Voice Therapy Research Articles

METHODOLOGY OF CORRECT BREATHING AND ITS CORRECT USE IN THE ACADEMIC SINGING CLASS" AT THE CHILDREN'S MUSIC AND ART SCHOOL

Singing has a significant impact on a child's mental and emotional growth and is strongly tied to the development of basic mental processes and physical processes. In this perspective, voice training with the goal of using the voice appropriately and efficiently is believed to be required in general music education, and breathing and vocal exercises have a particular importance for high and quality sound production in this process. With this in mind, the purpose of this study was to learn how Turkish music teachers felt about employing voice and breathing exercises while singing in contexts related to general music education.

Immediate effects of straw phonation in air or water on the laryngeal function and configuration of female speech-language pathology students visualised with strobovideolaryngoscopy: A randomised controlled trial.

A promising way to obtain vocal economy and efficiency is by semi-occluding the vocal tract while phonating. Current knowledge about the immediate effects of semi-occluded vocal tract (SOVT) phonation on the laryngeal function and configuration is based mainly on computer modelling or excised larynges studies. In in vivo SOVT studies, electroglottography (EGG) has been the most commonly used laryngeal outcome, showing contradictory results between studies. Therefore, exploring these aspects by direct visualisation of the human larynx during SOVT phonation using strobovideolaryngoscopy (SVL) is needed. The aim of this study was to investigate and compare the immediate effects of straw phonation (SP) in air, SP in 2cm water, and SP in 5cm water (with stirring straws), on the laryngeal function and configuration of a homogeneous group of vocally healthy female speech-language pathology students, visualised with flexible SVL. A randomised controlled trial was used. Fifty-two female speech-language pathology students (mean age: 18.7 years, SD: 0.6) were assigned randomly to one of three experimental groups or a control group: (1) SP in air, (2) SP in 2cm water, (3) SP in 5cm water or (4) [u] phonation with similar soft onset and slightly pursed lips as in SP but without a straw (control group). The participants underwent flexible SVL during habitual [u] phonation, followed by the specific SOVT exercise of their group assignment. All video samples were evaluated randomly and blindly by two experienced investigators using the Voice-Vibratory Assessment with Laryngeal Imaging (VALI) rating form, first independently and then by consensus. Compared to habitual phonation, the vibrational amplitude decreased during SP in 5cm water and SP in 2cm water, being more prominent in the first, more flow-resistant exercise. The mucosal wave also decreased during SP in 5cm water. The anteroposterior (AP) supraglottic compression similarly increased during SP in air, SP in 2cm water, and SP in 5cm water. Further, a rise in mediolateral (ML) compression and a decrease in phase symmetry and regularity were found during SP in 2cm water. A similar decrease in regularity was observed during SP in 5cm water. Both SP in air and SP in water cause positive immediate laryngeal effects for voice training opportunities. More AP supraglottic activity found during each SP exercise might indicate epilarynx narrowing, an economic phenomenon associated with SOVT. Immersing the straw in water additionally diminished the vibrational amplitude, lowering vocal fold impact stress and risk for phonotrauma during the exercise. The decreased regularity of the vibrational cycles during SP in water might be due to the varying back pressure created by the water bubbling. The impact of SP in water on ML supraglottic compression needs further investigation. What is already known on the subject A promising way to obtain vocal economy and efficiency is by semi-occluding the vocal tract while phonating. Current knowledge about the immediate effects of semi-occluded vocal tract (SOVT) phonation on the laryngeal function and configuration is based mainly on computer modelling or excised larynges studies. In in vivo SOVT studies, electroglottography (EGG) has been the most commonly used laryngeal outcome, showing contradictory results between studies. Therefore, exploring these aspects by direct visualisation of the human larynx during SOVT phonation using strobovideolaryngoscopy (SVL) is needed. What this paper adds to existing knowledge Group results of the current study generally support earlier computer modelling and in vivo studies, strengthening the current SOVT knowledge. Both SP in air and SP in water cause positive immediate laryngeal effects for voice training opportunities. More anteroposterior (AP) supraglottic activity found during each SP exercise might indicate epilarynx narrowing, an economic phenomenon associated with SOVT. Immersing the straw in water additionally diminished the vibrational amplitude, lowering vocal fold impact stress and risk for phonotrauma during the exercise. The decreased regularity of the vibrational cycles during SP in water might be due to the varying back pressure created by the water bubbling. The impact of SP in water on ML supraglottic compression needs further investigation. What are the potential or actual clinical implications of this work? Current results support that both SP in air and SP in water can be useful exercises in voice training. SP in water has shown the additional gain of lowering the vibrational amplitude during the exercise, hence supporting its appropriateness for vocal warm-ups by minimising vocal fold impact stress and the risk of phonotrauma. In the future, large-scale randomised controlled trials in other subgroups of voice users, including dysphonic patients, are needed to support evidence-based practice. SVL can facilitate the search for individualised training and therapy approaches.

