A machine-learning-enabled smart neckband for monitoring dietary intake.

The increasing need for precise dietary monitoring across various health scenarios has led to innovations in wearable sensing technologies. However, continuously tracking food and fluid intake during daily activities can be complex. In this study, we present a machine-learning-powered smart neckband that features wireless connectivity and a comfortable, foldable design. Initially considered beneficial for managing conditions such as diabetes and obesity by facilitating dietary control, the device's utility extends beyond these applications. It has proved to be valuable for sports enthusiasts, individuals focused on diet control, and general health monitoring. Its wireless connectivity, ergonomic design, and advanced classification capabilities offer a promising solution for overcoming the limitations of traditional dietary tracking methods, highlighting its potential in personalized healthcare and wellness strategies.

Analyzing Vocal Fold Frequency Dynamics Using High-Speed 3D Laser Video Endoscopy.

OBJECTIVE: To examine changes in lateral and vertical vibratory motion along the anterior, middle, and posterior sections of the vocal folds, as a function of vocal frequency variations. METHODS: Absolute measurements of vocal fold surface dynamics from high-speed videoendoscopy with custom laser endoscope were made on 23 vocally healthy adults during sustained /i:/ production at 10%, 20%, and 80% of pitch range. The 3D parameters of amplitude (mm), maximum velocity opening/closing (mm/s), and mean velocity opening/closing (mm/s) were computed for the lateral and vertical vibratory motion along the anterior, middle, and posterior sections of the vocal folds. Linear mixed model analysis was conducted to evaluate the differences in (a) vocal frequency levels (high vs. normal vs. low pitch), (b) axis level (vertical vs. lateral), (c) position level (anterior vs. middle vs. posterior), and (d) gender differences (male vs. female). RESULTS: Overall, the superior surface vertical motion of the vocal fold is greater compared with the lateral motion, especially in males. Along the superior surface, the mean and maximum closing velocities are greater posteriorly for low pitch. The location (anterior, middle, and posterior) along the superior surface is relevant only for vocal fold closing rather than opening, as the dynamics are different along the various locations. CONCLUSIONS: The study highlights the significance of assessing the vertical motion of the superior surface of the vocal fold to understand the complex dynamics of voice production. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3267-3276, 2024.

Laryngeal, Respiratory, and Acoustic Characteristics of Vocal Trillo With Simultaneous High-Speed Videoendoscopy, Inductive Plethysmography, and Acoustic Recordings.

OBJECTIVE: This study aimeed to examine the characteristics of formed and unformed trillo, an essential ornament found in 17th-century Italian vocal music, using simultaneous multimodality voice measurements. PARTICIPANT AND METHODS: A 28-year-old female with 12 years of classical voice training and 7 years of advanced training in historical performance produced formed trillo, unformed trillo, oscillating trill, vibrato, and straight tone on the vowel /i/. Simultaneous high-speed videoendoscopy, inductive plethysmography, and acoustic recordings were conducted to examine the laryngeal motion, respiratory kinematics, and output sound characteristics. RESULTS: The study findings reveal that trillo in this single participant is not only produced by the periodic adduction/abduction of the vocal fold but also with underlying differences in oscillatory mechanisms and increased glottal flow (use of percent vital capacity) controlled by increased activation of abdominal muscles and/or decreased activation (inspiratory braking) of the diaphragm relative to tidal breathing when compared with straight tone, vibrato, and oscillating trill. The formed trillo differs from the unformed trillo in the oscillatory mechanisms and glottal airflow utilization. CONCLUSIONS: The physiological mechanism responsible for trillo is more complex than simply adduction and abduction. Future studies with a greater number of participants are needed to evaluate the mechanisms responsible for the formation of and the auditory-perceptual differences between the formed versus unformed trillo.

Computational fluid dynamics of upper airway aerodynamics for exercise-induced laryngeal obstruction: A feasibility study.

