Vocal Disorders Research Articles

The Ability of Patient-Symptom Questionnaires to Differentiate PVFMD From Asthma

Goals of the current study were to (1) conduct initial validation of a new Paradoxical Vocal Fold Movement Disorder Screening Questionnaire (PVFMD-SQ); (2) determine if symptom-based questionnaires can discriminate between patients with confirmed PVFMD and those with diagnosed uncontrolled asthma without clinical suspicion for PVFMD; and (3) determine if a new questionnaire with diagnostic specificity could be created from a combination of significant items on previously validated questionnaires. This is a prospective, case-controlled study of patients with PVFMD only and asthma only, who completed five questionnaires: Dyspnea Index, Reflux Symptom Index, Voice Handicap Index-10, Sino-Nasal Questionnaire, and PVFMD-SQ. Factor analysis was completed on the new PVFMD-SQ, and the discrimination ability of selected factors was assessed by receiver operating characteristics curve. The factor with the greatest discriminatory ability was selected to create one diagnostic questionnaire, and scores for each participant were calculated to estimate how well the factor correlated with a PVFMD or asthma diagnosis. Mean scores on all questionnaires were compared to test their discriminatory ability. Patients with PVFMD showed greater voice handicap and reflux symptoms than patients with asthma. A 15-item one-factor questionnaire was developed from the original PVFMD-SQ, with a sensitivity of 89% and specificity of 73% for diagnosing asthma versus PVFMD. The combined questionnaires resulted in four factors, none of which showed discriminatory ability between PVFMD and asthma. This study represents the first time that a patient symptom-based screening tool has shown diagnostic sensitivity to differentiate PVFMD from asthma in a cohort of symptomatic patients.

Paradoxical vocal fold motion in children presenting with exercise induced dyspnea

IntroductionAlthough dyspnea with exercise in the pediatric population can be multifactorial, the diagnosis of paradoxical vocal fold motion disorder (PVFMD) in this group is not well characterized. The objective of this study is to review the multiple causes of dyspnea with exercise in children, including the prevalence of PVFMD within this study population. MethodsA retrospective review was conducted of patients seen at a tertiary pediatric hospital for exercise-induced dyspnea suspected to be related to PVFMD between January 2007 and July 2015. Inclusion criteria included assessment in a specialty exercise clinic and evaluation by a pediatric otolaryngologist and pulmonologist. Pre- and post-exercise pulmonary function tests and laryngoscopic examinations were performed. Data including co-morbidities, presenting symptoms, prior diagnoses and treatments, final diagnoses, prescribed treatments and outcomes were collected and analyzed. Results294 patients were evaluated at our institution during the study period. 4 patients were excluded for insufficient data, which left 290 for analysis. 75 were male, 215 female. All patients underwent treadmill testing with monitoring to simulate strenuous exercise. Average patient age was 14.6 years; average BMI was 21.53. The most common sports to elicit symptoms were running and soccer. Patients most frequently complained of stridor or wheezing in addition to dyspnea. Throat tightness was also a common complaint. After evaluation, 86 patients were given the primary diagnosis of exercise-induced PVFMD. 54 patients were diagnosed with physiologic dyspnea and 30 with exercise-induced asthma. ConclusionPediatric patients presenting with exercise-induced dyspnea can have multiple etiologies for their symptoms including PVFMD. Other causes of dyspnea with exercise should not be underestimated.

Tissue engineering-based therapeutic strategies for vocal fold repair and regeneration.

Vocal folds are soft laryngeal connective tissues with distinct layered structures and complex multicomponent matrix compositions that endow phonatory and respiratory functions. This delicate tissue is easily damaged by various environmental factors and pathological conditions, altering vocal biomechanics and causing debilitating vocal disorders that detrimentally affect the daily lives of suffering individuals. Modern techniques and advanced knowledge of regenerative medicine have led to a deeper understanding of the microstructure, microphysiology, and micropathophysiology of vocal fold tissues. State-of-the-art materials ranging from extracecullar-matrix (ECM)-derived biomaterials to synthetic polymer scaffolds have been proposed for the prevention and treatment of voice disorders including vocal fold scarring and fibrosis. This review intends to provide a thorough overview of current achievements in the field of vocal fold tissue engineering, including the fabrication of injectable biomaterials to mimic invitro cell microenvironments, novel designs of bioreactors that capture invivo tissue biomechanics, and establishment of various animal models to characterize the invivo biocompatibility of these materials. The combination of polymeric scaffolds, cell transplantation, biomechanical stimulation, and delivery of antifibrotic growth factors will lead to successful restoration of functional vocal folds and improved vocal recovery in animal models, facilitating the application of these materials and related methodologies in clinical practice.

