Consensus Auditory-Perceptual Evaluation Of Voice Research Articles

French-Language Adaptation of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)

ObjectivesThis study aimed to adapt the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) protocol for perceptual voice assessment to the French language. The primary objective was to achieve consensus among an international panel of voice experts on the content of the adapted protocol. MethodsTo ensure the relevance and robustness of the French CAPE-V protocol, this study employed a systematic Delphi method and involved an international panel primarily comprising speech therapists and lecturers from France and Belgium. The multi-stage process included an initial panel size of 15 experts. Three rounds of online questionnaires, integrating both quantitative and qualitative data collection, were conducted. Participants provided feedback and ratings on various protocol elements until consensus was reached. Adaptations targeted the choice of task stimuli (sustained vowel, sentence reading, semi-spontaneous speech), of the rating scales, and vocal quality terminology. ResultsThe Delphi process achieved consensus on all elements of the adapted CAPE-V protocol. Notably, the sustained vowel task saw consensus in favor of the vowel /a/. Sentence adaptations achieved substantial agreement, with the final set unanimously approved. The simple Visual Analog Scale (VAS) emerged as the preferred rating scale. Agreement on terms for describing vocal qualities marked a crucial step in establishing a shared vocabulary among French-speaking voice experts. ConclusionsThe study successfully adapted the CAPE-V protocol for perceptual voice assessment to the French language through a systematic Delphi process. The final protocol closely resembles the original English version, maintaining its structure and core objectives. Consensus on sustained vowel tasks, sentence adaptations, rating scales, and vocal quality terminology indicates the relevance and robustness of the adapted protocol. Ongoing validation studies in France demonstrate the potential clinical utility of the adapted CAPE-V in French-speaking contexts, representing a significant step toward standardized and validated voice assessment tools for clinicians and researchers globally.

Development and Validation of the Bilingual Catalan/Spanish Cross-Cultural Adaptation of the Consensus Auditory-Perceptual Evaluation of Voice.

This study aimed to develop a valid and reliable bilingual version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) for the auditory-perceptual evaluation of voice in Catalan and Spanish speakers. The development of this CAPE-V adaptation included Delphi methodology with 20 voice and speech experts reaching consensus on the optimal adapted terminology of the perceptual vocal attributes, considering also input from the original instrument authors. The adaptation and validation of vocal tasks followed a sequential validation procedure, with input from phoneticians and speech-language pathologists. Following pilot testing with a large sample of speech-language pathology students, a refined adapted version was empirically tested for validity and reliability. Concurrent validity was assessed by comparing the adapted CAPE-V with the reference Grade, Roughness, Breathiness, Asthenia, Strain scale. Construct validity was assessed through convergent and discriminant validity analysis. Intrarater and interrater reliability were assessed via intraclass correlation coefficient calculations. User experience was evaluated through a questionnaire. Scale properties were validated using a confusion matrix, and cutoff values were calculated to achieve the optimal balance between sensitivity and specificity. Through a formalized consensus process, optimal Catalan/Spanish terminology was determined for the perceptual attributes of voice present in the CAPE-V. An adapted protocol of tasks was obtained that preserves the objectives of the original instrument and the relevance of the phonetic criteria in the target languages. The results demonstrated concurrent validity, construct validity, and intrarater reliability. Interrater reliability was found to depend on the extent to which evaluators shared their internal standards. The raters identified CAPE-V as an effective and preferred instrument. An adapted, validated version of the CAPE-V is made available to clinical professionals for the evaluation of voice in Catalan and Spanish speakers.