Objective: Use of computational fluid dynamic (CFD) simulations to measure the changes in upper airway geometry and aerodynamics during (a) an episode of Exercise-Induced Laryngeal Obstruction (EILO) and (b) speech therapy exercises commonly employed for patients with EILO. Methods: Magnetic resonance imaging stills of the upper airway including the nasal and oral cavities from an adult female were used to re-construct three-dimensional geometries of the upper airway. The CFD simulations were used to compute the maximum volume flow rate (l/s), pressure (Pa), airflow velocity (m/s) and area of cross-section opening in eight planes along the vocal tract, separately for inhalation and exhalation. Results: Numerical predictions from three-dimensional geometrical modeling of the upper airway suggest that the technique of nose breathing for inhalation and pursed lip breathing for exhalation show most promising pressure conditions and cross-sectional diameters for rescue breathing exercises. Also, if EILO is due to the constriction at the vocal fold level, then a quick sniff may also be a proper rescue inhalation exercise. EILO affects both the inspiratory and the expiratory phases of breathing. Conclusions: A prior knowledge of the supraglottal aerodynamics and the corresponding upper airway geometry from CFD analysis has the potential to assist the clinician in choosing the most effective rescue breathing technique for optimal functional outcome of speech therapy intervention in patients with EILO and in understanding the pathophysiology of EILO on a case-by-case basis with future studies. Level of Evidence: 4.

High-Speed Videoendoscopic and Acoustic Characteristics of Inspiratory Phonation.

PURPOSE: Given the importance of inspiratory phonation for assessment of vocal fold structure, the aim of this investigation was to evaluate and describe the vocal fold vibratory characteristics of inspiratory phonation using high-speed videoendoscopy in healthy volunteers. The study also examined the empirical relationship between cepstral peak prominence (CPP) and glottal area waveform measurements derived from simultaneous high-speed videoendoscopy and audio recordings. METHOD: Vocally healthy adults (33 women, 28 men) volunteered for this investigation and completed high-speed videoendoscopic assessment of vocal fold function for two trials of an expiratory/inspiratory phonation task at normal pitch and normal loudness. Twelve glottal area waveform measures and acoustic CPP values were extracted for analyses. RESULTS: Inspiratory phonation resulted in shorter closing time, longer duration of the opening phase, and faster closing phase velocity compared to expiratory phonation. Sex differences were elucidated. CPP changes for inspiratory phonation were predicted by changes in the glottal area index and waveform symmetry index, whereas changes in CPP during expiratory phonation were predicted by changes in asymmetry quotient, glottal area index, and amplitude periodicity. CONCLUSIONS: Vocal fold vibratory differences were identified for inspiratory phonation when compared to expiratory phonation, the latter of which has been studied more extensively. This investigation provides important basic inspiratory phonation data to better understand laryngeal physiology in vivo and provides a basic model from which to further study inspiratory phonation in a larger population representing a broader age range. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22223812.

Identification of Breathing Pattern Disorder in Athletes With Exercise-Induced Laryngeal Obstruction: A Novel Assessment Tool.

OBJECTIVE: To report the diagnostic utility of the novel, high-ventilatory task assessment tool called the Milstein Breathing Pattern Assessment Index (M-BPAI) for evaluation of Breathing Pattern Disorder (BPD) in athletes with and without breathing difficulty, and to evaluate the prevalence of BPD in athletes referred for Exercise Induced Laryngeal Obstruction (EILO). BPD is an abnormal respiratory biomechanical pattern caused from functional or structural factors. The presence of BPD in athletes with EILO is unknown. The current clinical evaluations of dysfunctional breathing patterns are limiting for evaluation of BPD in patients with EILO, as these only evaluate the patients in low ventilatory output tasks of rest breathing. STUDY DESIGN AND METHODS: In this prospective study, a total of 77 athletes referred to the clinic for suspected EILO and 58 athletes without any respiratory difficulty underwent M-BPAI assessment. Data collection from the experimental group also included the Dyspnea Index, and laryngeal video endoscopic provocation test. RESULTS: The M-BPAI score was significantly larger in the patient group compared to the control group. An overall M-BPAI score of ≥8 corresponds to the AUC of 0.87 (95% CI: 0.81-0.93) with a sensitivity of 0.862 and specificity of 0.792. A total of 60 (78%) patients had an overall M-BPAI score of ≥8. CONCLUSION: The M-BPAI has the potential to be a valuable clinical diagnostic marker for identifying BPD in patients with suspected EILO with further research and validation.

