Perceptual Evaluation Of Voice Quality Research Articles

A New Voice Rating Tool for Clinical Practice

Perceptual rating of voice quality is a key component in the comprehensive assessment of voice, but there are practical difficulties in making reliable measurements. We have developed the Newcastle Audio Ranking (NeAR) test, a new referential system for the rating of voice parameters. In this article, we present our first results using NeAR. We asked five experts and 11 naive raters to assess 15 male and 15 female voices using the NeAR test. We assessed: validity with respect to the GRBAS scale; interrater reliability; sensitivity to subtle voice differences; and the performance of expert versus naïve raters. There was a uniformly excellent agreement with GRBAS (r=0.87) and interrater agreement (intraclass correlation coefficient=0.86). Considering each GRBAS grade of voice separately, there was still good interrater agreement in NeAR, implying it has good sensitivity to subtle changes. All these results were equally true for expert and naive raters. The NeAR test is a promising new tool in the assessment of voice disorders.

Vowel- and Text-Based Cepstral Analysis of Chronic Hoarseness

Automatic voice evaluation is usually performed on stable sections of sustained vowels, which often cannot capture hoarseness properly. The measures cepstral peak prominence (CPP) and smoothed CPP (CPPS) do not require exact determination of the cycles of fundamental frequency like established perturbation-based measures. They can also be applied to text recordings. In this study, they were compared with perceptual evaluation of voice quality and the German roughness-breathiness-hoarseness (RBH) scheme. Retrospective data analysis. Seventy-three hoarse patients (48.3±16.8 years) uttered the vowel /e/ and read the German version of the text "The North Wind and the Sun". The text recordings were evaluated perceptually by five speech therapists and physicians according to the RBH scale. The criterion "overall quality" was measured on a 4-point scale and a visual analog scale. For the human-machine correlation, the automatic measures of the Praat program (vowels only) and the "cpps" software were compared with the experts' ratings. The experiments were repeated for speakers with jitter ≤5% or shimmer ≤5% (n=47). For the entire group (n=73), the best human-machine results for most of the rating criteria were obtained for text-based CPP and CPPS (up to |ρ|=0.73). For the 47 selected speakers, the correlation was remarkably worse for all measures but still best for text-based CPP and CPPS (|ρ|≤0.50). Cepstrum analysis should be performed on a text recording. Then, it outperforms all perturbation-based measures, and it can be a meaningful objective support for perceptual analysis.

Effects of Consensus Training on the Reliability of Auditory Perceptual Ratings of Voice Quality

This study investigates the effect of consensus training of listeners on intrarater and interrater reliability and agreement of perceptual voice analysis. The use of such training, including a reference voice sample, could be assumed to make the internal standards held in memory common and more robust, which is of great importance to reduce the variability of auditory perceptual ratings. A prospective design with testing before and after training. Thirteen students of audiologopedics served as listening subjects. The ratings were made using a multidimensional protocol with four-point equal-appearing interval scales. The stimuli consisted of text reading by authentic dysphonic patients. The consensus training for each perceptual voice parameter included (1) definition, (2) underlying physiology, (3) presentation of carefully selected sound examples representing the parameter in three different grades followed by group discussions of perceived characteristics, and (4) practical exercises including imitation to make use of the listeners' proprioception. Intrarater reliability and agreement showed a marked improvement for intermittent aphonia but not for vocal fry. Interrater reliability was high for most parameters before training with a slight increase after training. Interrater agreement showed marked increases for most voice quality parameters as a result of the training. The results support the recommendation of specific consensus training, including use of a reference voice sample material, to calibrate, equalize, and stabilize the internal standards held in memory by the listeners.

Combined Modality Treatment of Adductor Spasmodic Dysphonia

The hallmark characteristic of adductor spasmodic dysphonia (ADSD) is irregular and uncontrollable spasms within the intrinsic laryngeal muscles, resulting in erratic disruption of normal voicing. Using a random assignment and the inclusion of a behavioral sham to determine the effect of voice therapy after initial botulinum toxin type A (BTX-A) injections for ADSD, this study examined duration of injection benefit, perceived vocal quality of life from the Voice-Related Quality of Life (V-RQOL) scale, acoustic measures of vocal instability, and perceptual ratings of voice quality. Measures of these variables were collected before initial injection; 3, 7, and 12 weeks postinjection; and immediately before reinjection. Thirty-one individuals with ADSD participated in this study. One-third received no further intervention after BTX-A injection, one-third received a standard 5-week course of voice therapy after BTX-A injection, and one-third received a 5-week course of sham voice therapy after BTX-A injection. Significant effects were observed on perceived quality of life and acoustic variables for all participants, over time. Participants who received voice therapy after BTX-A injection did not experience longer injection effect duration or significantly greater improvements in V-RQOL or acoustic variables than participants in BTX-A only or BTX-A plus sham therapy groups. Additionally, perceptual ratings of voice quality improved for all participants in response to BTX-A injection. For participants in this investigation, undertaking voice therapy did not appear to exert significant beneficial effects on the variables of interest.