Vocal Health Education and Medical Resources for Graduate-Level Vocal Performance Students

Most agree that education about vocal health and physiology can help singers avoid the development of vocal disorders. However, little is known about how this kind of education is provided to singers as part of their formal training. This study describes the amount of instruction in these topics provided through graduate-level curricula, who provides this instruction, and the kinds of affiliations such graduate singing programs have with medical professionals. This is an online survey of music schools with graduate singing programs. Survey questions addressed demographics of the programs, general attitudes about vocal health instruction for singers, the amount of vocal health instruction provided and by whom it was taught, perceived barriers to including more vocal health instruction, and any affiliations the voice program might have with medical personnel. Eighty-one survey responses were received. Instruction on vocal health was provided in 95% of the schools. In 55% of the schools, none of this instruction was given by a medical professional. Limited time in the curriculum, lack of financial support, and lack of availability of medical professional were the most frequently reported barriers to providing more instruction. When programs offered more hours of instruction, they were more likely to have some of that instruction given by a medical professional (P = 0.008) and to assess the amount of instruction provided positively (P = 0.001). There are several perceived barriers to incorporating vocal health education into graduate singing programs. Opportunity exists for more collaboration between vocal pedagogues and medical professionals in the education of singers about vocal health.

Prevalence of Voice Disorders in Iranian Primary School Students

The voice is the sound produced by vibration of our vocal cords and has an important role in verbal communication. A child's voice disorder may significantly impair his or her ability to be heard and understood. The purpose of this study was to determine the prevalence of voice disorders in primary school students. In this descriptive-analytical study, a total of 501 fourth through fifth grade primary school students (boys = 51.6%, girls = 48.4%) with the age range of 10-12 years were selected from nine public school systems in Tehran that were assessed in October 2013 through March 2014. Presence of a voice disorder characterized by hoarseness was identified by a dual approach including investigator screening and parent identification. We used the grade of overall dysphonia, roughness, breathiness, asthenia, and strain scale for perceptual evaluation of voice. All children were assessed with video laryngoscopy examination by an otorhinolaryngologist. The recordings were made during spontaneous speech, counting numbers, sustained utterance of the (/a/) vowel, reading a standard passage in Farsi, and the ratio of /s/ and /z/. Statistical analysis was done via chi-square test and t test. Results indicated that the prevalence of voice disorders in primary school students is 53.2%. The results indicated significant differences between gender and subjects with lesions (P = 0.00000), gender and vocal disorders (P = 0.04), and s/z ratio and type of lesion (P = 0.0002). Phonotrauma seems to play an important role in child dysphonia, with nodules as main diagnosis.

Comparing Mental Health of School-Age Children with and without Epilepsy.

Mental health problems frequently occur in children with epilepsy but the diagnosis is frequently missed and therapeutic opportunities are often lost. The aim of this study was to compare mental health statues between school-aged children with epilepsy and the healthy group. In this case, control study, 120 children aged 6 to 12 years with idiopathic epilepsy and 240 healthy control groups were followed up. Children with epilepsy were enrolled from Iranian Epilepsy Association in 2014. The parent version of Child Symptom Inventory-4 questionnaire was used. Mean comparisons were performed using Student's t test while effect sizes were estimated by Cohen's d coefficient. The Chi-Square test was used to assess the difference between frequency distribution of demographic variables in both groups. The significance level was considered less than 0.05. There were statistically significant differences between children with epilepsy and control group as for attention deficit hyperactivity disorder, generalized anxiety disorder, major depression, separation anxiety, social phobia, motor and vocal tics and oppositional defiant disorder. The carefully evaluating and prospectively following the psychopathology symptom of children with epilepsy are critical for early identification, prevention and treatment.

Dysfunctional breathing and reaching one's physiological limit as causes of exercise-induced dyspnoea.