Olfactory function in laryngectomised patients: tracheo-oesophageal versus oesophageal speech.

This study aimed to evaluate olfactory function in patients rehabilitated with oesophageal (ES) voice or tracheo-oesophageal (TES) prosthesis to further verify whether there were differences in smell alterations depending on voice rehabilitation modality. A total of 40 patients who had undergone total laryngectomy participated in the study. Speech rehabilitation was achieved through TES in 20 patients (Group A) or ES in 20 patients (Group B). Olfactory function was evaluated using the Sniffin' Sticks test. At olfactory evaluation, in Group A, 4/20 patients (20%) were anosmic, whereas 16/20 patients (80%) were hyposmic; in Group B, 11/20 patients (55%) were anosmic whereas 9/20 patients (45%) were hyposmic. A significant difference (p = 0.04) was found at global objective evaluation. The study shows that the rehabilitation with TES contributes to maintaining a functioning, albeit limited, sense of smell.

Postoperative Voice Surgical Outcomes in Professional Singers vs Non-Singers

Professional singers often are described as vocal athletes, and just as professional athletes get injured, injuries to professional singers can occur during practice and performances. In other fields of medicine, research has shown that competitive sports athletes recover more quickly after orthopedic surgical procedures compared to non-athletes. The purpose of this study was to determine whether similar differences occur with voice patients by comparing voice surgical outcomes between professional singers and non-singers. A retrospective cohort study was conducted that included a consecutive sample of 194 adult subjects who underwent voice surgical procedures in the operating room. All surgeries were performed by the same surgeon, the senior author of this study (RTS). Data were reviewed for patients with medical records between January 1, 2010 to February 1, 2022. Subjects who reported receiving income from singing or reported studying voice at a collegiate level or higher were classified as professional singers. Subjects reporting careers in all other professions, including unpaid avocational singers or singers without formal training, were assigned to the non-singer control group. The data were analyzed using SPSS statistical software. Statistical significance was determined using independent samples t test for continuous variables and Fisher's exact test or binary logistic regression for binary outcomes. There were 194 subjects included in this study (43.81% male/56.19% female). The average age was 42.60 ± 15.17. Ninety subjects were professional singers and 104 were non-singers. Revision of surgical plan was significantly different for professional singers compared to non-singers (14.44% versus 0%, P< 0.001). The rate of postoperative complications did not differ significantly between the singer and non-singer groups, even when adjusting for other factors. Professional singers presented with slightly more severe vocal fold hemorrhages on the first postoperative visit compared to non-singers (1.73 ± 0.73 versus 1.32 ± 0.65, P=0.003), but there was no difference by the second visit. Following surgery, professional singers adhered to a longer duration of voice rest. However, both groups participated equally in voice therapy postoperatively. No differences were found in operative complications between professional singers and non-singers. This study describes outcomes and considerations in patient care for professional singers. It also provides insight into potentially modifiable factors, such as voice rest, that could impact patient care postoperatively.

Indexing Cognitive Resource Usage for Acquisition of Initial Voice Therapy Targets.

