participants rated their vocal effort on a visual analog scale. The voice recordings were evaluated by a speech-language pathologist through the GRBAS scale and processed to calculate the within-participant centered sound pressure level (SPL) values, the mean pitch strength (PS), the time dose (Dt%), and cepstral peak prominence smoothed (CPPS). The effects of the feedback conditions on these acoustic parameters and vocal effort ratings were analyzed. RESULTS: The high sidetone amplification condition resulted in a statistically significant decrease in the within-participant centered SPL values and mean pitch strength across all participants. The feedback conditions had no statistically significant effects on the vocal effort ratings, time dose (Dt%), or CPPS. CONCLUSIONS: This study provides an evidence that bone conduction sidetone amplification contributes to a consistent adaptation in the within-participant centered SPL values (ΔSPL) in patients with vocal hyperfunction, glottal insufficiency, and organic/neurological laryngeal pathologies compared to conditions with no feedback.

Hyoid Bone Syndrome and Dysphonia: Can Throat Pain Affect the Voice?

OBJECTIVES/HYPOTHESIS: To investigate the relationship of throat pain and dysphonia. STUDY DESIGN: Prospective cohort study. METHODS: Forty-five subjects presenting with hyoid bone syndrome (HBS) and dysphonia were asked to rate their pain on a numerical rating scale and complete the 10-item Voice-Related Quality of Life (V-RQOL) questionnaire prior to and at 1-week follow-up after treatment with triamcinolone injection into the attachments to the affected greater cornu(s). Wilcoxon signed-rank tests were applied to evaluate if the overall V-RQOL scores, the physical functioning (PF) and social-emotional (SE) domain scores, and pain scores changed significantly after treatment. To evaluate how change in perceived pain affected V-RQOL, the differences in the V-RQOL, PF, and SE domain scores, and in pain scores were calculated for each subject. Three linear models were fit to the response variables, ΔV-RQOL, ΔPF, and ΔSE, using ΔPain as a predicting variable. RESULTS: V-RQOL, PF, and SE domain scores, and pain scores all improved significantly with treatment. A bigger decrease in the pain score led to a bigger increase in V-RQOL and domain scores, with slopes varying between -1.1 and -1.4. The PF domain scores showed the greatest improvement with decrease in pain scores. CONCLUSIONS: Effective treatment of HBS led to improvement in patients' voice complaints, suggesting that throat pain may have a direct effect on voice. This may be related to compensatory perilaryngeal adjustments patients make when speaking with a "guarding" effect when they have throat pain. LEVEL OF EVIDENCE: IV (Cohort study) Laryngoscope, 131:E2303-E2308, 2021.

The Effect of Unilateral Hearing Protection on Vocal Intensity With Varying Degrees of Background Noise.

INTRODUCTION: The Lombard effect (LE) is a phenomenon in which speakers adjust their vocal production by raising the volume in noisy environments. As a result, the LE can create problems of vocal strain, fatigue and potential injury. OBJECTIVES: This study aims to examine the difference in vocal intensity output in subjects wearing unilateral hearing protection versus no hearing protection in the presence of background noise. METHODS: Each subject was seated inside a sound booth wearing a head-mounted microphone. Subjects were asked to read an excerpt from "The Rainbow Passage" while various levels of background noise were played: 50, 60, 70, and 80 dBA (Multitalker Babble). Each noise level was played while the subject was with and without unilateral ear protection (Optime 98 Earmuff [3M]) in random order. The earmuff has a noise reduction rating of 25 dB. After each reading of the text, subjects were asked to rate communication disturbance, vocal clarity, and discomfort during talking using a 10 cm visual analogue scale. RESULTS: The LE is reduced from 0.38 dB/dB to 0.29 dB/dB with unilateral ear occlusion. However, self-perception of disturbance, clarity and comfort were not affected by unilateral occlusion, only by noise level. CONCLUSIONS: Unilateral hearing protection reduces the LE and may protect against phonotrauma when speaking in an environment with loud background noise.

Telemedicine and the Interdisciplinary Clinic Model: During the COVID-19 Pandemic and Beyond.

The emergence of the novel coronavirus disease 2019 (COVID-19) and the subsequent need for physical distancing have necessitated a swift change in health care delivery. Prior to the COVID-19 outbreak, many institutions utilized an interdisciplinary clinic model including both a laryngologist and a speech-language pathologist for the evaluation of patients with voice, swallowing, and upper airway disorders. To improve access, many providers are pursuing the use of interdisciplinary telemedicine to provide individualized patient-centered care while allowing for physical distancing. The purpose of this commentary is to review the current literature regarding telemedicine in laryngology and speech-language pathology as well as the current and future states of practice for interdisciplinary tele-evaluations.

Reproducibility of Voice Parameters: The Effect of Room Acoustics and Microphones.