Key pointsExcessive exercise-induced shortness of breath is a common complaint. For some, exercise-induced bronchoconstriction is the primary cause and for a small minority there may be an alternative organic pathology. However for many, the cause will be simply reaching their physiological limit or be due to a functional form of dysfunctional breathing, neither of which require drug therapy.The physiological limit category includes deconditioned individuals, such as those who have been through intensive care and require rehabilitation, as well as the unfit and the fit competitive athlete who has reached their limit with both of these latter groups requiring explanation and advice.Dysfunctional breathing is an umbrella term for an alteration in the normal biomechanical patterns of breathing that result in intermittent or chronic symptoms, which may be respiratory and/or nonrespiratory. This alteration may be due to structural causes or, much more commonly, be functional as exemplified by thoracic pattern disordered breathing (PDB) and extrathoracic paradoxical vocal fold motion disorder (pVFMD).Careful history and examination together with spirometry may identify those likely to have PDB and/or pVFMD. Where there is doubt about aetiology, cardiopulmonary exercise testing may be required to identify the deconditioned, unfit or fit individual reaching their physiological limit and PDB, while continuous laryngoscopy during exercise is increasingly becoming the benchmark for assessing extrathoracic causes.Accurate assessment and diagnosis can prevent excessive use of drug therapy and result in effective management of the cause of the individual’s complaint through cost-effective approaches such as reassurance, advice, breathing retraining and vocal exercises.This review provides an overview of the spectrum of conditions that can present as exercise-­induced breathlessness experienced by young subjects participating in sport and aims to promote understanding of the need for accurate assessment of an individual’s symptoms. We will highlight the high incidence of nonasthmatic causes, which simply require reassurance or simple interventions from respiratory physiotherapists or speech pathologists.

The role of acoustic analysis of fundamental frequency in differentiating arytenoid dislocation from vocal fold paralysis

Objective:Analysis of the sustained vowels of acoustic parameters in arytenoid dislocation and vocal fold paralysis. To investigate their acoustic characteristics and evaluate the role of this acoustic analysis method in differentiating arytenoid dislocation from vocal fold paralysis. Method:Thirty-three cases with unilateral vocal cord movement disorders were collected.All cases were divided into arytenoid dislocation group and vocal fold paralysis group through the laryngeal electromyography. Each group was further devided into male group and female group. The voice signals of sustained vowel of /a/ were measured using the software MDVP and obtain the acoustic parameters(Jitter, Shimmer, SPI and Fo). The acoustic characteristics between the two groups were observed and compared. Results were analyzed using Rank sum test for group design.Result:There were significant differences in Fo between arytenoid dislocation group and vocal fold paralysis group in both male and female group（P <0.05）. And mean rank order of Fo in arytenoid dislocation group was greater than vocal fold paralysis group. There were no significant differences in jitter,shimmer and SPI between arytenoid dislocation group and vocal fold paralysis group（P >0.05）.Conclusion:Mean rank order of Fo in arytenoid dislocation group is greater than vocal fold paralysis group in both the male and the female group. Fo is of value in differentiating arytenoid dislocation from vocal fold paralysis. This provides a theoretical basis for the acoustic analysis method to identify these two diseases.

Paradoxical Vocal Fold Motion Disorder: Etiology, Clinical Presentation and Diagnosis

Paradoxical vocal fold motion disorder (PVFMD) is a disease characterized by intermittent adduction of the vocal folds during inspiration and/or expiration, causing dyspnea and sensation of throat tightness. Usually there are intermittent symptoms of shortness of breath and inspiratory stridor that may lead patient to emergency units. The disease is frequently misdiagnosed and many patients are treated wrongly. Some neurologic alterations are accused but the etiology is still unclear. The diagnostic work-up should include a detailed history and physical examination, pulmonary function testing, measures of oxygenation and flexible laryngoscopy. Asthma, laryngopharyngeal reflux, some air irritants and some psychologic conditions should be ruled out in differential diagnosis.