The purpose of this study was to index cognitive resource usage for acquisition of initial targets of two common voice therapy techniques (resonant voice therapy [RVT] and conversation training therapy [CTT]) based on the theorized depletion effect (i.e., when an initial task requiring high cognitive load leads to poorer performance on a subsequent task). Eleven vocally healthy participants, ages 23-41 years, read aloud the Rainbow Passage and produced consonant-vowel resonant targets (/mi, ma, mu/) followed by a baseline computerized Stroop task and a 15-min washout. Following this baseline period, participants watched and interacted with two videos instructing them in RVT or CTT initial targets. After viewing each video and practicing the associated vocal skills, participants rated the degree of mental effort required to engage in the target vocal technique on a modified Borg scale. Participants recorded their attempts at RVT on /mi, ma, mu/ and CTT on the Rainbow Passage, which were later rated by three voice-specialized speech-language pathologists as to how representative they were of each respective target technique. Changes in fundamental frequency and average auditory-perceptual ratings from baseline were examined to determine if participants adjusted their technique from RVT and CTT baseline to acquisition. Performance on the Stroop task was, on average, worse post CTT than post RVT, but both post-CTT and post-RVT Stroop scores were poorer than baseline. These results suggest that both treatment techniques taxed cognitive resources but that CTT was more cognitively taxing than RVT. However, despite differences in raw averages, no statistically significant differences were found between the baseline, post-CTT, and post-RVT Stroop scores, likely due to the small sample size. Participant ratings of mental effort for CTT and RVT were statistically similar. Likewise, poorer post-RVT Stroop scores were associated with participants' greater perceived mental effort with RVT acquisition, but there was no significant association between mental effort ratings for CTT acquisition and post-CTT Stroop scores. Significantly higher fundamental frequency and perceived ratings of the accuracy of technique from baseline to acquisition for both CTT and RVT were found, providing evidence of vocal behavior changes as a result of each technique. Brief exposure to initial treatment tasks in CTT is more cognitively depleting than initial RVT tasks. Results also indicate that vocally healthy participants are able to make a voice change in response to a brief therapy prompt. Finally, participant-rated measures of mental effort and secondary measures of cognitive depletion do not always correlate.

Short Implicit Voice Training Affects Listening Effort During a Voice Cue Sensitivity Task With Vocoder-Degraded Speech.

Understanding speech in real life can be challenging and effortful, such as in multiple-talker listening conditions. Fundamental frequency ( fo ) and vocal-tract length ( vtl ) voice cues can help listeners segregate between talkers, enhancing speech perception in adverse listening conditions. Previous research showed lower sensitivity to fo and vtl voice cues when speech signal was degraded, such as in cochlear implant hearing and vocoder-listening compared to normal hearing, likely contributing to difficulties in understanding speech in adverse listening. Nevertheless, when multiple talkers are present, familiarity with a talker's voice, via training or exposure, could provide a speech intelligibility benefit. In this study, the objective was to assess how an implicit short-term voice training could affect perceptual discrimination of voice cues ( fo+vtl ), measured in sensitivity and listening effort, with or without vocoder degradations. Voice training was provided via listening to a recording of a book segment for approximately 30 min, and answering text-related questions, to ensure engagement. Just-noticeable differences (JNDs) for fo+vtl were measured with an odd-one-out task implemented as a 3-alternative forced-choice adaptive paradigm, while simultaneously collecting pupil data. The reference voice either belonged to the trained voice or an untrained voice. Effects of voice training (trained and untrained voice), vocoding (non-vocoded and vocoded), and item variability (fixed or variable consonant-vowel triplets presented across three items) on voice cue sensitivity ( fo+vtl JNDs) and listening effort (pupillometry measurements) were analyzed. Results showed that voice training did not have a significant effect on voice cue discrimination. As expected, fo+vtl JNDs were significantly larger for vocoded conditions than for non-vocoded conditions and with variable item presentations than fixed item presentations. Generalized additive mixed models analysis of pupil dilation over the time course of stimulus presentation showed that pupil dilation was significantly larger during fo+vtl discrimination while listening to untrained voices compared to trained voices, but only for vocoder-degraded speech. Peak pupil dilation was significantly larger for vocoded conditions compared to non-vocoded conditions and variable items increased the pupil baseline relative to fixed items, which could suggest a higher anticipated task difficulty. In this study, even though short voice training did not lead to improved sensitivity to small fo+vtl voice cue differences at the discrimination threshold level, voice training still resulted in reduced listening effort for discrimination among vocoded voice cues.