INTRODUCTION: Computer analysis of voice recordings is an integral part of the evaluation and management of voice disorders. In many practices, voice samples are taken in rooms that are not sound attenuated and/or sound-proofed; further, the technology used is rarely consistent. This will likely affect the recordings, and therefore, their analyses. OBJECTIVES: The objective of this study is to compare various acoustic outcome measures taken from samples recorded in a sound-proofed booth to those recorded in more common clinic environments. Further, the effects from six different commonly used microphones will be compared. METHODS: Thirty-six speakers were recorded while reading a text and producing sustained vowels in a controlled acoustic environment. The collected samples were reproduced by a Head and Torso Simulator and recorded in three clinical rooms and in a sound booth using six different microphones. Newer measures (eg, Pitch Strength, cepstral peak prominence, Acoustic Voice Quality Index), as well as more traditional measures (eg Jitter, Shimmer, harmonics-to-noise ratio and Spectrum Tilt), were calculated from the samples collected with each microphone and within each room. RESULTS: The measures which are more robust to room acoustic differences, background noise, and microphone quality include Jitter and smooth cepstral peak prominence, followed by Shimmer, Acoustic Voice Quality Index, harmonics-to-noise ratio, Pitch Strength, and Spectrum Tilt. CONCLUSIONS: The effect of room acoustics and background noise on voice parameters appears to be stronger than the type of microphone used for the recording. Consequently, an appropriate acoustical clinical space may be more important than the quality of the microphone.

The Art of Caring for the Professional Singer.

Training in care of the voice for the general otolaryngologist has improved with the presence of more fellowship-trained laryngologists within academic training programs. However, preparation for caring for the professional singer goes beyond the basic understanding of voice evaluation, laryngeal imaging, and microlaryngeal surgery. The otolaryngologist must have a deeper understanding of the demands, vocabulary, psyche, and economics of the professional singer to provide optimal care. The ramification of recommendations made or procedures undertaken by the otolaryngologist can have serious consequences in a singer's career. This article introduces the otolaryngologist to the specifics of caring for professional singers.

Comparison of Pitch Strength With Perceptual and Other Acoustic Metric Outcome Measures Following Medialization Laryngoplasty.

INTRODUCTION: The diagnoses of voice disorders, as well as treatment outcomes, are often tracked using visual (eg, stroboscopic images), auditory (eg, perceptual ratings), objective (eg, from acoustic or aerodynamic signals), and patient report (eg, Voice Handicap Index and Voice-Related Quality of Life) measures. However, many of these measures are known to have low to moderate sensitivity and specificity for detecting changes in vocal characteristics, including vocal quality. OBJECTIVE: The objective of this study was to compare changes in estimated pitch strength (PS) with other conventionally used acoustic measures based on the cepstral peak prominence (smoothed cepstral peak prominence, cepstral spectral index of dysphonia, and acoustic voice quality index), and clinical judgments of voice quality (GRBAS [grade, roughness, breathiness, asthenia, strain] scale) following laryngeal framework surgery. METHODS: This study involved post hoc analysis of recordings from 22 patients pretreatment and post treatment (thyroplasty and behavioral therapy). Sustained vowels and connected speech were analyzed using objective measures (PS, smoothed cepstral peak prominence, cepstral spectral index of dysphonia, and acoustic voice quality index), and these results were compared with mean auditory-perceptual ratings by expert clinicians using the GRBAS scale. RESULTS: All four acoustic measures changed significantly in the direction that usually indicates improved voice quality following treatment (P < 0.005). Grade and breathiness correlated the strongest with the acoustic measures (|r| ~ 0.7) with strain being the least correlated. CONCLUSIONS: Acoustic analysis on running speech highly correlates with judged ratings. PS is a robust, easily obtained acoustic measure of voice quality that could be useful in the clinical environment to follow treatment of voice disorders.

Pitch Strength as an Outcome Measure for Treatment of Dysphonia.