Correlation of Vocal Fold Nodule Size in Children and Perceptual Assessment of Voice Quality

We examined the relationship between the size of vocal fold nodules and perceptual rating of voice quality in children. We carried out an Institutional Review Board-approved retrospective study in a voice clinic within a tertiary-care pediatric medical center. We studied children seen between 2000 and 2009 with a primary diagnosis of vocal fold nodules as the cause of their voice disturbance. Pediatric vocal fold nodule size was rated with a published validated scale, and voice quality was rated on the Consensus Auditory-Perceptual Evaluation of Voice scale. One hundred forty-five patients met the inclusion criteria. Small nodules were noted in 23% of patients, medium nodules in 39%, and large nodules in 37%. Univariate and multivariate analyses demonstrated a statistically significant relationship (p < 0.05) between vocal fold nodule size and rated perceptual qualities of overall severity of voice disturbance, roughness, strain, pitch, and loudness. With the exception of loudness, as vocal fold nodule size increased, the mean value of perceptual characteristics became larger. The age of the patient was a significant factor associated with the overall severity of the voice disturbance and roughness. The overall severity of a child's voice disturbance and qualities of roughness, strain, pitch, and loudness have a strong correlational relationship with pediatric vocal fold nodule size, which is suggestive of causality.

Supracricoid Partial Laryngectomy: Swallowing, Voice, and Speech Outcomes

The purpose of the study was to describe the swallowing and vocal function of patients after supracricoid partial laryngectomy (SCPL) as they changed over the first postoperative year. Ten patients with laryngeal carcinoma underwent SCPL at Johns Hopkins Hospital between August 2003 and May 2005. Clinical and videofluoroscopic swallowing examinations and perceptual, acoustic, aerodynamic, and video-stroboscopic voice evaluations were completed before operation and at 3 weeks (swallowing only) and 2 (voice only), 6, and 12 months after operation. The mean time to gastrostomy tube removal was 82 days. The patients tolerated an increased variety of foods over the first postoperative year. All patients initially used therapeutic strategies to swallow safely, and some still required them at 1 postoperative year. Over the year, the perceptual ratings of voice quality improved significantly. There were no consistent changes in acoustic or aerodynamic measures. The number of patients who used multiple vibratory sources to phonate increased over the year. The patients tolerated regular diets, yet continued to exhibit silent aspiration and a variety of decompensations. Their voices were breathy, rough, and strained. Their voice quality ratings improved over the year. Group changes were not captured, and it appears that the changes in speech and voice 2 months after surgery were subtle.

Dysphonia Severity Degree and Phonation Onset Latency in Laryngeal Adductor Dystonia

Although the latency between the initiation of thyroarytenoid electrical activity and the onset of phonation generally is increased in patients with adductor laryngeal dystonia, there is disagreement about whether there is overlap of latency values in these patients and normal subjects. The goal of this article was to compare the severity of dysphonia with the latency between electrophysiological activation of the thyroarytenoid muscle (TA) and the onset of phonation in patients with adductor laryngeal dystonia and compare the values with normal controls. Twenty-one patients with adductor dystonia and 15 control patients underwent laryngeal electromyographic (EMG) examination of the left TA. We measured the latency from initiation spike of the electric activity of the TA muscle to the onset of phonation. Three speech-pathologists/voice specialists arrived at a consensus to rate the perceptual evaluation of voice quality for the study group. The average latency measured for patients with mild dysphonia was 332 milliseconds, for moderate dysphonia was 426 milliseconds, and for the severe dysphonia was 792 milliseconds. We used the Spearman's correlation test to compare the latency time values and the dysphonia's degree of severity (P<0.05). Latency was significantly and directly related to the degree of severity of dysphonia.

