Phonation Duration Research Articles

Voice Quality Following Unilateral Vocal Fold Paralysis: A Randomized Comparison of Therapeutic Modalities

In this work, a study on the efficacy of different therapeutic modalities in patients with unilateral vocal fold paralysis (UVFP) was carried out. The study included 20 patients with UVFP, divided into two groups. The objective of this work is to evaluate the voice quality in these patients and to compare the voice following surgery and voice therapy. Group I received voice therapy and group II underwent thyroplasty type I and type IV. The voice was assessed pretreatment and 1 and 3 months posttreatment. Different parameters, such as habitual fundamental frequency (F0), signal-to-noise ratio, jitter, shimmer, maximum phonation duration, s/z ratio, and objective and subjective ratings of dysphonia, were analyzed. It was observed that in group I, all the parameters in seven out of ten patients improved significantly, except for shimmer. In group II, voice quality improved in 70% of the patients with all the parameters. As per previous studies, jitter and shimmer improved after a rehabilitation procedure. However, in this work, it is observed that shimmer did not improve in patients receiving voice therapy. The present study is the first of its type documenting and comparing the efficacy of voice therapy and thyroplasty type I and type IV in patients with UVFP.

Acoustical properties in inhaling singing: A case-study

A highly experienced versatile female professional singer displaying no apparent vocal complaint, developed inhaling singing, an innovative approach to reverse phonation. Although there are some reports in literature that describe the characteristics of ingressive phonation and sounds, to the best of our knowledge, no reports on actual inhaling singing are available in literature. This paper reports a case study on the acoustical analysis of inhaling singing, comparing this innovative technique with traditional exhaling singing. As this is rather undiscovered territory, we have decided to address several questions: is it possible to match the same pitches using inhaling singing compared to exhaling singing? Is the harmonic structure and energy distribution similar? Is it possible to maintain the same phonation duration in both techniques? Are there differences in volume and tessitura (vocal range)? This paper, reporting on the experience of one individual, demonstrates that a tessitura can be mastered in inhaling singing. Spectral analysis reveals a similar frequency distribution in both conditions. However, in inhaling singing the energy of the harmonics is significantly lower for the first 3 overtones, while the maximum phonation time is larger, than in exhaling singing. The singer reports that less effort is required for inhaling singing in the high register. As such, inhaling singing offers new possibilities for vocal performance.

Proof of Concept of a Tracheoesophageal Voice Prosthesis Insufflator for Speech Production After Total Laryngectomy

There may have a variety of reasons why patients are unable to produce tracheoesophageal speech after total laryngectomy (TL) including poor pulmonary reserve or other comorbidities that prevent adequate stoma occlusion and intratracheal pressure to voice. Other patients find it difficult, uncomfortable, or socially awkward to manually occlude the stoma with the finger or thumb. The study aimed to assess the feasibility of achieving TE speech with a prototype TE voice prosthesis insufflator (TEVPI). We prospectively assessed the feasibility of achieving TE speech with a commercially available continuous positive airway pressure device in six TL patients. The intervention is the use of a prototype TEVPI. A battery of acoustic and perceptual metrics were obtained and compared between TEVPI speech and standard tracheoesophageal voice prosthesis (TEVP) speech. Voicing was accomplished with the TEVPI in five of six participants. On average, the duration of phonation with TEVPI was shorter, not as loud, and perceived to be more difficult to produce compared to TEVP speech. The TEVPI is a feasible, hands-free solution for restoring speech after TL. Although the current model produced inferior acoustic metrics compared with standard TEVP speech, further modification and refinement of the device has the potential to produce much improved speech.

Effect of Performance Time of the Semi-Occluded Vocal Tract Exercises in Dysphonic Children

This study aimed to verify the effects of execution time on auditory-perceptual and acoustic responses in children with dysphonia completing straw phonation exercises. A randomized, prospective, comparative intra-subject study design was used. Twenty-seven children, ranging from 5 to 10 years of age, diagnosed with vocal cord nodules or cysts, were enrolled in the study. All subjects included in the Experimental Group were also included in the Control Group which involved complete voice rest. Sustained vowels (/a/e/ε/e/) counting from 1 to 10 were recorded before the exercises (m0) and then again after the first (m1), third (m3), fifth (m5), and seventh (m7) minutes of straw phonation exercises. The recordings were randomized and presented to five speech therapists, who evaluated vocal quality based on the Grade Roughness Breathiness Asthenia/Strain Instability scale. For acoustic analysis, fundamental frequency, jitter, shimmer, glottal to noise excitation ratio, and noise parameters were analyzed. Reduced roughness, breathiness, and noise measurements as well as increased glottal to noise excitation ratio were observed in the Experimental Group after 3 minutes of exercise. Reduced grade of dysphonia and breathiness were noted after 5 minutes. The ideal duration of straw phonation in children with dysphonia is from 3 to 5 minutes.