BACKGROUND: Measurement of treatment outcomes is critical for the spectrum of voice treatments (ie, surgical, behavioral, or pharmacological). Outcome measures typically include visual (eg, stroboscopic data), auditory (eg, Consensus Auditory-Perceptual Evaluation of Voice; Grade, Roughness, Breathiness, Asthenia, Strain), and objective correlates of vocal fold vibratory characteristics, such as acoustic signals (eg, harmonics-to-noise ratio, cepstral peak prominence) or patient self-reported questionnaires (eg, Voice Handicap Index, Voice-Related Quality of Life). Subjective measures often show high variability, whereas most acoustic measures of voice are only valid for signals where some degree of periodicity can be assumed. However, this assumption is often invalid for dysphonic voices where signal periodicity is suspect. Furthermore, many of these measures are not useful in isolation for diagnostic purposes. OBJECTIVE: We evaluated a recently developed algorithm (Auditory Sawtooth Waveform Inspired Pitch Estimator-Prime [Auditory-SWIPE']) for estimating pitch and pitch strength for dysphonic voices. Whereas fundamental frequency is a physical attribute of a signal, pitch is its psychophysical correlate. As such, the perception of pitch can extend to most signals irrespective of their periodicity. METHODS: Post hoc analyses were conducted for three groups of patients evaluated and treated for voice problems at a major voice center: (1) muscle tension dysphonia/functional dysphonia, (2) vocal fold mass(es), and (3) presbyphonia. All patients were recorded before and after surgical/behavioral treatment for voice disorders. Pitch and pitch strength for each speaker were computed with the Auditory-SWIPE' algorithm. RESULTS: Comparison of pre- and posttreatment data provides support for pitch strength as a measure of treatment outcomes for dysphonic voices.

Autoimmune swallowing disorders.

PURPOSE OF REVIEW: Dysphagia can be the presenting symptom of autoimmune disease. The otolaryngologist should be familiar with and consider these disorders when assessing the patient with swallowing difficulties. RECENT FINDINGS: The present review gives a brief overview of Sjogren's syndrome, granulomatosis with polyangiitis, pemphigus and pemphigoid, rheumatoid arthritis, systemic lupus erythematosus, scleroderma and inflammatory myopathies, and how they affect swallowing. Diagnosis of these diseases is generally based off of clinical presentation, serology, and/or biopsy. Corticosteroids in combination with other immune modulators and symptomatic therapy are the mainstays of treatment. Treatment should be coordinated with a rheumatologist. SUMMARY: The otolaryngologist should be able to recognize when a systemic disease may be the cause of a patient's dysphagia and guide appropriate evaluation. Furthermore, the otolaryngologist can help localize the specific nature of the swallowing problem and guide or provide treatment.

Prospective multi-institutional transnasal esophagoscopy: Predictors of a change in management.

OBJECTIVES/HYPOTHESIS: To evaluate clinical indications and endoscopic findings for patients undergoing transnasal esophagoscopy (TNE). STUDY DESIGN: Prospective, multi-institutional, observational cohort study at four tertiary centers. METHODS: Demographics, reflux finding score, reflux symptom index, Eating Assessment Tool (EAT-10) scores, clinical indications, and endoscopic findings were compared among patients whose TNE findings resulted in a changes in management (FCIM), defined as a referral, new medication, or surgery recommendation. RESULTS: Of the 329 patients who were enrolled nine (3%) were unable to complete the exam. In an adjusted regression model, male gender and elevated body mass index were significantly predictive of a positive TNE (P =.013-.045); 51% (n = 162/319) had TNE with FCIM. Common FCIM were esophageal stricture (7.5%), irregular Z-line (27.4%), reflux esophagitis (12.8%), and infectious esophagitis (6.3%) (P <.001-.010). Overall, the average EAT-10 was higher for patients with FCIM (9.7 vs. 5.4) than in those without it (P =.014). Patients with a history of head and neck cancer (HNCA) had FCIM 64% of the time, which rose to 81% if they had both HNCA and dysphagia. CONCLUSIONS: In treatment-seeking patients TNE is predictive of a change in management in males and obese patients. In patients with HNCA and dysphagia, TNE is likely to yield findings that cause a change in management. LEVEL OF EVIDENCE: 2b. Laryngoscope, 126:2667-2671, 2016.

Dysphagia due to inclusion body myositis: case presentation and review of the literature.

OBJECTIVE: This report aimed to present a case of inclusion body myositis presenting with dysphagia and to review the literature. METHODS: Case report and literature review. RESULTS: Inclusion body myositis is a chronic progressive acquired myopathy, uniquely distinguished by its selective muscle involvement, normal or moderately elevated muscle enzyme concentrations, and a progressive corticosteroid-resistant course. Compared to other inflammatory myopathies, the esophagus is the most commonly involved organ. Specifically, upper esophageal sphincter dysfunction often occurs. Dysphagia may be the only symptom at the time of presentation. CONCLUSION: Unlike other inflammatory myopathies, dysphagia in inclusion body myositis is steroid resistant. Management can be difficult. The otolaryngologist must consider underlying neuromuscular processes when evaluating the patient presenting with oropharyngeal dysphagia.

The role of laryngoscopy in the diagnosis of spasmodic dysphonia.

