Voice Disorders Research Articles

Impact of Cultural-Linguistic Differences on Vocal Fatigue Perception: A Systematic Review and Meta-Analysis.

The perception of a clinical condition or disorder can vary across patients from different cultural-linguistic backgrounds. There is insufficient evidence to inspect this potential impact on the perception of vocal fatigue (VF) as a common condition perceived by patients with voice disorders. In order to more comprehensively explore this phenomenon, a systematic review was carried out to investigate the differences in perceived VF in a variety of cultural-linguistic contexts, based on a standard self-assessment instrument-the Vocal Fatigue Index (VFI), as translated in different languages. A thorough search was done in MEDLINE, CENTRAL, Web of Science, and Google Scholar by March 2024. Cross-sectional studies investigating the accuracy of the VFI to detect perceived VF in all available languages were considered. The VFI has three distinct parts or factors assessing: (a) tiredness of voice, (b) physical discomfort associated with voicing, and (c) improvement of symptoms with rest. The cutoff points and sensitivity and specificity of each factor were submitted to meta-analysis, and the summary receiver operating characteristic curves were used to determine pooled sensitivity and specificity of each factor of the VFI. Eight papers that examined the diagnostic accuracy of the VFI in English, Malayalam, Turkish, German, Mandarin Chinese, Polish, Cantonese, and Finnish languages were identified as being eligible for this meta-analysis. The pooled sensitivity and specificity along with their confidence intervals (CIs) were as follows: 0.91 CI [0.80, 0.96] and 0.88 CI [0.78, 0.94] for Factor 1, 0.83 CI [0.69, 0.91] and 0.84 CI [0.76, 0.89] for Factor 2, and 0.75 CI [0.67, 0.82] and 0.77 CI [0.59, 0.89] for Factor 3. The present research demonstrates medium to high but heterogeneous accuracy of the VFI for detecting perceived VF across cultural-linguistic contexts. Given the promising results, future studies should focus on (a) further investigating the underlying factors for the observed heterogeneity in diagnostic accuracy and (b) adapting and validating the VFI in more languages toward establishing its validity as a cross-linguistic diagnostic tool for the perception of VF. https://doi.org/10.23641/asha.26397106.

Reliability and Validity of the Turkish Version of the Screening Index for Voice Disorder (SIVD-TR)

ObjectivesWe investigated the reliability and validity of the Turkish version of the Screening Index for Voice Disorder (SIVD-TR). MethodsThe original Screening Index for Voice Disorder (SIVD)1 translated into Turkish, followed by a translation back into English by a linguist. The text was finalized by an evaluation committee. This translated version was then administered to a cohort of 223 teachers in Ankara, Turkey, encompassing both those with and without voice disorders (WVD and WOVD). After a duration of 7-14 days, a random selection of 53 teachers underwent the questionnaire once more. Statistical analyses were conducted to evaluate the reliability and validity of the index. Cronbach's alpha and test-retest methods were used to scale the reliability. A cutoff point was determined to decide the risk of a voice disorder, by using a receiver operating characteristic (ROC) curve. The validation process is concluded by computing sensitivity and specificity values, comparing mean scores between with and without voice disorders (WVD and WOVD) subjects, finally examining correlations between SIVD-TR and the Turkish version of the Voice Handicap Index (VHI-10). ResultsThe internal consistency reliability exhibited high significance, with Cronbach's alpha measuring at 0.872. The test-retest correlation coefficient for the total scores was 0.80. The SIVD-TR consists of 12 symptoms, each accounting for 1 point on the scale. The identified cutoff for identifying the risk of a voice disorder is 4 (four) symptoms, with a sensitivity of 55.2%. A correlation of 69% was observed between SIVD-TR and VHI-TR. A significant association was noted between the risk of having a voice disorder and the actual presence of a voice disorder. Subjects with a voice disorder exhibited higher mean SIVD scores, providing further evidence of the questionnaire's discriminative validity. ConclusionThe Turkish adaptation of SIVD demonstrated both reliability and validity, establishing itself as a robust tool for identifying voice disorders.