Unilateral Vocal Fold Paralysis and Voice Therapy: Predictors of Long-Term Quality of Life.

To date, little is known about the long-term predictors of quality of life (QoL) in unilateral vocal fold paralysis (UVFP). The main objective of this study was to evaluate the predictors of long-term QoL in UVFP patients submitted to voice therapy (VT) exclusively. Data from patients diagnosed with UVFP who followed a VT program between 2013 and 2019 were reviewed. Video laryngoscopy (VL) records were obtained at the beginning and at the end of VT. To assess QoL, Voice Handicap Index 30 (VHI-30) score was assessed in three temporal frames: before voice therapy (pre-VT), at the last VT session (post-VT), and in the present (cur-VHI). A longitudinal analysis was performed regarding the evolution of QoL and the factors influencing QoL through time were analyzed. Seventy-eight percent of patients had iatrogenic UVFP. The mean time of follow-up after VT was 3.942 years (range 6 months-7 years). There was a significant improvement in QoL through all time points (F (2,88)=72.179, p<0.001), with VHI-30 decrease from the baseline pre-VT to post-VT(p<0.001) and from post-VT to cur-VT (p=0.0013). In the iatrogenic UVFP population, patients starting VT earlier showed better long-term QoL (p=0.023). UVFP patients with dysphagia at presentation showed significantly worse QoL in the late follow-up (p=0.016). Hence, iatrogenic UVFP patients beginning VT rapidly may show better QoL in the future. Also, our results suggest that dysphagia at UVFP onset may predict higher morbidity later in life.

Effects of sensorimotor voice training on event-related potentials to pitch-shifted auditory feedback.

The pitch perturbation technique is a validated technique that has been used for over 30 years to understand how people control their voice. This technique involves altering a person's voice pitch in real-time while they produce a vowel (commonly, a prolonged /a/ sound). Although post-task changes in the voice have been observed in several studies (e.g., a change in mean fo across the duration of the experiment), the potential for using the pitch perturbation technique as a training tool for voice pitch regulation and/or modification has not been explored. The present study examined changes in event related potentials (ERPs) and voice pitch in three groups of subjects due to altered voice auditory feedback following a brief, four-day training period. Participants in the opposing group were trained to change their voice fo in the opposite direction of a pitch perturbation stimulus. Participants in the following group were trained to change their voice fo in the same direction as the pitch perturbation stimulus. Participants in the non-varying group did not voluntarily change their pitch, but instead were asked to hold their voice constant when they heard pitch perturbations. Results showed that all three types of training affected the ERPs and the voice pitch-shift response from pre-training to post-training (i.e., "hold your voice pitch steady" task; an indicator of voice pitch regulation). Across all training tasks, the N1 and P2 components of the ERPs occurred earlier, and the P2 component of the ERPs occurred with larger amplitude post-training. The voice responses also occurred earlier but with a smaller amplitude following training. These results demonstrate that participation in pitch-shifted auditory feedback tasks even for brief periods of time can modulate the automatic tendency to compensate for alterations in voice pitch feedback and has therapeutic potential.

The role of patient perceptions and hyperfunctional voice disorders in predicting voice therapy attendance