Vocal Effort and Acoustic Analysis of Gargle Phonation Versus Water Swallow in Patients With Muscle Tension Dysphonia: A Clinical Trial

PurposeTo determine the effects of gargle phonation (GP) on self-perceived vocal improvement, vocal effort, acoustic parameters, and speech rate in patients with muscle tension dysphonia (MTD). We hypothesized that GP would improve voice, reduce phonatory effort, and alter acoustic and speech measures. Study designProspective randomized, single-blind cross-over clinical trial Methods34 participants (26 females, 8 males; average age 53 years) who were diagnosed with muscle tension dysphonia completed the Voice Handicap Index-10 (VHI-10) and were assigned three study conditions: Baseline (B), GP, and Water Swallow (WS; sham), presented in one of two counterbalanced orders B-WS-GP (WS1st) or B-GP-WS (GP1st). Participants recorded stimuli from the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and rated their perceived vocal effort and vocal improvement. F0, vocal intensity, cepstral peak prominence (CPP), and speaking rate were measured. ResultsAverage VHI-10 scores by group were 16 (min/max 2-29) for WS1st and 15 (min/max 3-40) for GP1st. 73.53% reported more vocal improvement after GP, 17.65% after WS, and 8.8% noted no difference between conditions. Reduced effort was reported after GP, compared to B (p<0.001) and WS (p=0.005). Lower effort was also reported after the WS condition, compared to B (p=0.011). Key acoustic findings included an increase in F0 after GP for sustained /i/ for females. CPP was significantly higher for females reading CAPE-V sentences after GP, when GP preceded WS, compared to B (p=0.004) and WS (p=0.003). Speech rate was faster for females after GP versus B (p=0.029). ConclusionsGP may be beneficial in the treatment of muscle tension dysphonia. CPP may be a useful marker for vocal improvement after GP for women with mild MTD. Further studies would benefit from having more male participants and those with moderate and severe MTD.

Clinical Voice Outcomes for Two Voice Rest Protocols after Phonomicrosurgery.

Voice rest is commonly recommended for patients with benign vocal fold lesions (BVFLs) after phonomicrosurgery. The study compares the clinical voice outcomes of two protocols, 7-day complete voice rest (CVR) and 3-day CVR followed by 4-day relative voice rest (CVR + RVR), for patients with BVFLs after phonomicrosurgery. Prospective, randomized controlled trial. Patients with BVFLs undergoing phonomicrosurgery were recruited prospectively and randomly assigned to either protocol. Outcomes were assessed on objective measures of acoustics (fundamental frequency, frequency range, mean intensity, cepstral peak analysis) and aerodynamics (vital capacity, airflow rate, subglottal pressure, phonation threshold pressure), as well as subjective measures, both provider-reported through the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), and patient-reported through the Voice Handicap Index (VHI). Clinical measures were collected at three-time points: preoperatively, 1-week postoperatively (on voice rest), and 1-month postoperatively. In addition, adherence was estimated using a vocal dosimeter. Twenty-five patients were recruited and randomized to 7-day CVR (n = 13) and CVR + RVR regimen (n = 12). Statistically significant changes were found within both groups for subglottal pressure (p = 0.03) and VHI score (p < 0.001) comparing pre-operative baseline to 1-month postoperative follow-up. There were no statistically significant differences between the groups. Regardless of group assignment, a significant decrease in overall severity ratings for the CAPE-V was found by comparing the preoperative scores to postoperative scores at 1-week (p < 0.001) and 1-month (p < 0.001). Both groups improved their overall voice quality comparably 1 month after undergoing phonomicrosurgery as measured by objective and subjective parameters. 2. Laryngoscope, 2024.

Fidelity to the Consensus Auditory-Perceptual Analysis of Voice (CAPE-V): A Pilot Study

ObjectivesAuditory-perceptual measurements of voice are among the most common diagnostic tools used during a voice evaluation and are considered a gold standard for documenting voice disorders. The goal of this pilot study was to examine the fidelity of clinicians in the administration of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and its published protocol. This investigation aimed to determine how the CAPE-V is being used by clinicians and researchers and the extent to which users deviate from the published procedure. Study DesignSurvey MethodsData were collected by surveying a group (N=l7) of speech-language pathologists who regularly evaluate and treat patients with voice disorders. Survey results revealed that few of the sampled speech-language pathologists follow exactly the standardized instructions for administering the CAPE-V. Considerable variability in CAPE-V administration, including tasks and stimuli examined, was found across respondents. ConclusionsThis exploratory project may be used to develop a larger national survey study investigating fidelity to the CAPE-V and to motivate recommendations for possible revisions to the instrument and its protocol for administration.