Predictors of Effect of Atypical Antipsychotics on Speech.

Background:Most of the studies have looked into the effect of typical antipsychotics on speech secondary to tardive dyskinesia.Aims:This study was aimed to explore the factors predicting the effect of atypical antipsychotic medications on the production of speech.Materials and Methods:One hundred and forty patients on stable regimen of three or more months on risperidone (92), olanzapine (28), aripiprazole (14), and clozapine (6) were recruited for the study. Speech was assessed by maximum phonation duration task, s/z ratio, diadochokinetic task, acoustic analysis and Frenchay Dysarthria Assessment (FDA). Extrapyramidal symptoms (EPS) were assessed by Simpson Angus scale.Statistical Analysis:Spearman correlation analysis was carried out to find the association between speech parameters and continuous variables. Effect of EPS, duration and dose of antipsychotic treatment on speech parameters was compared using Mann-Whitney test.Results:The risperidone group differ from other antipsychotics groups significantly in s/z ratio (0.07), FDA-total (0.23) and FDA-reflex (0.25). People who took antipsychotic for more than 2 years had lower score of FDA-palate (P = 0.042), and FDA-respiratory (P = 0.04) and higher values in noise-harmonic ratio (P = 0.011) and maximum /fundamental frequency (MFF) for males (P = 0.02). Effect of EPS was seen on MFF for males (spearman correlation coefficient = 0.34) and on almost all sections of FDA (spearman correlation coefficients = -0.2 to -0.33).Conclusion:Both duration of use and propensity of atypical antipsychotics to cause EPS can influence the speech performance of the patients. This information can be useful, particularly in people with the requirement of high quality speech.

Verbal communication with the Blom low profile and Passy-Muir one-way tracheotomy tube speaking valves

ObjectiveTo investigate physiologic parameters, voice production abilities, and functional verbal communication ratings of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves. Study designCase series with planned data collection. SettingLarge, urban, tertiary care teaching hospital. Subjects and methodsReferred sample of 30 consecutively enrolled adults requiring a tracheotomy tube and tested with Blom and Passy-Muir valves. Physiologic parameters recorded were oxygen saturation, respiration rate, and heart rate. Voice production abilities included maximum voice intensity in relation to ambient room noise and maximum phonation duration of the vowel/a/. Functional verbal communication was determined from randomized and blinded listener ratings of counting 1–10, saying the days of the week, and reading aloud the sentence, “There is according to legend a boiling pot of gold at one end.” ResultsThere were no significant differences (p>0.05) between the Blom and Passy-Muir valves for the physiologic parameters of oxygen saturation, respiration rate, and heart rate; voice production abilities of both maximum intensity and duration of/a/; and functional verbal communication ratings. Both valves allowed for significantly greater maximum voice intensity over ambient room noise (p<0.001). ConclusionsThe Blom low profile voice inner cannula and Passy-Muir one-way speaking valves exhibited equipoise regarding patient physiologic parameters, voice production abilities, and functional verbal communication ratings.Learning outcomes: Readers will understand the importance of verbal communication for patients who require a tracheotomy tube; will be able to determine the differences between the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves; and will be confident in knowing that both the Blom and Passy-Muir one-way tracheotomy tube speaking valves are equivalent regarding physiological functioning and speech production abilities.

Evaluating the effect of risperidone on speech: A cross-sectional study.