IMPORTANCE: Spasmodic dysphonia (SD) can be difficult to diagnose, and patients often see multiple physicians for many years before diagnosis. Improving the speed of diagnosis for individuals with SD may decrease the time to treatment and improve patient quality of life more quickly. OBJECTIVE: To assess whether the diagnosis of SD can be accurately predicted through auditory cues alone without the assistance of visual cues offered by laryngoscopic examination. DESIGN, SETTING, AND PARTICIPANTS: Single-masked, case-control study at a specialized referral center that included patients who underwent laryngoscopic examination as part of a multidisciplinary workup for dysphonia. Twenty-two patients were selected in total: 10 with SD, 5 with vocal tremor, and 7 controls without SD or vocal tremor. INTERVENTIONS: The laryngoscopic examination was recorded, deidentified, and edited to make 3 media clips for each patient: video alone, audio alone, and combined video and audio. These clips were randomized and presented to 3 fellowship-trained laryngologist raters (A.D.R., A.T.H., and A.M.K.), who established the most probable diagnosis for each clip. Intrarater and interrater reliability were evaluated using repeat clips incorporated in the presentations. MAIN OUTCOMES AND MEASURES: We measured diagnostic accuracy for video-only, audio-only, and combined multimedia clips. These measures were established before data collection. Data analysis was accomplished with analysis of variance and Tukey honestly significant differences. RESULTS: Of patients with SD, diagnostic accuracy was 10%, 73%, and 73% for video-only, audio-only, and combined, respectively (P < .001, df = 2). Of patients with vocal tremor, diagnostic accuracy was 93%, 73%, and 100% for video-only, audio-only, and combined, respectively (P = .05, df = 2). Of the controls, diagnostic accuracy was 81%, 19%, and 62% for video-only, audio-only, and combined, respectively (P < .001, df = 2). CONCLUSIONS AND RELEVANCE: The diagnosis of SD during examination is based primarily on auditory cues. Viewing combined audio and video clips afforded no change in diagnostic accuracy compared with audio alone. Laryngoscopy serves an important role in the diagnosis of SD by excluding other pathologic causes and identifying vocal tremor.

Spindle cell carcinoma of the larynx presenting as a vocal fold cyst.

Spindle cell carcinoma (SPCC) is a rare, malignant variant of squamous cell carcinoma (SCC), which shows biphasic proliferation of the conventional SCC component and malignant spindle shape cells with sarcomatous appearance. We present two cases of SPCC of the true vocal fold that presented as a benign appearing subepithelial mass. We discuss the patient presentation, voice assessment, surgical treatment, and a review of the literature.

Analysis of supraglottic activity during vocalization in healthy singers.

OBJECTIVES/HYPOTHESIS: The present study aims to evaluate the degree of anterior-posterior and medial supraglottic laryngeal compression in healthy singers of different voice classifications while singing different pitches, loudness, and phonatory tasks. STUDY DESIGN: Prospective study. METHODS: Thirty-six classically trained singers (11 sopranos, 11 mezzo-sopranos, six tenors, and eight baritones) with at least 5 years of voice training and absence of any voice pathology within the past year were included. Flexible endoscopic voice evaluations were recorded and edited to include samples of different pitches, levels of loudness, and phonatory tasks. Sound was removed from the video samples. Two blinded laryngologists were asked to assess medial and anterior-posterior supraglottic compression using a visual analog scale for each sample. RESULTS: Medial compression was significantly greater in male subjects and specifically tenors during loud phonation, during high pitch, and while phonating the vowel /a/. Anterior-posterior compression was also significantly greater in males and specifically baritones during loud voice production and with phonation of the vowel /a/. No difference was noted in relation to pitch. Correlation between anterior-posterior and medial compression was demonstrated. Medial compression was less severe than anterior-posterior compression. CONCLUSIONS: Supraglottic hyperfunction is present in healthy singers. Recognizing factors that might affect supraglottic hyperfunction in the healthy voice may help us to understand when hyperfunction is truly contributing to a patient's vocal pathology. LEVEL OF EVIDENCE: 4.

Globus pharyngeus: effectiveness of treatment with proton pump inhibitors and gabapentin.

OBJECTIVES: This study was performed to investigate the effectiveness of treatment of globus pharyngeus with proton pump inhibitors, gabapentin, or both. METHODS: The subjects all presented with globus pharyngeus during the years 2006 to 2011. The inclusion criteria included a chief (primary) complaint of globus pharyngeus; a trial of proton pump inhibitor therapy for at least 2 months and/or a trial of gabapentin for at least 2 weeks; and at least 1 follow-up visit. We reviewed 331 charts; 87 patients met the criteria. The response to treatment was graded as none, partial, or complete. RESULTS: Seventy-seven percent of all patients had improvement. Sixty-seven percent of patients had a partial or complete response from aggressive reflux management. Sixty-six percent of patients who had a trial of gabapentin reported improvement. Eight of 14 patients who did not improve with aggressive reflux management improved with gabapentin. CONCLUSIONS: A majority of patients with globus pharyngeus can be helped by treating reflux or neuralgia. A trial of gabapentin should be considered for patients who do not respond or only partially respond to reflux management.