Treatment Outcomes of Type 1 Thyroplasty Using Gore-Tex® Following Injection Laryngoplasty.

OBJECTIVE: To compare voice-related outcomes of type 1 thyroplasty using Gore-Tex® between patients with and without augmentation injection laryngoplasty (IL) prior to surgery. METHODS: Forty-five patients who underwent Gore-Tex® thyroplasty at a single institution by a single surgeon between November 2016 and February 2019 were identified as those who previously had IL (n = 20) and those without IL (n = 25). Pre- and post-operative voice-related primary outcomes were evaluated using the GRBAS, and CAPE-V auditory-perceptual rating scales and secondary outcome were evaluated using the VRQOL. Pre- and post-operative voice samples were blinded, randomized, and analyzed by 3 voice-specialized speech pathologists to obtain CAPE-V scores. The VRQOL and GRBAS scores were obtained from retrospective chart review. Student's t test with a paired one-tailed distribution was used for comparisons within groups and 2-sample equal variance for comparisons between groups. Intraclass correlation coefficient determined interrater agreement. RESULTS: GRBAS, and VRQOL significantly improved post Gore-Tex® thyroplasty. There was no difference in improvement between patients who received pre-surgery IL and those who did not in either GRBAS or VRQOL scores, but CAPE-V showed significant improvement in the IL group. A strongly positive correlation was demonstrated between the severity of CAPE-V pre-op score and the overall improvement following surgery for both groups combined. CONCLUSION: Patients with vocal fold paralysis have a significantly better voice after Gore-Tex® thyroplasty by self-report (VRQOL) and assessment by trained voice professionals (GRBAS). Having IL prior to surgery does not adversely affect later surgical outcomes. This paper represents one of the largest analyses of voice quality outcomes of Gore-Tex® thyroplasty using validated patient scales and randomized blinded analyses.

Globus Pallidus Interna and Ventral Intermediate Nucleus of the Thalamus Deep Brain Stimulation for Adductor Laryngeal Dystonia: a Case Report of Blinded Analyses of Objective Voice Outcomes in 2 Patients.

BACKGROUND: Adductor laryngeal dystonia (ADLD) is a substantially debilitating focal progressive neurological voice disorder. Current standard of care is symptomatic treatment with repeated injections of botulinum toxin into specific intrinsic laryngeal muscles with extremely variable and temporary benefits. We report the use of bilateral deep brain stimulation (DBS) of globus pallidus (GPi) for long-term improvement of ADLD voice symptoms. OBJECTIVE: To investigate the effects of bilateral DBS of the GPi and ventral intermediate nucleus (VIM) of the thalamus on vocal function in 2 patients with ADLD associated with voice and hand tremor. METHODS: Blinded objective and quantitative analyses of voice were conducted before and after treatment in 2 female patients (70 and 69 years). Paired t-tests were conducted to compare voice measurements pre-GPi and post-GPi and VIM-DBS. A 2-way analysis of variance was conducted to determine the interaction between target (GPi/VIM) and time (pre/post) for each voice measure. RESULTS: Although the follow-up period differed between patients, the GPi-DBS implanted patient had notable improvement in vowel voicing (%), extent of tremor intensity (%), and overall speech intelligibility (%), compared with preoperative status. GPi-DBS also resulted in significant improvement in cepstral peak prominence (dB). VIM-DBS resulted in a significantly greater change in the tremor rate (Hz). CONCLUSION: Changes in phonatory function provide preliminary support for the use of bilateral GPi-DBS for treatment of ADLD and bilateral VIM-DBS for vocal tremor predominant ADLD. Future studies with larger sample sizes and standardized follow-up periods are needed to better assess the role of DBS for ADLD.