Prospective Teacher's Voice Questionnaire (PTVQ): Development of a Questionnaire to Assess Training-Related Voice Symptoms Among Prospective Teachers

AimTo develop and validate a self-administered population-specific survey, available in Spanish, Portuguese, and English, which investigates the prevalence of voice symptoms and perceptions of risk factors associated with training among prospective teachers. MethodsThe present study had three stages: The first stage included a literature review and content validation by experts that supported the survey development. From this phase, we defined six aspects of the PTVQ: (1) target population, (2) research objectives, (3) questions to be included, (5) scales for the answers, and (6) relevance, comprehensiveness, clarity and understandability of the questions. This process was performed in parallel for the three languages (Spanish, Portuguese, and English). The second stage included pilot testing. This involved administering the first draft of the survey to a group of 120 students to evaluate the feasibility and effectiveness of the survey instrument, identify any potential problems with the survey, and refine the instrument based on feedback from the pilot participants. The third stage includes the restructuring of the questionnaire's voice quality section to eliminate redundant questions. Through PCA, multicollinear variables were condensed, facilitating the removal of redundant items, and ensuring that the final questionnaire comprised only the most relevant and discriminative questions. Results and DiscussionThe final version of the survey, available in Spanish, Portuguese, and English, consists of four sections with a total of 57 questions. The development of the PTVQ represents a significant step toward better understanding and addressing voice disorders among prospective teachers. Future research could further refine the questionnaire and explore its predictive validity in identifying individuals at risk of voice disorders early in their teaching careers. Additionally, interventions based on the findings from the PTVQ could be developed to support the voice health and well-being of prospective teachers, ultimately improving teaching quality and job satisfaction in educational settings.

Analysis of 1782 Pediatric Hoarseness Cases: A Clinical Retrospect Study

ObjectiveThis study aims to clarify the clinical characteristics of pediatric voice disorders. MethodsThe clinical data of 1,782 pediatric patients presenting with voice disorders were retrospectively analyzed. These cases were categorized into four age-based cohorts: 0–3 years, 4–7 years, 8–11 years, and 12–15 years. Variables such as gender disparities, laryngoscopic manifestation, disease types, and acoustic parameters were thoroughly examined. ResultsA total of 1,782 children with acoustic hoarseness were included in this study, comprising 1,325 males and 457 females. When the sex ratio among the children in each group was compared, males were found to outnumber females. A notable male predominance was observed across all age groups.Laryngoscopic results revealed that the most prevalent condition was vocal cord nodules (1,363 cases, 76.48%), followed by vocal cord polyps (271 cases, 15.20%). Other diseases included laryngeal papillomas, vocal fold movement impairment, vocal cord cysts, functional dysphonia, leukoplakia of the vocal cords, and benign laryngeal tumors such as laryngeal amyloidosis and subglottic granular cell tumors. Among these, adenoid hypertrophy was presented in 382 children (21.44%). Additionally, the Reflux Finding Score (RFS) was conducted, and 799 cases (44.83%) were found to have a score above 7.The distribution of various diseases across different age groups indicated that children with vocal cord nodules (637 cases, 46.74%), vocal cord polyps (109 cases, 40.22%), and laryngeal papillomas (35, 36.84%) were predominantly found in the 4–7 years age group. Pediatric acute laryngitis (3 cases, 75%) and vocal fold movement impairment (8 cases, 36.36%) were more common in the 0–3 years age group. Functional dysphonia (4 cases, 66.67%) and vocal cord leukoplakia (4 cases, 80%) were mainly observed in the 12–15 years age group, while vocal cord cysts were predominantly seen in the 8–11 years age group (4 cases, 57.14%).A comparative analysis of acoustic parameters among 153 children showed statistically significant differences in jitter, fundamental frequency (F0), voice handicap index (VHI), reflux symptom index (RSI), and reflux finding score (RFS) across different pathologies. ConclusionThis study highlighted that vocal cord nodules, vocal cord polyps, and laryngeal papillomas were the primary causes of pediatric hoarseness, although the possibility of tumors and rare diseases cannot be disregarded. There was a noticeable gender bias towards males, and functional dysphonia was significantly more prevalent in older children.