The Effect of Adding Cricothyroid Visor Maneuver to Voice Facilitating Techniques on Improving Voice in Individuals With Primary Muscle Tension Dysphonia: A Pilot Randomized Clinical Trial

The purpose of the present study was to examine the effect of adding a cricothyroid visor maneuver to conventional voice-facilitating techniques on voice quality and reported symptoms in patients with primary muscle tension dysphonia. This was a double-blind two parallel-group clinical trial in which 20 adult patients participated through convenience sampling. Participants were allocated to intervention (combined treatment) and control (conventional treatment) groups. The intervention was performed for both groups for five sessions, twice a week. The two groups were compared after the intervention for primary outcome measures including maximum phonation time, jitter, shimmer, harmonic-to-noise ratio, and consensus auditory-perceptual evaluation of voice, and for secondary outcome measures including the voice handicap index, the voice activity and participation profile, the voice-related pain scale, and the vocal tract discomfort scale. Within-group primary outcome comparison showed that both groups showed significant improvement in maximum phonation time and consensus auditory-perceptual evaluation of voice indices after treatment. the between-group comparison showed that the maximum phonation time increased significantly in the intervention group after the treatment (P=0.03) and the effect size was large (es=1.05). within-group secondary outcome comparison showed that all indices improved significantly in both groups except for the voice-related pain scale frequency. The between-group comparison showed that except for voice-related pain scale frequency, the intervention group reported significantly more improvement in all other self-reporting indices with a large effect size. The study showed that adding cricothyroid visor maneuver to conventional voice-facilitating techniques, compared to conventional treatment alone, resulted in a significant increase in maximum phonation time, reduction in pain and vocal tract discomfort, increase in activity and participation, and improvement in voice-handicapped index in primary muscle tension dysphonia patients. Therefore adding cricothyroid visor maneuver to other treatments can be an effective method in improving primary muscle tension dysphonia which needs more studies in the future.

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

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

Investigating the Prevalence of Dysphagia and Dysphonia in Patients with COVID-19 in the Intensive Care Unit

Introduction: The world has been suffering from COVID-19 since 2020 and the disease continues up to now. COVID-19 patients are at high risk of dysphagia and dysphonia. Accordingly, this study aims to determine the prevalence of dysphonia and dysphagia and identify correlated factors to develop dysphagia and dysphonia in COVID-19 patients admitted to intensive care units (ICU).&#x0D; Materials and Methods: A total of 70 patients with COVID-19 (Mean±SD age of 63.1±18.6; males=39) hospitalized in ICUs were evaluated by an expert on speech and language. The patients were evaluated for swallowing disorder via the Mann assessment of swallowing ability and the Persian version of the functional oral intake scale. The consensus auditoryperceptual evaluation of voice was also used to evaluate voice disorders.&#x0D; Results: Overall, 58.6% of patients presented dysphagia and 74.3% of patients had dysphonia. Meanwhile, 34.3% of the patients were on mechanical ventilation. A correlation was detected between dysphagia severity and the number of mechanical ventilation days, the length of stay, and age (P&lt;0.05). Dyspnea impacts the prevalence of dysphonia and dysphagia in COVID-19 patients (P&lt;0.05). Vomiting has been effective on only the prevalence of dysphagia (P&lt;0.05). Furthermore, a significant correlation was found between dysphagia and dysphonia (P&lt;0.01).&#x0D; Conclusion: A high prevalence rate of dysphagia and dysphonia exists in patients with COVID-19 admitted to ICUs. An early evaluation by a speech and language pathologist is essential to identify the suspected patients and provide early intervention to prevent further complications and improve their quality of life.