SYNTHESIZABLE AND PROTOTYPIC VISUAL-TACTILE SYSTEM-IN FPGA: AN ALTERNATIVE TO ANALYSIS AND IMPROVEMENT OF THE VOICE QUALITY FOR THE HEARING IMPAIRED PEOPLE

Oral communication comprises one of the most important forms of social interaction. The process of learning the spoken language depends on the hearing, therefore, the total or partial loss of hearing sensitivity hinders such aspect. Digital signal processing techniques with non-invasive character are used for diagnosis, support and improvement of the voice quality of the deaf. Thus, the present study aims to propose and develop a system of analysis and correction of vocal disorders by means of visual and tactile feedback with module implemented in programmable device type FPGA (Field Programmable Gate Array). The results point to the potential of a proposed intervention as a helper for sensory substitution, being based on the monitoring and control of speech, in order to allow for the assessment and remediation by means of an electronic resource, allowing deaf individuals to obtain a support for learning the spoken language. The possibilities for improvements in communication skills observed in this study are dependent on the capability of the device together with the speech therapist, integrating therapies with the support of the family, the time and the motivation of the user, factors that cooperate for the success of this approach.

Analysis of Acoustic Parameters to Objectively Reflect the Change of Voice Quality before and after Surgery in Benign Vocal Fold Mucosal Disorders

Analysis of Acoustic Parameters to Objectively Reflect the Change of Voice Quality before and after Surgery in Benign Vocal Fold Mucosal Disorders

Tic &amp; Tourette Syndrome and Motor Disorders

Motor disorder refers to neuropsychiatric disorders such as abnormal movements, meaningless repetitive movements, and impairment in acquisition and performance of motor skills. Motor disorder was included as a sub-category of neurodevelopmental disorder chapter in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [1]. DSM-5’s motor disorders include tic disorders (Tourette’s disorder, persistent motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder), developmental coordination disorder, and stereotypic movement disorder. This review overviews and summarizes current knowledge on the motor disorder’s cause, diagnosis, and treatment. TIC DISORDERS

Comparison of Pre and Post-operational Phonatory Aerodynamic Parameters in Vocal Polyp and Vocal Cord Palsy Patients

Background and Objectives Aerodynamic analysis is an examination which provides information regarding various vocalization measures indicating laryngeal efficiency. Voice evaluation using such examination must be capable of distinguishing between normal to abnormal voice. It also observes variables on aerodynamic characteristics by gender in regards to patients of vocal disorders, especially of vocal cord paralysis and vocal polyp, and compares the conditions before and after surgery. This paper therefore, seeks to build a framework for establishing standard levels of aerodynamical characteristic on vocal disorders. Subjects and Methods The study was intended for a total number of 20 patients with vocal polyp or unilateral vocal cord paralysis. Those with the vocal polyp underwent laryngomycroscopy surgery and the vocal cord paralysis, vocal fold injection using Restylane. Aerodynamic analysis fulfilled the Maximum sustained Phonation (MXPH) and Voicing Efficiency (VOEF) by using PAS Model 6600 (KayPENTAX, USA). Results In MXPH, increase in PHOT were evident with vocal polyp after surgery. As for patients with vocal cord paralysis, MAXDB, MEADB, DHODB, PHOT all have increased and MEAP, PEF, MEAF decreased after surgery. In VOEF, patients with vocal cord paralysis who underwent surgery showed increase in MAXDB, MEADB, DHODB, FET100, ARES, but decreases in PEF, TARF. Conclusion Overall, it can be concluded that patients with the vocal polyp and vocal cord paralysis seemed to get closer to the normal values after than before surgery in majority of measures. This confirms that the function of their vocal cord has improved nearly to normality through operations. Key words: Vocal cord palsy ㆍ Vocal polyp ㆍ Phonatory aerodynamic 핵심용어: ì„±ëŒ€ìš©ì¢ ã† 성대마비 ㆍ 공기역학