Current Practices in the Assessment of Voice: A Comparison of Providers Across Different Clinical Settings

ObjectiveTo investigate the current assessment practices of speech-language pathologists (SLPs) in the United States working with adult clients with voice disorders with regard to the frequency, utility, and confidence in the use of the five elements of a comprehensive voice evaluation, as well as training, access to instrumentation, and the use of published scales. MethodsAn online survey was distributed to SLPs who currently see adults with dysphonia as part of their caseload. Clinicians in a voice-focused setting were compared to those who worked in a general medical setting. ResultsNearly all of the 86 participants reported using published validated scales for patient self-assessment and auditory-perceptual ratings. Most respondents had received training in auditory-perceptual voice assessment, acoustic assessment, and videostroboscopy, but a minority reported training in aerodynamic assessment. The majority of SLPs had access to acoustic equipment but a minority had access to the instrumentation for videostroboscopic or aerodynamic assessment. Auditory-perceptual voice evaluation was the procedure most commonly performed and most highly rated for diagnostic utility. Post-graduate training and access to instrumentation were associated with significantly higher frequency of use and confidence with all three instrumental assessment methods. SLPs in voice-focused settings were more likely to have received training in videostroboscopy and perform or interpret it. SLPs in voice-focused settings were also significantly more likely to have access to equipment for all three instrumental techniques and reported significantly higher confidence in their use. Both groups rated the utility of the different components of a voice evaluation similarly and there were no significant differences between the groups in the use of validated patient questionnaires or auditory-perceptual scales. ConclusionsMost clinicians in our survey reported following practice guidelines when performing comprehensive voice evaluations across settings despite barriers of training and access to instrumentation.

Asymmetric triangular body-cover model of the vocal folds with bilateral intrinsic muscle activation.

Many voice disorders are linked to imbalanced muscle activity and known to exhibit asymmetric vocal fold vibration. However, the relation between imbalanced muscle activation and asymmetric vocal fold vibration is not well understood. This study introduces an asymmetric triangular body-cover model of the vocal folds, controlled by the activation of bilateral intrinsic laryngeal muscles, to investigate the effects of muscle imbalance on vocal fold oscillation. Various scenarios were considered, encompassing imbalance in individual muscles and muscle pairs, as well as accounting for asymmetry in lumped element parameters. Measurements of amplitude and phase asymmetries were employed to match the oscillatory behavior of two pathological cases: unilateral paralysis and muscle tension dysphonia. The resulting simulations exhibit muscle imbalance consistent with expectations in the composition of these voice disorders, yielding asymmetries exceeding 30% for paralysis and below 5% for dysphonia. This underscores the relevance of muscle imbalance in representing phonatory scenarios and its potential for characterizing asymmetry in vocal fold vibration.

Normative Values for the Children Voice Handicap Index-10 (CVHI-10) and for the Children Voice Handicap Index-10 for Parents (CVHI-10-P)