Re-Training of Convolutional Neural Networks for Glottis Segmentation in Endoscopic High-Speed Videos.

Endoscopic high-speed video (HSV) systems for visualization and assessment of vocal fold dynamics in the larynx are diverse and technically advancing. To consider resulting "concepts shifts" for neural network (NN)-based image processing, re-training of already trained and used NNs is necessary to allow for sufficiently accurate image processing for new recording modalities. We propose and discuss several re-training approaches for convolutional neural networks (CNN) being used for HSV image segmentation. Our baseline CNN was trained on the BAGLS data set (58,750 images). The new BAGLS-RT data set consists of additional 21,050 images from previously unused HSV systems, light sources, and different spatial resolutions. Results showed that increasing data diversity by means of preprocessing already improves the segmentation accuracy (mIoU + 6.35%). Subsequent re-training further increases segmentation performance (mIoU + 2.81%). For re-training, finetuning with dynamic knowledge distillation showed the most promising results. Data variety for training and additional re-training is a helpful tool to boost HSV image segmentation quality. However, when performing re-training, the phenomenon of catastrophic forgetting should be kept in mind, i.e., adaption to new data while forgetting already learned knowledge.

Glottal Airflow and Glottal Area Waveform Characteristics of Flow Phonation in Untrained Vocally Healthy Adults.

OBJECTIVE: To examine flow phonation characteristics with regard to vocal fold vibration and voice source properties in vocally healthy adults using multimodality voice measurements across various phonation types (breathy, neutral, flow, and pressed) and loudness conditions (typical, loud, and soft). PARTICIPANTS AND METHODS: Vocal fold vibration, airflow, acoustic, and subglottal pressure was analyzed in 13 untrained voices (six female and seven male). Participants repeated the syllable / pæ:/ using breathy, neutral, flow, and pressed phonation during typical, loud, and soft loudness conditions. Glottal area (GA) waveforms were extracted from high-speed videoendoscopy; glottal flow was derived from inverse filtering the airflow or the audio signal; and subglottal pressure was measured as the intraoral pressure during /p/ occlusion. RESULTS: Changes in phonation type and loudness conditions resulted in systematic variations across the relative peak closing velocity derived from the GA waveform for both males and females. Amplitude quotient derived from the flow glottogram varied across phonation types for males. CONCLUSION: Multimodality evaluation using the GA waveform and the inverse filtered waveforms revealed a complex pattern that varied as a function of phonation types and loudness conditions across males and females. Emerging findings from this study suggests that future large-scale studies should focus on spatial and temporal features of closing speed and closing duration for differentiating flow phonation from other phonation types in untrained adults with and without voice disorders.

Semi-occluded vocal tract exercises in healthy young adults: Articulatory, acoustic, and aerodynamic measurements during phonation at threshold.

Semi-occluded vocal tract exercises (SOVTEs) are increasingly popular as therapeutic exercises for patients with voice disorders. This popularity is reflected in the growing research literature, investigating the scientific principles underlying SOVTEs and their practical efficacy. This study examines several acoustic, articulatory, and aerodynamic variables before, during, and after short-duration (15 s) SOVTEs with a narrow tube in air. Participants were 20 healthy young adults, and all variables were measured at threshold phonation levels. Acoustic variables were measured with a microphone and a neck accelerometer, and include fundamental frequency, glottal open quotient, and vocal efficiency. Articulatory variables were measured with ultrasound, and include measures of the tongue tip, tongue dorsum, and posterior tongue height, and horizontal tongue length. Aerodynamic variables were measured with an intraoral pressure transducer and include subglottal, intraoral, and transglottal pressures. Lowering of the posterior tongue height and tongue dorsum height were observed with gender-specific small changes in the fundamental frequency, but there were no significant effects on the transglottal pressure or vocal efficiency. These findings suggest that the voices of healthy young adults already approach optimal performance, and the continued search for scientific evidence supporting SOVTEs should focus on populations with voice disorders.