Speech subsystems are susceptible to the effects of several factors including medications. The atypical antipsychotics can also adversely affect the speech because of its action on serotonin and dopamine neurotransmitters. The present study aims to analyze the speech characteristics associated with atypical antipsychotic risperidone. Speech of 92 patients on risperidone with or without trihexyphenidyl and/or clonazepam were compared with that of 31 persons who were not on any psychotropic medicines. Compared to control group, maximum phonation duration, sequential motion rate of diadochokinesia was reduced by about 3s and 1syllable/s respectively and s/z ratio was increased by 0.16 in patients with risperidone. Performance of larynx, lips and tongue sub-system and intelligibility of speech were also significantly reduced in risperidone group. Risperidone did impact the phonation and articulation sub-systems of speech mildly, which was independent of tardive dyskinesia and extrapyramidal symptoms. Randomized controlled prospective study looking into impact on speech and related effect on drug adherence, functioning and quality of life needs to be conducted with risperidone and other atypical antipsychotics.

Vocal Performance of Group Fitness Instructors Before and After Instruction: Changes in Acoustic Measures and Self-Ratings

(1) To quantify acute changes in acoustic parameters of the voices of group fitness instructors (GFIs) before and after exercise instruction. (2) To determine whether these changes are discernible perceptually by the instructor. This is a pilot prospective cohort study. Participants were six female GFIs, based in Brisbane, Australia. Participants performed a series of vocal tasks before and after instruction of a 60-minute exercise class. Data were obtained pertaining to fundamental frequency (pitch), intensity (volume), jitter, shimmer, harmonic-to-noise ratio (HNR), maximum duration of sustained phonation (MDSP), and pitch range. Additionally, self-ratings of voice quality were obtained before and after instruction. Data were analyzed using the Wilcoxon signed rank test. Significant increases (P ≤ 0.05) were found in fundamental frequency and intensity after instruction. No significant changes in jitter, shimmer, HNR, or MDSP were found before and after instruction. For the group, no significant change in self-ratings of voice quality occurred before and after instruction. Statistically significant changes in pitch and volume were found on acoustic analysis. However, these subtle changes remained within the limits of what is considered normal and representative of the participant's age and gender. Further research into the effects of exercise instruction on the voice is needed.

Comparison of esophageal and tracheoesophageal speech modes in dual-mode alaryngeal speakers

Objective: The main purpose of this study was to compare different speech related parameters in dual-mode esophageal and tracheoesophageal speakers. A second purpose was to compare the speech characteristics of these (tracheo) esophageal speakers with age- and gender matched controls. Materials and Methods: Four male laryngectomees who were proficient esophageal and tracheoesophageal speakers provided audio recordings of sustained vowels and connected speech using both alaryngeal methods. The participants from the control group also followed the same procedure. From the recorded samples, fundamental frequency (F0), maximum phonation duration (MPD), formant frequencies, and speech rate related parameters were extracted. Results: Although there was no statistically significant difference between the two alaryngeal modes for any of the measured parameters, the absolute fundamental frequency and MPD values were higher in TE mode. However, when compared to controls, both the alaryngeal modes depicted significantly shorter MPD values, higher first formant frequency values, slower speech rate, and higher frequency of pauses. Conclusion: The results suggest that most group differences found between esophageal and tracheoesophageal speech in the past may be due to large inter-subject variability, and that within speakers, similarity is more between esophageal and tracheoesophageal speech than with laryngeal speech. These results have implications for understanding the pseudoglottic voice mechanism.

Subglottal Impedance-Based Inverse Filtering of Voiced Sounds Using Neck Surface Acceleration.

A model-based inverse filtering scheme is proposed for an accurate, non-invasive estimation of the aerodynamic source of voiced sounds at the glottis. The approach, referred to as subglottal impedance-based inverse filtering (IBIF), takes as input the signal from a lightweight accelerometer placed on the skin over the extrathoracic trachea and yields estimates of glottal airflow and its time derivative, offering important advantages over traditional methods that deal with the supraglottal vocal tract. The proposed scheme is based on mechano-acoustic impedance representations from a physiologically-based transmission line model and a lumped skin surface representation. A subject-specific calibration protocol is used to account for individual adjustments of subglottal impedance parameters and mechanical properties of the skin. Preliminary results for sustained vowels with various voice qualities show that the subglottal IBIF scheme yields comparable estimates with respect to current aerodynamics-based methods of clinical vocal assessment. A mean absolute error of less than 10% was observed for two glottal airflow measures -maximum flow declination rate and amplitude of the modulation component- that have been associated with the pathophysiology of some common voice disorders caused by faulty and/or abusive patterns of vocal behavior (i.e., vocal hyperfunction). The proposed method further advances the ambulatory assessment of vocal function based on the neck acceleration signal, that previously have been limited to the estimation of phonation duration, loudness, and pitch. Subglottal IBIF is also suitable for other ambulatory applications in speech communication, in which further evaluation is underway.