ObjectivesThe objective of this study was to establish normative data and cut-off scores for the Children Voice Handicap Index-10 (CVHI-10) and the Children Voice Handicap Index-10 for Parents (CVHI-10-P) MethodsFor normative data, CVHI-10 and CVHI-10-P questionnaires originally developed in the Italian language were completed by 201 children without dysphonia and with no history of voice disorders, and by one of their parents. The results were analyzed for mean, standard deviation (SD), and standard error of the mean (SEM) for both questionnaires. For cutoff values determination, data from 49 dysphonic children and from one of their parents were also used. This analysis was based on the sensitivity and specificity indicators of the questionnaires using the ‘‘receiver operating characteristic’’ (ROC) curve. ResultsAnalysis of the questionnaires related to healthy children revealed a mean of 0.26 (SD 0.74; SEM 0.06) for CVHI-10 and a mean of 0.15 (SD 0.49; SEM 0.04) for CVHI-10-P for the normative values. ROC curve analysis allowed us to establish the cutoff scores of 2.5 for CVHI-10 and 1.5 for CVHI-10-P. ConclusionsThis study offers normative data for CVHI-10 and CVHI-10-P and provides cutoff values for both questionnaires to distinguish healthy and pathologic responders.

Voice Disorder Prevalence and Vocal Health Characteristics in Adolescents

Voice disorders impede communication and detract from quality of life, yet little is known about how voice problems present in adolescents. This study characterized the prevalence of voice problems and vocal health characteristics of adolescents throughout the US. To determine the prevalence of adolescent voice problems in the US as well as the symptoms, voice use patterns, and risk factors associated with these problems. This prospectively performed, cross-sectional survey study conducted from March to June 2023 included a probability sample of adolescents (aged 13-17 years) who were located across the US. Adolescents were surveyed concerning voice use, voice symptoms, demographic information, and substance use patterns. The Vocal Fatigue Index (VFI) was also completed. Fisher exact tests, χ2 tests, and logistic regression were used to compare those with and without reported voice problems. Five-hundred and two adolescents participated (51.6% participation rate), including 248 female (49.4%), 7 nonbinary (1.3%), 254 male (50.6%), 4 transfemale (0.7%), and 3 transmale individuals (0.5%) (mean [SD] age, 15.2 [1.3] years). The lifetime prevalence of voice problems was 24.3%, and current prevalence was 7.4%. Voice-related diagnoses included dysphonia associated with acute illness, vocal hyperfunction, benign lesions, and muscle tension. The mean (SD) VFI score was 4.7 (8.09) for part 1, 1.6 (3.2) for part 2, and 2.1 (3.2) for part 3. Adolescents with voice complaints presented with significantly higher VFI scores than those without voice problems (Cohen d for part 1 = 0.78, part 2 = 0.59, and part 3 = 0.79). Voice problems interfered with daily tasks, prevented participation in extracurricular activities, limited the ability to sing, and were associated with school absences. Voice use patterns associated with voice problems included frequent loud voice use, coughing, and/or throat clearing. Risk factors for increased voice problem prevalence included part-time employment in childcare (odds ratio [OR], 6.4; 95% CI, 1.6-26.3), singing (OR, 2.08; 95% CI, 1.3-3.1), performance-related extracurricular activities (ie, musical theater [OR, 2.67; 95% CI, 1.1-6.6 ], karaoke [OR, 3.08; 95% CI, 1.3-6.9]), vaping (OR, 1.99; 95% CI, 1.1-3.5), and/or secondhand smoke exposure (OR, 1.83; 95% CI, 1.2-2.7). Adolescents identifying as transgender were more than 4 times (OR, 4.44; 95% CI, 0.63-31.2) as likely to report voice problems compared with cisgender adolescents. The results of this survey study illuminate the nature of voice problems in adolescents and may guide clinicians in preventing and treating voice disorders in this population. Future work may define the mechanisms through which these factors are associated with the risk for voice disorders in adolescents and determine whether observed relationships are causal or associative.

Exploring Biomechanical Correlates in Voice Analysis of Multiple Sclerosis Patients.