Pediatric Unilateral Vocal Fold Paralysis

Purpose: The aim of this case study was to provide a review of a pediatric patient diagnosed with unilateral vocal fold paralysis. Method: The case history, voice samples, laryngeal examinations, and diagnostic probes were reviewed in a 10-year-old girl with the chief complaint of persistent dysphonia, characterized by use of both a breathy and a typical voice. Perceptual ratings were completed using both Consensus Auditory-Perceptual Evaluation of Voice and Grade, Roughness, Breathiness, Asthenia, and Strain scales. Cepstral peak prominence was determined and compared for the same file segment using both Praat and Analysis of Dysphonia in Speech and Voice analysis programs. Treatment probes during the initial preoperative visit are described. Results: The patient was able to compensate for short phonation tasks, but longer conversations were judged to have increased dysphonia and increased vocal fatigue. Because noted compensation was unable to be stabilized or sustained, both a reinnervation of the ansa cervicalis to the recurrent laryngeal nerve and voice therapy techniques were recommended as part of the multidisciplinary team plan. Conclusion: Pediatric patients with unilateral vocal fold paralysis may present with complex phonatory behaviors. This case study paired with supplemental acoustic and videostroboscopy files provides an opportunity to practice both an auditory-perceptual and acoustic assessment and to rate a laryngeal examination. Supplemental Material: https://doi.org/10.23641/asha.24163926

Dysphonia Outperforms Voice Change as a Clinical Predictor of Dysphagia.

Changes in voice quality after consuming food or drink have been used as a clinical indicator of dysphagia during the clinical swallowing evaluation (CSE); however, there is conflicting evidence of its efficacy. This study investigated if dysphonia and/or voice change after swallowing are valid predictors of penetration, aspiration, or pharyngeal residue. Our approach aimed to improve current methodologies by collecting voice samples in the fluoroscopy suite, implementing rater training to improve interrater reliability and utilizing continuous measurement scales, allowing for regression analyses. In this prospective study, 30 adults (aged 49-97 years) referred for a videofluoroscopic swallowing study (VFSS) were audio-recorded completing a sustained /i/ prior to VFSS and again after swallowing each bolus during the VFSS. Swallowing function was measured using the reorganized Penetration-Aspiration Scale and the Normalized Residue Ratio Scale. Following listener training, 84 voice samples were perceptually rated using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Ordinal and logistic regression were used to determine whether voice quality and voice quality change after swallowing were predictors of airway invasion and pharyngeal clearance. Results indicated that the presence of dysphonia at baseline during a sustained /i/ task as measured by the CAPE-V predicted airway invasion but not pharyngeal residue. Voice change after swallowing associated with vowel /i/ production as measured by the CAPE-V did not predict either dysphagia measure. These results indicate that voice change during a sustained /i/ after swallowing appears unrelated to airway invasion or pharyngeal residue; however, in the absence of known laryngeal pathology, dysphonia prior to a CSE should alert speech-language pathologists of a possible comorbid dysphagia.

Quantitative Evaluation of Vocal Bowing Following Bilateral Thyroplasty in Age-Related Vocal Atrophy.

Age-related vocal atrophy (ARVA) is associated with vocal fold bowing, persistent glottal gap during phonation, and dysphonia. Bilateral medialization thyroplasty is sometimes performed in patients with ARVA to improve vocal fold closure and voice. We set out to quantify stroboscopic changes in vocal fold bowing, glottal closure, and abduction angle following bilateral thyroplasty and determine how these changes affect voice quality among patients with ARVA. Fifteen individuals with ARVA who underwent bilateral medialization thyroplasty were included in this study. Two independent investigators calculated bowing index (BI), normalized glottal gap area (NGGA), and maximum abduction angle from laryngostroboscopic exams using ImageJ™. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and patient-reported measures were collected before and after thyroplasty. Thyroplasty resulted in a 10-point improvement in overall CAPE-V (Mean dif -10; 95% CI -17, -3.3, p < 0.01) and VHI-10 (mean dif -3.8; 95% CI -9.8, 2.3, p = 0.19, n = 8). NGGA and BI significantly decreased following surgery (mean dif -78; 95% CI -155, -1.5, p = 0.05; and mean dif -2.1; 95% CI -2.4, -0.84, p < 0.01, respectively). BI correlated with CAPE-V scores (r = 0.66, 95% CI 0.22, 0.87, p < 0.01). When considering the normalized combined contributions of both NGGA and BI, there was a stronger correlation in CAPE-V scores (r = 0.87, 95% CI 0.50, 0.97, p < 0.01) compared with either measure alone. Thyroplasty resulted in a decrease in vocal fold bowing, glottal gap area, and CAPE-V scores in patients with ARVA. Correction of vocal bowing and glottal gap, following bilateral thyroplasty, improved voice measures following surgery. Quantitative evaluation of vocal fold morphology may be valuable when assessing the severity and treatment-response in patients with ARVA following bilateral thyroplasty. Laryngoscope, 134:835-841, 2024.