Adaptation and Validation of the Voice Handicap Index (VHI)-30 into Serbian

To evaluate the internal consistency, test-retest reliability, and clinical validity of the Serbian version of the self-administered Voice Handicap Index (VHI)-30. Cross-sectional study. The English version of VHI-30 was translated into Serbian and then back-translated into English. The Serbian VHI-30 was administered to 91 patients divided into four groups according to voice pathology: structural, inflammatory, neurologic, and functional groups. The control group included 90 subjects with no voice problems. The internal consistency (Cronbach's alpha coefficient α), test-retest reliability (interclass correlation coefficient) of VHI-30, comparison of patient's and control's VHI-30 scores (Mann-Whitney U test; Kruskal-Wallis test), and correlation with overall severity of dysphonia (Spearman correlation coefficient, ρ) were calculated. In the patient group, we observed excellent internal consistency for the Serbian VHI-30 (α = 0.95) and good internal consistency for all VHI-30 subscales: physical (α = 0.88), functional (α = 0.88), and emotional (α = 0.88). The interclass correlation coefficient indicated strong test-retest reliability for patients (0.99) and controls (0.84). The mean scores of all 30 items in dysphonic participants were significantly higher than in controls (P < 0.001). Good correlation was obtained between the total scores of VHI-30 and patients' self-perceived overall severity of dysphonia (ρ = 0.748, P < 0.001). Within the patient group, the female participants displayed significantly higher VHI-30 scores than male participants (Mann-Whitney U test, P < 0.001). The VHI-30 scores showed strong correlation within different patient groups and controls (Spearman correlation coefficient: structural, 0.942; inflammatory, 0.756; neurologic, 0.888; functional, 0.982; controls, 0.882). The Serbian VHI-30 is a useful and valuable tool for the evaluation of patients with vocal disorders and for making subsequent clinical decisions.

Automatic Speech Recognition of Pathological Voice

Background/Objectives: Automatic speech recognition (ASR) benefits human beings in many useful applications. Various ASR systems exhibiting good performance have been developed for normal speakers. The speech produced by a voice disordered patient is not like a normal speaker due to irregular vibration and incomplete closure of vocal fold. Therefore, an investigation is required by exploring the different speech features to develop an ASR system which can perform well for both pathological and normal speakers. Methods: In this paper, we proposed an automatic speech recognition system using Hidden Markov Model Toolkit (HTK) for normal and pathology voice. Four techniques are applied for feature extraction; Mel Frequency Cepstral Coefficient (MFCC), Perceptual Linear Prediction (PLP), RelAtiveSpecTrA - Perceptual Linear Predictive (RASTA-PLP), and linear prediction coefficients (LPC). The database that used to evaluate the performance of the developed system; includes a total of 297 speakers 121 of them were normal speakers and the remaining containing five types of vocal fold disorders. Findings: Experimental results show that the developed system gives good accuracies for normal and pathology voice. The highest accuracy of 94.44 % with a word error rate 5.55% is achieved in case of normal voice, and 88.63 % with a word error rate 11.63 % in case of pathology voice. Fuzzy logic controller is proposed to automatically segmentation the normal and disorders voice.

Voice of Reimbursement: Medicare Coverage for Vocal Disorders

Speech-language pathologists (SLPs) who treat patients with vocal disorders find they are the exception —rather than the rule—when it comes to Medicare policy. This article addresses statute, regulations, and policies related to acoustical assessments, endoscopy, electronic speech aids, and tracheo-esophageal prostheses (TEPs). Acoustical assessments have limited recognition in the Medicare program and are only reimbursed in certain states, despite advocacy efforts by the American Speech-Language-Hearing Associaiton and members of the State Medicare Administrative Contractor (SMAC) Network. For endoscopy evaluations, confusion is still prevalent related to the level of physician supervision required, primarily due to the changing policies in 2011. Electronic speech aids are a benefit that is often forgotten, though the national policy allows relatively broad coverage. Finally, TEPs are the subject of SLPs, patients, manufacturers, and Congressional attention due to their limited available secondary to poor reimbursement rates and a 2010 enforcement of distribution policy. Clarification regarding the provision of traditional Medicare services (not Medicare Advantage or supplemental plans managed by private companies) and statute is discussed.

Voice Handicap Index evaluation in patients with moderate to profound bilateral sensorineural hearing loss

SummaryVoice and speech are regulated by hearing. Vocal disorders in patients with hearing loss have not been evaluated yet as to the subjective degree of disability they cause in this group.Aimto compare the results of the Voice Handicap Index (VHI) obtained for patients with normal hearing and moderate to profound bilateral sensorineural hearing loss. Study design: Controlled, cross-sectional.Materials and MethodsA total of 76 adult patients being treated on a University Otolaryngology center were enrolled (38 with and 38 without hearing loss), ages ranging between 19 and 59 years, were asked to complete the Portuguese version of the VHI.ResultsTotal VHI score median values obtained were 23.5 and 4.0 for the study and control groups, respectively (p = 0.000). Significant differences between the two groups were found for all three VHI subscales (functional, physical and emotional) (p = 0.000).ConclusionOur results lead us to infer a greater social and economical disadvantage as per assessed in the VHI of patients with moderate and higher bilateral sensorineural hearing loss.