Measuring voice outcomes: state of the science review

Researchers evaluating voice disorder interventions currently have a plethora of voice outcome measurement tools from which to choose. Faced with such a wide choice, it would be beneficial to establish a clear rationale to guide selection. This article reviews the published literature on the three main areas of voice outcome assessment: (1) perceptual rating of voice quality, (2) acoustic measurement of the speech signal and (3) patient self-reporting of voice problems. We analysed the published reliability, validity, sensitivity to change and utility of the common outcome measurement tools in each area. From the data, we suggest that routine voice outcome measurement should include (1) an expert rating of voice quality (using the Grade-Roughness-Breathiness-Asthenia-Strain rating scale) and (2) a short self-reporting tool (either the Vocal Performance Questionnaire or the Vocal Handicap Index 10). These measures have high validity, the best reported reliability to date, good sensitivity to change data and excellent utility ratings. However, their application and administration require attention to detail. Acoustic measurement has arguable validity and poor reliability data at the present time. Other areas of voice outcome measurement (e.g. stroboscopy and aerodynamic phonatory measurements) require similarly detailed research and analysis.

Speech pathology for chronic cough: A new approach

Chronic cough may persist despite systematic evaluation and medical treatment of known associated diseases such as asthma, rhinitis, and gastro-esophageal reflux. These patients have refractory chronic cough and many exhibit laryngeal hypersensitivity that is manifest at both a sensory and motor level. Examples of this are heightened sensitivity of the cough reflex to capsaicin, and laryngeal motor dysfunction with hoarse vocal quality and paradoxical vocal cord movement. Chronic cough that persists despite medical treatment may respond to speech pathology intervention. A multidimensional speech pathology treatment programme was designed based upon methods used to treat hyperfunctional voice disorders and paradoxical vocal fold movement. This included education, vocal hygiene training, cough suppression strategies and psychoeducational counseling. When tested in a single-blind, randomized, placebo-controlled trial involving 87 patients, participants in the treatment group demonstrated a significant reduction in cough, breathing, voice and upper airway symptoms following intervention, as well as improvements in auditory perceptual ratings of voice quality (breathy, rough, strain and glottal fry) and significant improvement in voice acoustic parameters (maximum phonation time, jitter and harmonic-to-noise ratio). Speech pathology intervention can be an effective way to treat refractory chronic cough.

S196 – Phonation and Electric Activity in Adductor Dystonia

Objectives To compare the degree of dysphonia's severity with the latency between the electrophysiological activation of the TA muscle and the phonation onset in patients with adductor laryngeal dystonia. Methods 21 patients with adductor dystonia and 15 controls underwent laryngeal electromyography (EMG) exam of the left TA muscle. The latency time was registered from rise of the electric activity of the TA muscle until the phonation onset. Perceptual evaluation of voice quality was performed for the study group and judged by consensus of three speech-pathologists/voice specialists. The evaluation considered 4 tasks: 1) sustained vowel /e/ in habitual pitch and loudness; 2) sustained vowel /i/ in ascending and descending glissando; 3) sustained vowel /i/ at high pitch; 4) phrases including words with voiced and voiceless phonemes. The dysphonia's severity degree was classified in the following scale: 0 -; no alteration perceived; 1 -; mild degree; 2 -; moderate degree; 3 -; severe degree. The Spearman's Correlation Test was used to compare the latency time values and the dysphonia's severity degree (p&lt;0,05). Results The average latency time registered for patients with mild dysphonia was 332ms, for moderate dysphonia it was 426ms, and for the severe group was 791ms (p=0.02*). Conclusions The latency time was significantly and directly related to the degree of dysphonia's severity.

Child Voice and Noise: A Pilot Study of Noise in Day Cares and the Effects on 10 Children's Voice Quality According to Perceptual Evaluation

The purpose of this investigation was to study children's exposure to background noise at the ears during a normal day at the day care center and also to relate this to a perceptual evaluation of voice quality. Ten children, from three day care centers, with no history of hearing and speech problems or frequent infections were selected as subjects. A binaural recording technique was used with two microphones placed on both sides of the subject's head, at equal distance from the mouth. A portable digital audio tape (DAT) recorder (Sony TCD-D 100, Stockholm, Sweden) was attached to the subject's waist. Three recordings were made for each child during the day. Each recording was calibrated and started with three repetitions of three sentences containing only sonorants. The recording technique allowed separate analyses of the background noise level and of the sound pressure level (SPL) of each subjects' own voice. Results showed a mean background noise level for the three day care centers at 82.6dBA Leq, ranging from 81.5 to 83.6dBA Leq. Day care center no. 2 had the highest mean value and also the highest value at any separate recording session with a mean background noise level of 85.4dBA Leq during the noontime recordings. Perceptual evaluation showed that the children attending this day care center also received higher values on the following voice characteristics: hoarseness, breathiness, and hyperfunction. Girls increased their loudness level during the day, whereas for boys no such change could be observed.