The Influence of Multisensory Input On Voice Perception and Production Using Immersive Virtual Reality

The purpose was to examine the influence of auditory vs visual vs combined audiovisual input on perception and production of one's own voice, using immersive virtual reality technology. Thirty-one vocally healthy men and women were investigated under 18 sensory input conditions, using immersive virtual reality technology. Conditions included two auditory rooms with varying reverberation times, two visual rooms with varying volumes, and the combination of audiovisual conditions. All conditions were repeated with and without background noise. Speech tasks included counting, sustained vowel phonation, an all-voiced sentence from the Consensus Auditory-Perceptual Evaluation of Voice, and the first sentence from the Rainbow Passage, randomly ordered. Perception outcome measures were participants' self-reported perceptions of their vocal loudness, vocal effort, and vocal comfort in speech. Production outcome measures were sound pressure level (SPL) and spectral moments (spectral mean and standard deviation in Hz, skewness, and kurtosis). Statistical analyses used self-reported vocal effort, vocal loudness, and vocal comfort in percent (0 = "not at all," 100 = extremely), SPL in dB, and spectral moments in Hz. The reference level was a baseline audiovisual deprivation condition. Results suggested (i) increased self-perceived vocal loudness and effort, and decreased comfort, with increasing room volume, speaker-to-listener distance, audiovisual input, and background noise, and (ii) increased SPL and fluctuations in spectral moments across conditions. Not only auditory, but also visual and audiovisual input influenced voice perception and production in ways that have not been previously documented. Findings contribute to the basic science understanding the role of visual, audiovisual and auditory input in voice perception and production, and also to models of voice training and therapy. The findings also set the foundation for the use of virtual reality in voice and speech training, as a potentially power solution to the generalization problem.

The Relationship Between the Stomatognathic System and Voice in Classical Singers

PurposeTo evaluate stomatognathic system’s structures and functions in classical singers, relating them to the auditory-perceptual judgment of voice quality and voice self-perception. MethodsA cross-sectional pilot study was conducted to evaluate the Stomatognathic System (SS) using orofacial myofunctional evaluation (MBGR Protocol). Voice handicap self-perception was assessed by the Classical Singing Handicap Index (CSHI) and the Voice Handicap Index (VHI-10). Voice samples, recorded according to the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) protocol, underwent auditory-perceptual judgment by two voice experts. All statistical analyses adopted a 5% significance level. ResultsThe study included 15 classical singers (nine women and six men). Adequate assessments of lip and tongue functionality and mobility, upper and lower lip, mentum, and tongue tone were higher compared with altered assessments (P < 0.001). Nasal and oronasal breathing showed similar proportions among singers (P = 0.273). Participants reported greater pain in the masseter muscle (P ≤ 0.001), temporomandibular joint (TMJ) (P ≤ 0.001), and sternocleidomastoid muscle (SCM), especially on the left side (P ≤ 0.001). MBGR score showed no association with singers’ voice handicap and voice quality self-perception. ConclusionMBGR-evaluated SS items were not related to auditory-perceptual judgment of voice quality and voice self-perception. Singers reported more pain with palpation in the SCM, masseter muscle, and TMJ. Preference for a chewing side was higher than bilateral chewing. Assessing SS is paramount for the multidimensional evaluation of classical singers’ voice.