Objectives/hypothesisAttendance is essential to voice therapy's effectiveness in the treatment of voice and laryngeal disorders. With such high rates of drop-out and non-attendance, it is important to understand the factors that influence this behavior. This study sought to identify potential predictors of attendance to voice therapy at an interdisciplinary voice clinic. Study designSingle-institution retrospective cohort study. MethodsIn this retrospective cohort study, patients evaluated at an interdisciplinary voice clinic who received a referral for voice therapy were identified. Age, gender, voice-related diagnoses, Voice Handicap Index-10 scores, Reflux Symptom Index scores, and measures of patient perceptions (self-rated severity, importance of voice in one's life, and “feelings about voice therapy”) were recorded to evaluate associations with attendance to at least one therapy session. Standard statistical analysis and logistic regressions were performed. ResultsOf 168 subjects included, 111 (66.1 %) attended at least one session of voice therapy. Patients diagnosed with primary hyperfunctional voice disorders had a significantly higher attendance rate than other groups. Attenders had higher self-ratings of severity and more positive “feelings about voice therapy” compared to non-attenders. Regression models found three significant predictors of therapy attendance: primary diagnosis of hyperfunctional voice disorder, self-rated severity, and “feelings about voice therapy.” ConclusionIn this cohort, patients with more positive feelings about voice therapy, higher self-rated severity, and a diagnosis of primary hyperfunctional voice disorder were more likely to attend voice therapy. Level of evidence3.

Gender-affirming voice surgery: Pitch elevation

Voice and communication are a critical contributor to gender presentation. Various options are available for gender affirming voice care depending on the needs of the patient, and include hormone replacement therapy, voice therapy, and voice surgery. Despite a traditionally poor reputation, more recent literature has shown voice surgery, particularly anterior glottoplasty, to be a low risk and effective treatment for pitch elevation that may be considered as an adjunct to voice therapy. Voice and communication are a critical contributor to gender presentation. Various options are available for gender affirming voice care depending on the needs of the patient, and include hormone replacement therapy, voice therapy, and voice surgery. Despite a traditionally poor reputation, more recent literature has shown voice surgery, particularly anterior glottoplasty, to be a low risk and effective treatment for pitch elevation that may be considered as an adjunct to voice therapy.

Voice Hoarseness with Reflux as a Suspected Etiology: Incidence, Evaluation, Treatment, and Symptom Outcomes

PurposeTo describe the clinical evaluation course, treatments, and outcomes of patients with a primary complaint of hoarseness due to suspected laryngopharyngeal reflux (LPR). MethodsA retrospective chart review was conducted of patients with a primary complaint of hoarseness with acid reflux as the suspected cause at a single institution between October 2011 and March 2020 who underwent clinical evaluation, treatment, and follow-up. Data collected included diagnostic procedures and treatments received, subjective symptom outcomes, and final diagnosis as determined by the treating physician. ResultsA total of 134 patients met the inclusion criteria. Videostroboscopy was the most performed procedure (n = 59, 44%) followed by endoscopy (n = 38, 28%) and pH monitoring (n = 28, 21%). Three patients were removed for statistical analysis of treatment differences and outcomes due to variant treatment plans. Most patients received sole medical management (n = 86, 66%), 7 patients received only voice therapy (5%), and 10 patients underwent surgical management (8%). Several patients received combined medical management and voice therapy (n = 21, 16%). Final diagnoses included gastroesophageal reflux disease (GERD) (25%), followed by multifactorial causes (17%) and dysphonia with unclear etiology (13%). Among all patients, 82 (61%) reported symptom improvement. Twenty-eight patients were diagnosed with LPR or LPR with GERD (21%), and 22 reported symptom improvement (79%). There was a statistically significant relationship between a final diagnosis with a reflux component and symptom improvement (p = .038). There was no statistically significant difference between treatment types and symptom outcomes both within the total patient population (p = .051) and patients diagnosed with a reflux condition (p = .572). ConclusionLPR remains a difficult diagnosis to establish and represents a minority of patients with voice complaints. Despite varying evaluation and treatment modalities, most patients with LPR improved during their treatment and evaluation period without a clear association with any specific type of treatment. Further studies should explore diagnostic criteria for LPR, the necessary and efficient clinical evaluation to establish a diagnosis, and possible beneficial treatments.

Use of Botulinum Toxin in Spasmodic Dysphonia: A Review of Recent Studies.