The nature and severity of voice disorders in lung cancer patients

This study examines the nature and severity of voice disorders in a set of lung cancer patients. Patients’ concern for their voice, relative to other lung cancer symptoms, will also be examined. Voice assessment included both the patients’ view (Voice Handicap Index) and expert clinicians’ perceptual rating of voice quality (GRBAS). Additionally, visual analogue scales measured how much patients were concerned by their symptoms relative to other symptoms. The Medical Research Council dyspnoea and Eastern Cooperative Oncology Group performance status scales were completed. The majority of lung cancer patients (90%) were perceptually dysphonic. However, a smaller proportion of patients (27.5%), were concerned by their voices and perceived significant handicap from it. These patients report comparable levels of voice handicap to other dysphonic patient groups in the literature.

Reliability and confidence in using a paired comparison paradigm in perceptual voice quality evaluation

One of the ways to improve the reliability in perceptual voice quality rating is to provide listeners with external anchors. A paired comparison matching paradigm using synthesized Cantonese voice stimuli that covered a range of rough and breathy qualities were used to investigate the rating reliability. Twenty‐five speech pathology students rated the severity of roughness and breathiness of natural pathological voice samples using two paradigms: an eight‐point anchored matching (paired comparison) paradigm and an eight‐point non‐anchored equal‐appearing‐interval (EAI) scale paradigm. The listeners also rated their confidence in judging each testing stimulus on a seven‐point EAI scale. The results showed that the paired comparison method specifically improved the inter‐rater reliability in rating male rough stimuli and mildly dysphonic female stimuli. The intra‐rater agreement and confidence ratings remained similar across the two rating paradigms. These results suggest that the paired comparison paradigm may be used as an alternative perceptual voice quality evaluation tool.

Oral myofunctional and vocal characteristics in subjects subjected to oral rehabilitation with osseointegrated implants

The aim of this study was to evaluate the effect of oral rehabilitation using immediately loaded fixed implant-supported mandibular prostheses, considering chewing, swallowing, speech and voice aspects. Fourteen patients subjected to this treatment were evaluated by a clinical examination of the stomatognathic system and perceptual evaluation of voice quality before oral rehabilitation, as well as after 1 and 4 months. After oral rehabilitation, the results showed that there were no significant modifications in the aspects investigated. Thus, implant-supported prosthetic rehabilitation, despite providing a more satisfactory occlusal standard, did not yield changes in the functional patterns of individuals in this study.

Multiparametric Evaluation of Dysphonic Severity

In recent years, the multiparametric approach for evaluating perceptual rating of voice quality has been advocated. This study evaluates the accuracy of predicting perceived overall severity of voice quality with a minimal set of aerodynamic, voice range profile (phonetogram), and acoustic perturbation measures. One hundred and twelve dysphonic persons (93 women and 19 men) with laryngeal pathologies and 41 normal controls (35 women and six men) with normal voices participated in this study. Perceptual severity judgement was carried out by four listeners rating the G (overall grade) parameter of the GRBAS scale. The minimal set of instrumental measures was selected based on the ability of the measure to discriminate between dysphonic and normal voices, and to attain at least a moderate correlation with perceived overall severity. Results indicated that perceived overall severity was best described by maximum phonation time of sustained /a/, peak intraoral pressure of the consonant-vowel /pi/ strings production, voice range profile area, and acoustic jitter. Direct-entry discriminant function analysis revealed that these four voice measures in combination correctly predicted 67.3% of perceived overall severity levels.

Méthodes actuelles d’évaluation des dysphonies

The aim of this review article was to provide an update on current techniques for evaluation of dysphonia in routine clinical practice. Recent medical and other scientific literature was reviewed and pertinent current theories concerning the physiology of laryngeal function described. Perceptual voice quality evaluation by a professional jury of listeners is still considered to be the most reliable and complete means of evaluating pathologic voice, even though it is difficult to perform in routine and the results lack reproducibility. The objective evaluation of the vocal fundamental frequency and its variations and the spectral characteristics of voice has the advantage of being simple to perform, reproducible and quantifiable. However, automatic measurements need to be analyzed with precaution for severe dysphonia, the computer algorithms being designed for voices retaining a certain periodicity. Aerodynamic measurements are quantifiable and reproducible and provide information as to the quality of laryngeal function as a transducer of aerodynamic energy into acoustic energy. Videostroboscopy and electroglottography provide information as to the quality of the laryngeal vibrations, the source of sound production. All of these types of analysis are complementary, informing as to different aspects of vocal quality and laryngeal function. No one measurement alone can diagnose or characterize dysphonia.