Comparison of Voice Therapy Outcomes: Clinic vs Telehealth

Voice therapy provides patients with valuable exercises and techniques to optimize vocal behaviors and improve their ability to communicate effectively and efficiently. These sessions were typically held by speech-language pathologists (SLPs) in clinic. During the COVID-19 pandemic, SLPs were provisionally able to provide billable voice therapy services in telehealth format. There is a lack of existing research studies comparing outcomes based on the format of voice therapy. A retrospective chart review was performed on 101 patients who underwent voice therapy at a large academic institution in order to compare outcomes between clinic, telehealth, and mixed voice therapy formats. Demographics, dysphonia etiology, duration of symptoms, number of therapy sessions, and pre- and postvoice therapy scores using reflux symptom index (RSI), voice handicap index (VHI-10), consensus auditory-perceptual evaluation of voice (CAPE-V), and Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scoring were collected. Statistical comparisons were performed using Fisher's exact test and analysis of covariance. There were no statistically significant differences in pre- to postvoice therapy RSI, VHI-10, CAPE-V, or GRBAS scores based on format of voice therapy, after adjustment for number of therapy sessions received. There were no differences in these outcomes when comparing voice therapy by etiology of dysphonia. Overall, these data support the effectiveness of the telehealth voice therapy format. It is a promising platform for greater patient access to therapy. All formats of voice therapy were effective in improving key measures of voice perception.

Relationship Between Vocal Fatigue Index and Acoustic Voice Scales in Patients With Coronavirus Infection

The voice quality of patients with Coronavirus Disease 2019 (COVID-19) seems to be affected due to lower and upper respiratory involvement. Patient-based voice assessment scales are important clinical measures to diagnose voice disorders and monitor treatment outcomes in COVID-19 patients. This study compared vocal fatigue between COVID-19 patients and those with normal voices. Furthermore, the relationship between vocal fatigue and acoustic voice parameters of COVID-19 patients was evaluated. This cross-sectional study enrolled 30 laboratory-confirmed patients with COVID-19 (18 males and 12 females) and 30 healthy individuals with normal voices (14 males and 16 females) to compare their respiratory or phonatory parameters. The Persian versions of the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) and the vocal fatigue index (VFI) were conducted before and after reading the text. The Jitter, shimmer, maximum phonation time, and harmonic-to-noise ratio (HNR) were analyzed by Praat software based on the recorded voices of CAPE-V tasks. The acoustic assessment and VFI questionnaire results were compared between COVID-19 patients and the control group. There were significant differences between COVID-19 patients and their healthy counterparts in all VFI subscales (P<0.001). Moreover, after reading the text, we found significant differences between the two groups regarding Jitter, shimmer, and HNR of /a/ and /i/ vowels (P<0.05). Our findings also indicated a significant correlation between symptom improvement with rest and acoustic parameters in all tasks, except the Jitter of /a/ before reading the text. Patients with COVID-19 showed significantly more vocal fatigue than people with normal voices after reading the text. Moreover, there was a significant relationship between Jitter, shimmer, and HNR and the tiredness of voice and physical discomfort subscales of VFI.

Acoustic-Aerodynamic Voice Outcome Ratios Identify Changes in Vocal Function Following Vocal Fold Medialization for Unilateral Vocal Fold Paralysis

This study aimed to determine whether ratio-based measures that combine acoustic (output) and aerodynamic (input) parameters detect postoperative change in vocal function following vocal fold medialization for unilateral vocal fold paralysis. Pre- and postoperative acoustic and aerodynamic measures were analyzed retrospectively from 149 patients who underwent vocal fold medialization for unilateral vocal fold paralysis. A 2×2 repeated-measures analysis of variance was conducted for each of four acoustic-aerodynamic ratios-traditional vocal efficiency (VE), sound pressure level to aerodynamic power (SPL/AP), SPL to average airflow (SPL/AFLOW), and SPL to subglottal pressure (SPL/Ps)-to investigate the main effects and interaction of treatment stage and loudness level (comfortable and loud). The patient group showed significant postoperative improvements in self reports of vocal function (voice-related quality of life) and clinical auditory-perceptual judgments of dysphonia (consensus auditory-perceptual evaluation of voice). Main effects for both treatment stage and loudness level were statistically significant for all measures except SPL/Ps. There were interaction effects for VE and SPL/AP, suggesting that magnitude of the treatment effect differs based on loudness. SPL/AFLOW had medium-to-large effect sizes in both loudness conditions. There were postoperative changes in SPL/Ps that were dependent on the magnitude of the reduction in AFLOW; as expected, SPL/Ps increased postoperatively in a subgroup that had large postoperative reductions in AFLOW at the comfortable loudness level. Acoustic-aerodynamic ratios can aid in tracking changes in vocal function following vocal fold medialization. SPL/AFLOW exhibited the largest effect size, which is expected since a reduction in abnormally high AFLOW typically accompanies the increased modulation of glottal air flow associated with successful vocal fold medialization. Future study is needed to model physiological changes in acoustic-aerodynamic voice outcome ratios across different types of voice disorders.