Spasmodic dysphonia (SD), also known as laryngeal dystonia, is a neurological voice disorder that causes involuntary spasms of the vocal cord muscles. This impacts speech to varying degrees and results in strained and strangled voice quality, as in adductor spasmodic dysphonia, or weak, quiet, and breathy, as in abductor spasmodic dysphonia. While there is currently no cure for SD, voice therapy and chemodenervation with botulinum toxin (btx) injections remain the mainstay of management. Surgery may be performed in some cases; however, btx injections are widely used to treat both adductor and abductor forms of SD. While btx injections may show vocal improvement in both types of SD, results can depend on several factors such as the general health of the patient, onset and severity of the condition, dosage, interval between injections, and expertise of the practitioner. While many studies have documented the efficacy of btx for improving vocal symptoms in individuals with SD, this review aims to discuss some of those studies from the last 10 years.

The positive effects of online group singing on psycho-physiological variables during the COVID-19 pandemic-A pilot randomized controlled trial.

The psychological variables that were particularly influenced by social distancing during the COVID-19 pandemic-stress, loneliness, social participation, and well-being-correspond closely to variables that can also be influenced by music. The present study is a pilot randomized controlled trial examining the effects of online group singing on psycho-physiological variables during the pandemic. Over 4 weeks, an online singing group sang together once a week, for 1 h, under the guidance of a professional voice coach. In a first control group, participants also met for 60 min per week but only discussed and exchanged personal experiences about music. A second control condition consisted of a waiting list group. Across all variables studied (positive and negative affect, life satisfaction, stress, loneliness, social participation, self-efficacy, and body perception), positive effects were revealed in the singing group and in the discussion group, but not in the waiting list group. The effects of the variables self-efficacy, social participation, loneliness, and life satisfaction were markedly stronger in the singing group than in the discussion group. The results demonstrate the effectiveness of group singing on a number of psycho-physiological variables, which can be used profitably in and outside of times of crisis, in both clinical and non-clinical settings.

Patient Satisfaction and Acoustic Changes in Trans Women after Gender Affirming Voice Training.

Gains in pitch from gender affirming voice training (GVT) alone in trans women have historically been shown to decline after 1 year. Currently no standard exists for length and type of GVT that yields meaningful behavioral change and patient satisfaction with voice outcomes in trans women. This study aims to determine whether GVT alone leads to sustained pitch elevation and patient satisfaction in trans women. Retrospective review from 2016 to 2020 of trans women patients who underwent GVT alone for voice change. Charts were reviewed for acoustic analysis of pitch including sustained vowel fundamental frequency, speaking fundamental frequency, and quality of life data from the Trans Woman Voice Questionnaire at pre-therapy, immediate post-therapy, and extended post-therapy time intervals. A total of 157 patients presented to our Voice Center, of which 34 participated in the full course of GVT. Patients underwent an average of six sessions of GVT (range 5-7) over an average of 13.14 weeks (range 6-16). Average time between completing GVT and presenting for extended follow-up was 11.37 months (range 6-31). Compared to initial presentation prior to therapy, at extended follow-up after completing GVT average change in F0/a/, SF0, and TWVQ were 64.6 Hz, 31.3 Hz, and 32.45. No significant change was noted between immediate post-therapy and extended post-therapy acoustic measures. TWVQ demonstrated continued improvement between immediate post-therapy and extended post-therapy. In self-selected patients who present for extended follow-up, GVT alone can result in sustained pitch elevation and voice-related quality life in trans women. 4 Laryngoscope, 133:2340-2345, 2023.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis.

Telepractice program in voice therapy for primary school teachers: A Pilot study

Background: Teaching is an occupation where teachers consistently use their voices. However, excessive voice use causes voice disorders, especially in primary school teachers. Therefore, to prevent voice disorder problems in teachers during the COVID-19 pandemic, voice therapy using telepractice was adopted so that teachers would gain knowledge and know how to prevent voice disorders. Objectives: The main aim of this study was to develop and implement a pilot study on a telepractice program in voice therapy for primary school teachers. Materials and methods: Telepractice program for primary school teachers was designed from the literature review under the theory of voice therapy for those people with voice disorders. Five experts with more than five years’ experience in voice therapy tested the content validity, and five teachers undertook the entire program. Descriptive statistics were used to analyze the data. Results: The results of index of item-objective congruence (IOC) for content validity in Part 1 (program outline), Part 2 (program manual), Part 3 (telepractice videos), and Part 4 (telepractice program quizzes) were 0.8, 0.89, 0.88, and 0.87, respectively. The IOC of the entire telepractice program was found to be 0.86, which passed the criteria. The try-out phase resulted in teachers suggesting adjusting their participation time to after 6 pm. for more convenience. Other suggestions for using voice for online and onsite teaching during COVID-19 pandemic were also provided, e.g., voice level control while using a microphone, a headset, and a computer setting during online teaching. Conclusion: The pilot study of the telepractice program in voice therapy for primary school teachers passed the content validity test and try-out criteria for primary school teachers. Thus, the program could be used in voice therapy for teachers with voice disorders to eliminate program's efficiency in the next phase.