Quantitative and Qualitative Electroglottographic Wave Shape Differences in Children and Adults Using Voice Map-Based Analysis.

Purpose The purpose of this study is to identify the extent to which various measurements of contacting parameters differ between children and adults during habitual range and overlap vocal frequency/intensity, using voice map-based assessment of noninvasive electroglottography (EGG). Method EGG voice maps were analyzed from 26 adults (22-45 years) and 22 children (4-8 years) during connected speech and vowel /a/ over the habitual range and the overlap vocal frequency/intensity from the voice range profile task on the vowel /a/. Mean and standard deviations of contact quotient by integration, normalized contacting speed, quotient of speed by integration, and cycle-rate sample entropy were obtained. Group differences were evaluated using the linear mixed model analysis for the habitual range connected speech and the vowel, whereas analysis of covariance was conducted for the overlap vocal frequency/intensity from the voice range profile task. Presence of a "knee" on the EGG wave shape was determined by visual inspection of the presence of convexity along the decontacting slope of the EGG pulse and the presence of the second derivative zero-crossing. Results The contact quotient by integration, normalized contacting speed, quotient of speed by integration, and cycle-rate sample entropy were significantly different in children compared to (a) adult males for habitual range and (b) adult males and adult females for the overlap vocal frequency/intensity. None of the children had a "knee" on the decontacting slope of the EGG slope. Conclusion EGG parameters of contact quotient by integration, normalized contacting speed, quotient of speed by integration, cycle-rate sample entropy, and absence of a "knee" on the decontacting slope characterize the wave shape differences between children and adults, whereas the normalized contacting speed, quotient of speed by integration, cycle-rate sample entropy, and presence of a "knee" on the downward pulse slope characterize the wave shape differences between adult males and adult females. Supplemental Material https://doi.org/10.23641/asha.15057345.

High-Speed Characterization of Vocal Fold Vibrations in Normally Cycling and Postmenopausal Women: Randomized Double-Blind Analyses.

Purpose The aim of this study was to examine the influence of menstrual cycle phases (follicular, ovulatory, luteal, and ischemic) and hormone levels (estradiol, testosterone, progesterone, and neuropeptide Y) on vocal fold vibrations in reproductive and postmenopausal women. Method Glottal area waveforms were extracted from high-speed videoendoscopy during sustained phonation, inhalation phonation, and voice onset/offset in the reproductive (n = 15) and postmenopausal (n = 13) groups. Linear mixed-model analysis was conducted to evaluate hormone levels and high-speed videoendoscopy outcome variables between the reproductive and postmenopausal groups. In the reproductive group, simple linear regression and multiple regression were conducted to determine the effects of hormones on the dependent variables. Results Group differences between reproductive and postmenopausal women were identified for stiffness index, oscillatory onset time, and oscillatory offset time. Neuropeptide Y hormone in the ischemic phase significantly predicted changes in the reproductive group for some dependent variables; however, the relationship varied for sustained phonation and inhalation phonation. Conclusion These findings provide preliminary evidence that vocal fold vibrations in the reproductive group are different predominantly in the ischemic phase due to neuropeptide Y changes.

Vocal tract shape and acoustic adjustments of children during phonation into narrow flow-resistant tubes.