Human mutant huntingtin disrupts vocal learning in transgenic songbirds.

Speech and vocal impairments characterize many neurological disorders. However, the neurogenetic mechanisms of these disorders are not well understood, and current animal models do not have the necessary circuitry to recapitulate vocal learning deficits. We developed germline transgenic songbirds, zebra finches (Taneiopygia guttata) expressing human mutant huntingtin (mHTT), a protein responsible for the progressive deterioration of motor and cognitive function in Huntington's disease (HD). Although generally healthy, the mutant songbirds had severe vocal disorders, including poor vocal imitation, stuttering, and progressive syntax and syllable degradation. Their song abnormalities were associated with HD-related neuropathology and dysfunction of the cortical-basal ganglia (CBG) song circuit. These transgenics are, to the best of our knowledge, the first experimentally created, functional mutant songbirds. Their progressive and quantifiable vocal disorder, combined with circuit dysfunction in the CBG song system, offers a model for genetic manipulation and the development of therapeutic strategies for CBG-related vocal and motor disorders.

An Empirical Examination of Symptom Substitution Associated With Behavior Therapy for Tourette's Disorder

Over the past six decades, behavior therapy has been a major contributor to the development of evidence-based psychotherapy treatments. However, a long-standing concern with behavior therapy among many nonbehavioral clinicians has been the potential risk for symptom substitution. Few studies have been conducted to evaluate symptom substitution in response to behavioral treatments, largely due to measurement and definitional challenges associated with treated psychiatric symptoms. Given the overt motor and vocal tics associated with Tourette’s disorder, it presents an excellent opportunity to empirically evaluate the potential risk for symptom substitution associated with behavior therapy. The present study examined the possible presence of symptom substitution using four methods: (a) the onset of new tic symptoms, (b) the occurrence of adverse events, (c) change in tic medications, and (d) worsening of co-occurring psychiatric symptoms. Two hundred twenty-eight participants with Tourette’s disorder or persistent motor or vocal tic disorders were randomly assigned to receive behavioral therapy or supportive therapy for tics. Both therapies consisted of eight sessions over 10weeks. Results indicated that participants treated with behavior therapy were not more likely to have an onset of new tic symptoms, experience adverse events, increase tic medications, or have an exacerbation in co-occurring psychiatric symptoms relative to participants treated with supportive therapy. Further analysis suggested that the emergence of new tics was attributed with the normal waxing and waning nature of Tourette’s disorder. Findings provide empirical support to counter the long-standing concern of symptom substitution in response to behavior therapy for individuals with Tourette's disorder.

Irritant-Induced Paradoxical Vocal Fold Motion Disorder: Diagnosis and Management.

To review our experience with the diagnosis and treatment of irritant-induced paradoxical vocal fold motion disorder (IPVFMD). Retrospective chart review. Tertiary academic referral center. Thirty-four cases that met IPVFMD criteria and 76 cases of non-IPVFMD were selected from a database of patients with paradoxical vocal fold motion disorder-the diagnosis of which was made on the basis of flexible fiberoptic laryngoscopy and augmented by an odor challenge. Clinical charts were reviewed to document history of environmental allergies, pulmonary disease, gastroesophageal reflux, psychiatric disorder, fibromyalgia, tobacco use, alcohol use, dysphonia, cough, dysphagia, and treatment outcomes. There were no statistical differences between the IPVFMD and non-IPVFMD groups. Of the patients who were assigned and attended laryngeal control therapy, 13 (65%) reported improvement of symptoms. Symptom improvement increased to 100% in those patients who attended at least 2 laryngeal control therapy sessions. IPVFMD should be considered in patients presenting with respiratory symptoms after irritant exposure. Sensitivity of diagnosis can be improved via a standardized approach consisting of a careful history and physical examination, including laryngoscopy in the presence of triggers. Laryngeal control therapy is a well-tolerated and effective method of managing IPVFMD.