Acupuncture Combined with Voice Training Improved Voice Function in Patients with Primary Muscular Tension Dysphonia (MTD): A Randomized, Three‐Armed, Open‐Label Clinical Trial

Objective. This randomized controlled trial aimed to evaluate the clinical efficacy of acupuncture combined with voice training for treating patients with primary muscular tension dysphonia (MTD) (Qi stagnation and blood stasis type in traditional Chinese medicine). Methods. A total of 108 patients with primary MTD (Qi stagnation and blood stasis type) were recruited in this study. The participants were randomly divided into 3 equal groups: a test group and two control groups (control groups 1 and 2). An additional 38 participants without primary MTD were recruited as the healthy group. Control group 1 received acupuncture sessions 3 times per week on alternate days on the Hegu (LI 4), Taichong (LR 3), Open Voice No. 1 point, and Open Voice No. 2 points. Control group 2 received a 40‐minute voice training session once weekly. The test group received both treatments. The total treatment course for all groups was 30 days. The healthy participants did not receive any interventions. The physiological and functional voice improvements after treatment were compared between all 3 MTD groups and healthy participants. The Voice Handicap Index (VHI‐10), the VHI‐10 emotional score, the Chinese Medicine Symptom Score Scale (TCM), and the Grade Roughness Breathiness Asthenia Strain (GRBAS) were used to evaluate the changes in the voice after treatment. A laryngeal muscle blood oxygen monitoring was used to measure the blood oxygen saturation (SO2) of the suprahyoid and infrahyoid muscles, and a stroboscopic laryngoscopy was used to measure the dysphonia severity index (DSI). Acoustic voice analysis was used to measure the maximum phonation time (MPT), the jitter, and the shimmer. Result. The SO2 levels of the laryngeal muscle were significantly higher in the healthy subjects than in pretreatment MTD patients and were correlated with the VHI‐10 and DSI scores. A significant improvement in the physiological and functional scores, the total VHI‐10, the GRBAS score, the voice acoustic analysis indices, MPT, jitter, shimmer, and DSI, was noted after treatment in all 3 MTD groups (P &lt; 0.05). However, the posttreatment scores in the test group were significantly higher compared to control group 2, whose score were superior than that in control group 1 (P &lt; 0.05). Both the test group and control group 1 showed a significant increase in the SO2 levels of the laryngeal muscles after treatment, where the test group had a higher elevation than control group 1. No significant difference was noted in the posttreatment SO2 of the laryngeal muscles in control group 2 (P &gt; 0.05). Conclusion. Acupuncture monotherapy or in combination with voice training can reduce the anxiety emotion, relieve MTD‐associated systemic symptoms, and increase the SO2 levels of the laryngeal muscle. This combination is a promising approach for the treatment of MTD. This trial is registered with ChiCTR2200061469.