The goal of the study is to quantify the salient vocal tract acoustic, subglottal acoustic, and vocal tract physiological characteristics during phonation into a narrow flow-resistant tube with 2.53 mm inner diameter and 124 mm length in typically developing vocally healthy children using simultaneous microphone, accelerometer, and 3D/4D ultrasound recordings. Acoustic measurements included fundamental frequency (fo), first formant frequency (F1), second formant frequency (F2), first subglottal resonance (FSg1), and peak-to-peak amplitude ratio (Pvt:Psg). Physiological measurements included posterior tongue height (D1), tongue dorsum height (D2), tongue tip height (D3), tongue length (D4), oral cavity width (D5), hyoid elevation (D6), pharynx width (D7). All measurements were made on eight boys and ten girls (6-9 years) during sustained /o:/ production at typical pitch and loudness, with and without flow-resistant tube. Phonation with the flow-resistant tube resulted in a significant decrease in F1, F2, and Pvt:Psg and a significant increase in D2, D3, and FSg1. A statistically significant gender effect was observed for D1, with D1 higher in boys. These findings agree well with reported findings from adults, suggesting common acoustic and articulatory mechanisms for narrow flow-resistant tube phonation. Theoretical implications of the findings are discussed.

Recommended Protocols for Instrumental Assessment of Voice: American Speech-Language-Hearing Association Expert Panel to Develop a Protocol for Instrumental Assessment of Vocal Function.

Purpose: The aim of this study was to recommend protocols for instrumental assessment of voice production in the areas of laryngeal endoscopic imaging, acoustic analyses, and aerodynamic procedures, which will (a) improve the evidence for voice assessment measures, (b) enable valid comparisons of assessment results within and across clients and facilities, and (c) facilitate the evaluation of treatment efficacy. Method: Existing evidence was combined with expert consensus in areas with a lack of evidence. In addition, a survey of clinicians and a peer review of an initial version of the protocol via VoiceServe and the American Speech-Language-Hearing Association's Special Interest Group 3 (Voice and Voice Disorders) Community were used to create the recommendations for the final protocols. Results: The protocols include recommendations regarding technical specifications for data acquisition, voice and speech tasks, analysis methods, and reporting of results for instrumental evaluation of voice production in the areas of laryngeal endoscopic imaging, acoustics, and aerodynamics. Conclusion: The recommended protocols for instrumental assessment of voice using laryngeal endoscopic imaging, acoustic, and aerodynamic methods will enable clinicians and researchers to collect a uniform set of valid and reliable measures that can be compared across assessments, clients, and facilities.

Clinical relevance of endoscopic three-dimensional imaging for quantitative assessment of phonation.

OBJECTIVE/HYPOTHESIS: Laser-based three-dimensional (3D) imaging allows realistic visualization and absolute measurement of the vocal folds for comprehensive characterization of the oscillation pattern. STUDY DESIGN: Exploratory study with descriptive data analysis in healthy cohort. METHODS: The custom-developed miniaturized measuring device is an endoscopic camera-laser setup for stereo triangulation and suitable for in vivo application. The laser projection unit generates a regular laser grid that is projected on the vocal folds and recorded at 4000 fps using a high-speed camera. Recordings are performed during sustained phonation on 10 healthy subjects. RESULTS: We present absolute values for the lateral and vertical displacement amplitudes and maximum velocities during opening and closing phase. On average over all study participants, the vertical parameters are at least 50% higher than their lateral counterparts. The mean male/female amplitudes are 0.93 mm/0.80 mm in the lateral and 1.28 mm/1.45 mm in the vertical direction. Only 20% of the healthy subjects displayed slight asymmetries in the lateral direction, but 70% showed significant asymmetries in the vertical component. In only 30% of all subjects, the asymmetry trends matched in the lateral and vertical direction. CONCLUSIONS: The study illustrates the additional benefit of 3D imaging: consideration of the vertical component and computation of metric units. New, relevant, and even unexpected information was obtained by the incorporation of the additional vertical dimension. Metric units allow for an absolute evaluation of anatomy and dynamics and therefore enables cross-study comparability. The noninvasive acquisition of quantitative measures for evidence-based medicine has the potential to enhance diagnostic and therapeutic procedures as well as basic medical research. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2367-2374, 2018.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update) Executive Summary.