The Effectiveness of Group Therapy for Students With Mild Voice Disorders: A Controlled Clinical Trial

Previous studies of students studying to be teachers have indicated that these students commonly have voice disorders. Ideally, voice disorders should be treated before students start their work as teachers, but the resources for this treatment are often limited. This study examines whether group voice therapy is effective for teacher students. Accordingly, 20 teacher students with mild voice disorders received group voice therapy (in three small groups), whereas 20 students with similar voice disorders served as a control group and consequently did not receive voice therapy. Two out of three outcome measures (perceptual evaluation of voice quality and a questionnaire on the occurrence of vocal symptoms) indicated significant changes in the treatment group compared with the control group. No differences between groups were noted in the laryngeal status. The results suggest that group voice therapy seems to be an effective method to treat students with mild voice disorders.

Perceptual evaluation of voice quality and its correlation with acoustic measurements

To determine whether a correlation exists between the Grade, Roughness, Breathiness, Aesthenia, Strain (GRBAS) scale (a subjective measure of voice) and the Multi-Dimensional Voice Program (MDVP) scale (an objective measure of voice). A retrospective review of 37 voice patients (12 male/25 female) was conducted. Each voice was perceptually evaluated using the GRBAS scale by an experienced speech pathologist and acoustically analyzed using the MDVP scale. Statistical analysis using a multivariate regression model identified a significant correlation between the noise-related parameters of MDVP and the components of the GRBAS scale. Grade correlated with voice turbulence index (VTI), noise harmonic ratio (NHR), and soft phonation index (SPI). Roughness correlated with NHR only. Breathiness correlated with SPI only. Aesthenia also correlated with SPI only. Of the 19 acoustic variables measured by the MDVP system, only three noise parameters significantly correlated with the GRBAS perceptual voice analysis. Perhaps “noise” is the perceived acoustical quality of the dysphonic voice. A voice quantifying measure such as a “voice index score” could be proposed using the GRBAS scoring and the three clinically relevant MDVP values following further studies.

Equal appearing interval and visual analogue scaling of perceptual roughness and breathiness

One of the factors that affects the reliability of perceptual voice evaluation is the rating scale. Equal‐appearing interval (EAI) and visual analogue (VA) scales are the two most common scales used and have attracted much attention in recent studies of perceptual voice evaluation. Available findings are contradictory, with one study finding the EAI scale to be more desirable while an earlier study showed equivocal results. The objective of the present study was to compare the reliability of using an 11‐point EAI scale and a VA scale, each of 10 cm long, for perceptual voice quality evaluation. Thirty listeners with no prior experience in perceptual voice evaluation were asked to rate the breathy and rough qualities of 28 voice samples. The results showed that the listeners demonstrated a significantly higher intra‐rater agreement and lower inter‐rater variability in rating the two perceptual voice qualities using the EAI scale, when compared to the VA scale. However, listeners tend to show more bias in using certain points on the EAI scale than on the VA scale. In addition, a linear relationship was found between the EAI and VA ratings, suggesting the psychoperceptual characteristics of breathy and rough qualities could be captured equally well by the EAI and VA scales. Since the ease of use of the rating scale is an important consideration in clinical situations, the 11‐point, 10 cm long EAI scale is therefore more preferable, although not necessarily more superior, than the VA scale for evaluating breathy and rough qualities.

Perceptual and acoustic evaluation of individuals with laryngopharyngeal reflux pre- and post-treatment

Summary Thirteen individuals with laryngopharyngeal reflux (LPR) were studied pre- and post-treatment. The effect of treatment on perceptual ratings of voice quality and frequency and intensity measures was examined. Relationships between perceptual and acoustic parameters were assessed descriptively. Results showed a small, but significant improvement in the perception of voice quality post-treatment. No significant differences were found between pre- and post-treatment means for any of the acoustic measures except harmonics-to-noise ratio (HNR). Descriptive analyses showed some association between perceptual ratings and acoustic measures. Discussion of results focuses on severity of LPR.