Pediatric Dysphonia: When to Refer.

The reported prevalence of voice disorders in the pediatric population varies widely between studies, ranging from 3.9% to 23%. Despite this, not all children with dysphonia are referred to a voice specialist for further evaluation. The objective of this study is to examine the relationship between dysphonia history, voice assessment, and laryngeal findings to help guide referrals of dysphonic children. A retrospective review was conducted of pediatric patients at a tertiary voice clinic between January 2014 and December 2017. Data including dates of presentation, demographics, co-morbidities, presenting symptoms, laryngeal exam findings, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores, and Pediatric Voice Handicap Index (pVHI) scores were collected and analyzed. Of 475 patients initially identified, 459 met inclusion criteria and were reviewed. In all, 272 (59.3%) were male and 187 (40.7%) were female. Mean age at first presentation was 8.6 years old (range: 2-18). Males were more likely to present at a younger age than females. CAPE-V data were available for 439 patients, and pVHI data were available for 109 patients. The mean CAPE-V Overall Severity score was 38.2. The mean total pVHI score was 25.4. Males had higher CAPE-V Overall Severity (40.0 vs. 35.4), Roughness (32.2 vs. 27.6), and Strain scores (37.2 vs. 32.4) than females. Patient pVHI scores did not differ by gender. In all, 283 patients self-reported a length of symptoms prior to evaluation. Children with a longer duration of symptoms prior to evaluation had higher CAPE-V Overall Severity scores. Diagnoses of vocal fold movement impairment and benign vocal fold lesions that were not nodules were associated with higher average CAPE-V Overall Severity scores. Overall, 310 patients (67.5%) were recommended intervention for their dysphonia. These patients had higher CAPE-V Overall Severity scores than those who were solely recommended observation (42.8 vs. 28.0). Males were more likely than females to present with dysphonia and presented with more severe perceptual dysphonia scores on average. The length of symptoms and certain diagnoses correlated with higher CAPE-V Scores. Referrals to a pediatric voice clinic should be considered in patients with a dysphonia history lasting greater than 3 months and in patients with more severe symptoms.

Chronic voice disorder after coronavirus disease 2019 infection and its treatment using the cricothyroid visor maneuver: a case report

BackgroundRegarding human coronavirus, the severe acute respiratory syndrome coronavirus 2 pandemic, the novelty of disease, and consequently the lack of studies, the etiology of dysphonia in patients with coronavirus disease 2019 is still unknown and needs to be investigated. The purpose of the current study is to investigate the effect of a new manual therapy technique, cricothyroid visor maneuver, on muscle tension dysphonia symptoms for a patient who had experienced dysphonia symptoms due to the coronavirus disease 2019 infection.Case presentationA 55-year-old retired Iranian teacher who was diagnosed with muscle tension dysphonia by an otolaryngologist participated in this study. Fifty days before being referred to an otolaryngologist, he was diagnosed with coronavirus disease 2019 on the basis of the results of a standard laboratory test, namely real-time polymerase chain reaction. Treatment was provided in ten sessions. Pre- and post-treatment audio recordings of sustained vowels, selected sentences, and connected speech samples were submitted for auditory perceptual and acoustic analysis to assess the effects of the treatment program. Also, videolaryngostroboscopy voice quality perceptions by the patient, both before and after therapy, were assessed. The reduction in all features of the Consensus Auditory-Perceptual Evaluation of Voice was observed. The results of acoustic assessment showed that jitter (35.13%) and shimmer (20.48%) decreased; moreover, the harmonics-to-noise ratio (1.17%), cepstral peak prominence smoothed (28.53%) and maximum phonation time (15.5%) increased after treatment sessions. The scores of four parameters of Stroboscopy Examination Rating Form (SERF) form changed after cricothyroid visor maneuver therapy. Also, the visual analog scales score at the pre-treatment assessment was 40, and increased to 90 at the post-treatment assessment.ConclusionsThe effectiveness of cricothyroid visor maneuver therapy on dysphonia associated with coronavirus disease 2019 was investigated in the current study. This case study has highlighted chronic dysphonia after coronavirus disease 2019 infection, and suggests that the cricothyroid visor maneuver therapy approach may have positive outcomes for patients with muscle tension dysphonia with this background.