Pre- and Postoperative Voice Therapy for Benign Vocal Fold Lesions: An International Electronic Delphi Consensus Study

Voice therapy management of benign vocal fold lesions (BVFLs) is variable and there are currently no clinical guidelines. Poor descriptions of voice therapy interventions lead to unwarranted variation in treatment. Triangulation of the current evidence identifies a number of potential best practice elements, but also a number of outstanding questions to be explored. The aim of this study was to refine and gain global consensus on "best practice" for a pre- and postoperative voice therapy intervention for adults with BVFLs. An international sample of expert voice therapists (n=42) were recruited to take part in this three-round electronic modified Delphi study. Participants were presented with statements concerning a pre- and postoperative voice therapy intervention. Statements were developed from previous research and based on the TIDieR checklist (eg, why, when, what, how?) Participants rated the extent to which they agreed or disagreed with a statement and gave comments to support their response. Consensus was defined as >75% of participants agreeing or strongly agreeing with a given statement. If consensus was not reached, participant comments were used to generate new statements and were rated in the next round. Stability of consensus between rounds was assessed. The 42 international experts achieved consensus on 33 statements relating to components of a best practice pre- and postoperative voice therapy intervention for patients with BVFLs. Consensus on statements ranged from 81% to 100%. These statements were explicitly mapped to the TIDieR checklist to ensure that all aspects of the intervention were considered and the questions of "why, what, how, when and individual tailoring" were addressed. This study has significantly enhanced our understanding of what should be in a best practice pre- and postoperative voice therapy intervention. It is important to now test these findings for acceptability and feasibility, prior to considering effectiveness research.

Enhancing the Performance of Pathological Voice Quality Assessment System Through the Attention-Mechanism Based Neural Network

Doctors, nowadays, primarily use auditory-perceptual evaluation, such as the grade, roughness, breathiness, asthenia, and strain scale, to evaluate voice quality and determine the treatment. However, the results predicted by individual physicians often differ, because of subjective perceptions, and diagnosis time interval, if the patient's symptoms are hard to judge. Therefore, an accurate computerized pathological voice quality assessment system will improve the quality of assessment. This study proposes a self_attention-based system, with a deep learning technology, named self_attention-based bidirectional long-short term memory (SA BiLSTM). Different pitches [low, normal, high], and vowels [/a/, /i/, /u/], were added into the proposed model, to make it learn how professional doctors evaluate the grade, roughness, breathiness, asthenia, and strain scale, in a high dimension view. The experimental results showed that the proposed system provided higher performance than the baseline system. More specifically, the macro average of the F1 score, presented as decimal, was used to compare the accuracy of classification. The (G, R, and B) of the proposed system were (0.768±0.011, 0.820±0.009, and 0.815±0.009), which is higher than the baseline systems: deep neural network (0.395±0.010, 0.312±0.019, 0.321±0.014) and convolution neural network (0.421±0.052, 0.306±0.043, 0.3250±0.032) respectively. The proposed system, with SA BiLSTM, pitches, and vowels, provides a more accurate way to evaluate the voice. This will be helpful for clinical voice evaluations and will improve patients' benefits from voice therapy.

Voice therapy with a respiratory approach in older adults: the practice of Brazilian speech-language-hearing therapists

RESUMO Objetivo: investigar a prática de fonoaudiólogos brasileiros em terapia vocal para idosos com ênfase na respiração e verificar possíveis associações entre realização de cursos específicos e conhecimento sobre parâmetros respiratórios, entre o uso de incentivadores e dispositivos respiratórios e entre a idade e o uso destes instrumentos. Métodos: participaram 156 especialistas em voz, contatados via e-mail, que responderam um formulário na plataforma Google Forms. Foram incluídos especialistas em voz, com experiência maior ou igual a três anos e excluídos aqueles que não preencheram o questionário completamente. Analisaram-se frequências absolutas e relativas e a associação pelo teste Qui-quadrado, com significância de 5%. Resultados: a maioria realizou cursos com abordagem respiratória. Destacaram-se: uso de sons facilitadores, exercícios de função vocal e uso de instrumentos respiratórios, com relatos de melhora vocal. Houve associação entre o uso de incentivadores e dispositivos respiratórios e entre idade e o uso de instrumentos respiratórios. Conclusão: fonoaudiólogos experts em voz realizam terapia vocal para idosos disfônicos com ênfase na abordagem respiratória. Profissionais que usam incentivadores respiratórios usam também os dispositivos respiratórios. Aqueles com mais idade são os que mais utilizam instrumentos respiratórios. A realização de cursos específicos não está associada ao conhecimento sobre parâmetros respiratórios.