Speech characteristics and swallowing functions post-segmental mandibulectomy

Objective: To describe the speech and swallowing characteristics following segmental mandibulectomy and coronoidectomy to release trismus. Materials and Methods: A detailed speech and swallowing function assessment was carried out using various formal and informal tests following the surgeries. Result: After the initial assessment, the patient had severe impairment with the movement of articulators, and distortion was observed for labio dentals, lingual sounds, and vowels. Speech intelligibility, diadokokinetic rate, maximum phonation duration were reduced, and also patient had severe voice problem and swallowing problems. Following the assessment post-coronoidectomy, patient had articulatory errors such as distortion, omission, and substitution for majority of sounds secondary to reduced articulatory movements. Swallowing and voice characteristics have improved slightly, and the voice parameters were near normal. Conclusion: Segmental mandibulectomy can have several effects on an individual's daily living as it affects speech, which becomes a major hindrance for communication. Also, due to the swallowing difficulties, there may be health issues. Hence, the affected individuals should be evaluated by a speech language pathologist to define the exact nature of changes in communication (including speech and voice), and swallowing that also helps to plan a comprehensive management strategy that includes speech therapy and surgical recommendation, which will have good prognosis in speech and swallow characteristics to give a good quality of life.

Spindle-shaped glottis: Sulcus vocalis, presbilarynx and other causes

Spindle-shaped glottal insufficiency may appear at any age. This disorder significantly affect the voice quality and hence the life quality. Degenerative, neuromuscular, inflammatory, functional, iatrogenic and psychogenic originated pathologies can lead to spindle-shaped glottal insufficiency. Sulcus vocalis, vocal scars and presbylarynx constitutes degenerative causes. The term sulcus vocalis is used to describe a groove at the free edge of the vocal folds resulting in an area of mucosal stiffness and giving the vocal folds a bowed aspect during phonation. It may involve all or any segment of the edge of the fold. The defect may be confined to the superficial layer of the mucosa or penetrate deeply in the vocal ligament and muscle. According to involvement, three types have been described. Etiology remains controversial and the authors present arguments for each theory, acquired or congenital. The term lpresbylarynx\' denotes vocal changes due to aging of the larynx. Symptoms are characterized by poor vocal projection, shorter phonation duration and vocal roughness. Videolaryngostroboscopy is a highly effective diagnostic tool for spindle-shaped glottal insufficiency. The glottis is spindle-shaped during phonation and vibration is frequently asymmetrical and reduced in amplitude. Because of closing defects; median line air leakage is observed in the anterior two-thirds of the vocal folds during phonation. Treatment options include phonosurgery and speech therapy in spindle-shaped glottis. The aim of the present paper is to review the reasons of vocal fold curvature, particularly presbylarynx and sulcus vocalis, and the clinical features of spindle-shaped glottal insufficiency.

A study of voice profiles and acoustic signs in patients with Parkinson’s disease in North India

We aimed to study the voice profiles of patients with Parkinson’s disease (PD) and correlate the profiles with disease severity. A total of 133 patients with PD were recruited. Patients were divided into two groups: Group 1 with a Unified Parkinson’s Disease Rating Scale (UPDRS) score of ⩽45; and Group 2 with a UPDRS >45. Speech was analyzed using the Indian Speech and Hearing Association (ISHA) articulation assessment and Vaghmi software. A total of 87 patients (65.41%) reported a history of speech problems. Examination revealed slow reading speed (64.7% of patients), hoarseness of voice (60.2%), articulatory defect (39.8%) and jerky speech (32.3%) as common abnormalities. Misarticulation was most often observed among the labial (42.1%), followed by lingual and palatal syllables. The ISHA articulation test demonstrated significant differences in mean numbers of words distorted (p<0.001) and intelligible speech (p=0.004) between patients with early and advanced PD. Vaghmi software analysis (Speech and Voice Systems, Bangalore, India) also revealed significant difference between the two groups in maximum phonation duration (p=0.034), inability to phonate (noiseless speech, Z; p=0.002) and the mean noise-to-noiseless speech (S/Z) ratio (p=0.006).