Correlation Between Auditory-Perceptual Parameters and Acoustic Characteristics of Voice in Theater Actors

Background: Theater actors are a subgroup of professional voice users who may present their performances at a high-pressure vocal demand, like loud talking, shouting, or even stage singing. Disturbances in auditory-perceptual or acoustic parameters of voice are commonly experienced by theater actors and are known as a frequent occupational hazard for them. Objectives: This study aimed to examine the relationship between auditory-perceptual and acoustic parameters of the voice in Iranian theater actors. Methods: This descriptive-analytical study was conducted on 45 Iranian theater actors, including 22 females and 23 males, with a mean age of 30.76 ± 7 years. The auditory-perceptual evaluation was performed using the Persian version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Acoustic characteristics, including mean fundamental frequency (F0), local shimmer, local jitter, and harmonic-to-noise ratio (HNR), were extracted from the subjects’ “speech sample.” Correlation analyses were performed to examine the relationship between the measures of auditory-perceptual and acoustic voice characteristics. Results: The overall auditory-perceptual severity was negatively correlated with mean F0 (r = -0.592, P &lt; 0.05) and HNR (r = - 0.324, P &lt; 0.05). Roughness was also negatively correlated with voice mean F0 (r = -0.629, P &lt; 0.05) and HNR (r = -0.322, P &lt; 0.05) and positively correlated with voice local jitter (r = 0.310, P &lt; 0.05). We also found that pitch was negatively correlated with voice mean F0 (r = -0.309, P &lt; 0.05) and positively correlated with voice local jitter (r = 0.292, P = 0.050). Conclusions: Acoustic measures, including F0, HNR, and jitter, correlate with auditory perceptual parameters of the voice quality in Iranian theater actors. These findings highlight the significance of acoustic parameters in assessing voice quality in professional voice users such as theater actors.

Phonation Threshold Pressure as a Unique Outcome Measure of Phonatory Physiology Changes Following Submucosal Saline Injection for Vocal Fold Scarring

Purpose: This study aimed to describe the utility of phonation threshold pressure (PTP) measurement as an additional outcome measure for changes in vocal fold vibration secondary to submucosal saline injection in the case of an individual with idiopathic vocal fold scarring. Method: An 8-week program of voice therapy, followed by submucosal saline infusion, was administered, using multiple outcome measures to assess voice quality, effort, and function in a 38-year-old woman with idiopathic bilateral vocal fold scarring. Transoral rigid video-endoscopy with stroboscopy in conjunction with the Stroboscopy Evaluation Rating Form provided measures of the vibratory characteristics of the vocal folds (amplitude, mucosal wave, nonvibratory portion, edge smoothness, and straightness). Auditory-perceptual measures were obtained using the Consensus Auditory-Perceptual Evaluation of Voice. Acoustic measures included jitter (%local), shimmer (%local), harmonics-to-noise ratio (dB), and Cepstral Spectral Index of Dysphonia. Additionally, PTP was measured 1 day prior to, and 1 month after, saline infusion. Results: Acoustic, auditory-perceptual, and stroboscopic variables suggested minimal change to the vibratory properties of the vocal folds in response to submucosal saline infusion for the treatment of vocal fold scarring. PTP measurements across the patient's frequency range, however, revealed a marked decrease post infusion. This was consistent with the patient's report of improved functioning and her request for repeat saline infusion. Conclusion: These results are consistent with the possibility of using PTP as an independent means of quantifying changes in phonatory physiology across the frequency range in patients with vocal fold scarring. Supplemental Material: https://doi.org/10.23641/asha.21313725