Objective This guideline provides evidence-based recommendations on treating patients presenting with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia. Purpose The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology-head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology. Action Statements The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include but are not limited to recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids in patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia. Differences from Prior Guideline (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).

Objective This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia. Purpose The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology-head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology. Action Statements The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia. Disclaimer This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia.

Biomechanical simulation of vocal fold dynamics in adults based on laryngeal high-speed videoendoscopy.

MOTIVATION: Human voice is generated in the larynx by the two oscillating vocal folds. Owing to the limited space and accessibility of the larynx, endoscopic investigation of the actual phonatory process in detail is challenging. Hence the biomechanics of the human phonatory process are still not yet fully understood. Therefore, we adapt a mathematical model of the vocal folds towards vocal fold oscillations to quantify gender and age related differences expressed by computed biomechanical model parameters. METHODS: The vocal fold dynamics are visualized by laryngeal high-speed videoendoscopy (4000 fps). A total of 33 healthy young subjects (16 females, 17 males) and 11 elderly subjects (5 females, 6 males) were recorded. A numerical two-mass model is adapted to the recorded vocal fold oscillations by varying model masses, stiffness and subglottal pressure. For adapting the model towards the recorded vocal fold dynamics, three different optimization algorithms (Nelder-Mead, Particle Swarm Optimization and Simulated Bee Colony) in combination with three cost functions were considered for applicability. Gender differences and age-related kinematic differences reflected by the model parameters were analyzed. RESULTS AND CONCLUSION: The biomechanical model in combination with numerical optimization techniques allowed phonatory behavior to be simulated and laryngeal parameters involved to be quantified. All three optimization algorithms showed promising results. However, only one cost function seems to be suitable for this optimization task. The gained model parameters reflect the phonatory biomechanics for men and women well and show quantitative age- and gender-specific differences. The model parameters for younger females and males showed lower subglottal pressures, lower stiffness and higher masses than the corresponding elderly groups. Females exhibited higher subglottal pressures, smaller oscillation masses and larger stiffness than the corresponding similar aged male groups. Optimizing numerical models towards vocal fold oscillations is useful to identify underlying laryngeal components controlling the phonatory process.

Oscillatory Onset and Offset in Young Vocally Healthy Adults Across Various Measurement Methods.

OBJECTIVE: This study aimed to investigate the relationship between (1) oscillatory onset-offset time across various approaches that use different measurement criteria and (2) oscillatory onset and offset times in vocally healthy young adults. METHOD: Oscillatory onset-offset times were obtained from 71 vocally normal adults, using high-speed videoendoscopy. Comparisons between the different onset methods involved measurement of the oscillatory onset time (OOT), voice initiation period (VIP), and the phonation onset time (POT), and for offset methods involved computation of the oscillatory offset time (OOToff) and the phonation offset time. RESULTS: Correlation of the OOT with the VIP was 0.240 (P = 0.04) and with the POT form glottal area waveform was 0.248 (P = 0.04); however, correlation between the VIP and the POT glottal area waveform was 0.661 (P < 0.001). For offset, there was a moderate correlation (rS = 0.503, P < 0.001) across OOToff and vocal offset period. The onset time was longest for the OOT followed by the VIP and the POT. There was no correlation between onset and offset for all methods. CONCLUSIONS: A framework for quantification of oscillatory onset-offset time was developed for /hi/ tasks, which can be used for future measurements of disordered voice. A positive relationship was observed between VIP and POT and between OOToff and vocal offset period. There was a nonlinear relationship between the OOT, VIP, and POT measures. Onset-offset times are strongly influenced by the calculation method used, the pros and cons of which are discussed in this paper. Vibratory onset and offset represent physiologically different phenomena.