A Case Report in Changes in Phonatory Physiology Following Voice Therapy: Application of High-Speed Imaging

To clinically evaluate changes in vocal fold vibration and voice production caused by voice therapy in hoarseness resulting from contact granuloma. Single-subject before-after prospective study using multiple measures of vocal function. A 6-week program of vocal function exercises (VFEs) was conducted using multiple assessments of vocal function to identify and measure the changes pre- and posttreatment, in a 51-year-old male with unilateral contact granuloma. Multiple outcome measures were recorded. High-speed digital imaging (HSDI) measures of voice onset time (milliseconds), open quotient, speed quotient, maximum amplitude, peak closing velocity, peak-to-average opening velocity, and peak-to-average closing velocity were derived from motion data. Acoustic measures of maximum phonation duration (seconds), noise-to-harmonic ratio, average fundamental frequency (hertz), the lowest fundamental frequency (hertz), and the highest fundamental frequency (hertz); aerodynamic measures of expiratory volume (milliliter) and mean expiratory airflow (liter/second); stroboscopic measures of glottal closure and phase closure; and perceptual assessment of voice quality (total score) using the Consensus Auditory-Perceptual Evaluation of Voice were obtained. Stroboscopic, acoustic, aerodynamic, and audioperceptual measures were minimally informative related to pre- and posttreatment vocal function in a patient with contact granuloma. HSDI measures provided multiple physiologic and kinematic measures demonstrating pre- and posttreatment efficiency of vocal function, including vibratory motion, closure, and impact stress. The results have implications for the use of high-speed imaging to identify and measure change in phonatory physiology in patients with contact granuloma. Changes in phonatory physiology support the use of voice therapy techniques, such as VFEs that facilitate a semioccluded vocal tract for treatment of contact granuloma.

Verbal communication for the ventilator‐dependent patient requiring an inflated tracheotomy tube cuff: A prospective, multicenter study on the Blom tracheotomy tube with speech inner cannula

The purpose of this study was to present our findings on the impact of the Blom tracheotomy tube with speech inner cannula on voice production abilities and speech intelligibility scores of ventilator-dependent patients requiring a fully inflated tracheotomy tube cuff. Prospective single group case-series design permitted consecutive accrual of 23 adult inpatients from acute care and rehabilitation settings. Maximum ambient room noise, voice intensity, phonation duration of vowel /a/, and speech intelligibility scores were determined over 3 sessions. All participants achieved audible voicing with the Blom tracheotomy tube. Voice intensity was significantly greater than ambient room noise by >10 dB SPL (p = .003). Speech intelligibility scores improved significantly from 80% to 85% (p = .03). Phonation duration averaged from 3.30 to 3.45 seconds. There were no significant changes in oxygen saturation (p > .05), and no significant complications occurred. The Blom tracheotomy tube with speech inner cannula permitted individuals requiring mechanical ventilation with a fully inflated tracheotomy tube cuff to produce excellent speech intelligibility for verbal communication. © 2012 Wiley Periodicals, Inc. Head Neck, 2013.

Novel Approach of Medialization Thyroplasty with Arytenoid Adduction Performed under General Anesthesia with a Laryngeal Mask

To objectively assess the voice outcomes of patients with unilateral vocal fold paralysis treated with medialization thyroplasty and arytenoid adduction suture. Case series of patients who underwent medialization thyroplasty and arytenoid adduction suture. Preoperative and postoperative voice testing was performed and the data were compared by statistical analysis. Tertiary referral teaching hospital in Sydney, Australia. All patients had a unilateral vocal fold paralysis, with a large posterior glottic gap and vocal symptoms affecting their quality of life. Thirteen patients with a diagnosis of a unilateral vocal fold paralysis with a large posterior glottic gap, vocal symptoms, and total denervation of the vocal fold underwent medialization thyroplasty and arytenoid adduction suture. The surgery was performed in a novel method under a general anesthetic using a laryngeal mask and with direct intraoperative endoscopic feedback. Preoperative and postoperative measures of voice performance were compared, including acoustic analysis (fundamental frequency, speech intensity against quiet and loud background noise, speech rate) and aerodynamic assessment (airflow, maximum phonation time). Medialization thyroplasty with arytenoid adduction suture significantly improved aerodynamic assessment and phonation duration for both male and female subjects overall. There were 2 of 13 treatment failures. Median follow-up time was 6 months. Preliminary results indicate that in selected patients with vocal fold paralysis, medialization thyroplasty with arytenoid adduction suture leads to significant improvements in objective voice measures. Longer follow-up data are required to further quantify the voice outcomes after this procedure.

The Effects of Swim Training on Respiratory Aspects of Speech Production in Adolescents With Down Syndrome

Reduced respiratory muscle strength in individuals with Down syndrome (DS) may affect speech respiratory variables such as maximum phonation duration (MPD), initiation volume, and expired mean airflow. Researchers randomly assigned adolescents with DS (N = 28) to either 12 weeks of swim training (DS-ST) or a control group (DS-NT). Repeated measures MANOVA demonstrated a significant increase in MPD for DS-ST participants from pretest to posttest, t(11) = -3.44, p = 0.006, that was not maintained at follow-up, t(11) = 6.680, p < .001. No significant change was observed for DS-NT participants across time, F(2, 11) = 4.20, p = 0.044. The lack of long-term change in DS-ST participants may be related to the relatively short training period.

Voice quality after organ‐preservation therapy with definitive radiotherapy for laryngeal cancer

The purpose of this study was to analyze voice quality among patients treated by definitive radiotherapy for laryngeal cancer. Ten patients with laryngeal cancer who had completed radiotherapy were involved in this pilot study. A standardized protocol was administered assessing: (1) sustained vowel production following maximal inspiration, (2) sustained vowel production for a 7-second duration repeated 5 times, and (3) spontaneous speech for 10 seconds. The acoustic parameters among patients with early-stage cancer were not statistically different from healthy age-corresponding controls, except for shimmer (0.20 vs 0.16 dB, ρ = 0.01) and maximum phonation duration (24.37 vs 30.10 seconds, ρ = 0.04). For patients with locally advanced cancer, differences with controls were observed with shimmer (2.29 vs 0.16 dB, ρ = 0.01), jitter (7.49% vs 1.04%, ρ = 0.01), harmonics-to-noise ratio (2.67 vs 9.22, ρ = 0.01), and maximum phonation duration (14.12 vs 30.10 seconds, ρ = 0.01). Despite the subtle differences in voice quality that existed, radiotherapy as a curative treatment for laryngeal cancer allows maintenance of a functional voice.

Student Voice Use and Vocal Health During an All-State Chorus Event

This field-based case study documented students’ ( N = 256) voice use and voice health perceptions during a 3-day all-state high school chorus event through daily surveys, phonation duration data, analysis of rehearsal voice use behaviors, and field notes. Among the primary results are the following: (a) First and final day survey comparisons indicated significant declining changes in 5 of 7 voice health indicator statements and in self-perceptions of singing voice quality, yet (b) most students (78.8%) believed they had taken good care of their voices; (c) self-reported sleep hours decreased significantly; (d) vocal fold contact time measured with two students ranged from 15% to 38% during rehearsal periods, 1% to 27% during on-site non-rehearsal times, and 3% to 17% during measured pre- and post-event activities, but (e) overall percentages of vocal fold contact varied little between regular rehearsal and on-site non-rehearsal events (female: 19.37% rehearsal, 20.11% non-rehearsal; male: 22.89% rehearsal, 20.54% non-rehearsal); (f) rehearsal voice rest time (63%) exceeded voice use time (37%); (g) students sat in close proximity to other choristers for approximately 73% of rehearsal time; and (h) the two compositions ranked highest relative to demands on adolescent voices consumed 61% of rehearsal time.

Laryngopharyngeal Reflux in a Gastroenterology Practice

Otolaryngology–Head and Neck SurgeryVolume 143, Issue S2 p. P216-P216 Poster Presentation Laryngopharyngeal Reflux in a Gastroenterology Practice Boris Bentsianov MD, Boris Bentsianov MD presenterSearch for more papers by this authorBhawna Halwan MSc, MD, Bhawna Halwan MSc, MDSearch for more papers by this author Boris Bentsianov MD, Boris Bentsianov MD presenterSearch for more papers by this authorBhawna Halwan MSc, MD, Bhawna Halwan MSc, MDSearch for more papers by this author First published: 20 June 2017 https://doi.org/10.1016/j.otohns.2010.06.425Read the full textAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume143, IssueS2August 2010Pages P216-P216 RelatedInformation