The predominant alterations in voice of patients with multiple sclerosis (MS) are phonatory instability, vocal asthenia and roughness, shortness of breath, hypophonia, and hypernasality. However, research on alterations of acoustic parameters has few studies and disparate results. The objective of this study was to investigate voice disturbances in patients with MS, both with objective measures (analysis of biomechanical) and subjective measures (scales and questionnaires). This is an experimental study with a total of 20 participants with MS. Voice samples were collected, and biomechanical correlates were analyzed through the Clinical Voice Systems program, Online Lab App. The VHI-30 (Voice Handicap Index) questionnaire, the GRBAS (grade, roughness, breathiness, asthenia, strain) scale, and the Hospital Anxiety and Depression Scale were used as subjective measures. Ninety-five percentages of participants feel and describe dysphonic difficulties. Self-perception of vocal disability correlated with auditory vocal perceptual analysis in the sample of women. The biomechanical parameters showed alterations in the strength of the glottic closure, the efficiency index, and the structural imbalance index.

Validity and Reliability of the German Vocal Fatigue Index in Adults With Voice Disorders.

Vocal fatigue-related symptoms, frequent in patients with voice disorders, are reliably quantifiable with the Vocal Fatigue Index (VFI) in several languages. The main aim of this work was to investigate the content and construct validity of the German Vocal Fatigue Index (VFI-D) by comparison with the German Voice Handicap Index 9 international (VHI9i) and the Vocal Tract Discomfort Scale (VTD). Moreover, the scale and retest reliability were investigated. In a prospective cohort study at two tertiary care hospitals, 93 adults with all types of voice complaints filled out the VFI-D, the VHI-9i, and the VTD. Eighty-one adults (Mage = 53.5 years, SD = 15.7) completed them one time, and additional 12 patients (Mage = 53.8 years, SD = 15.6) did a test-retest, completed them twice at an interval of 1 week. The validity was assessed by Spearman's rho and Mokken scaling and the reliability by a factor analysis and a two-tailed t test. Mokken scaling has proven the VFI-D as one-dimensional questionnaire (one cluster, r = .95). All VFI-D items could be assigned to one of three factors according to principal component and principal axis factor analysis. Although Factor 1 related best to the VHI9i (∅ rs = .76) and Factor 2 to the VTD (∅ rs = .74), Factor 3 correlated moderately with the VHI9i (rs = .34) and weakly with the VTD (rs = .25). Results from the first and second VFI-D completion agreed strongly (t = -1.78, p = .10). In this study, the content and construct validity of the VFI-D were confirmed. Also, both scale reliability with identical factors as those in the original study and retest reliability were verified. The VHI9i and VTD were highly indicative of VFI-D Factors 1 and 2, respectively. No correlation between Factor 3 and the other questionnaires was determined. Future research should evaluate which characteristics are specific to vocal fatigue versus general voice disorder-related symptoms.

Assessing the Impact of Novafon Local Vibration Voice Therapy on Voice Disorders: A Comprehensive Review

Assessing the Impact of Novafon Local Vibration Voice Therapy on Voice Disorders: A Comprehensive Review

Screening of voice and vocal tract changes in professional wind instrument players

PurposePlaying wind instruments is a strenuous task on the larynx, predisposing players to voice disorders. This study aims to evaluate potential vocal symptoms and vocal tract alterations in professional wind instrumentalists.MethodsIn this cross-sectional study, 26 male military subjects were interviewed, completed the voice handicap index (VHI) -10 questionnaire, and subjected to auditory-perceptual assessment, neck examination, rigid laryngostroboscopy and flexible nasofiberoscopy both before and during instrument playing.ResultsAll participants had vocal fatigue symptoms, around one-quarter complained of voice change, one-quarter complained of shortness of breath while or after performing, and one-third complained of neck symptoms. The average score of VHI-10 was 16.2 ± 6.5, and approximately three-quarters of participants scored above the cut-off point. There were no significant correlations between age, years of instrument playing, average hours of daily practice, and VHI-10. Participants with neck symptoms had significantly higher VHI-10 scores. Those (around one-fifth) with an external neck swelling during Valsalva maneuver had a significantly higher VHI-10 score. Dysphonia, mainly mild and of strained, leaky quality, was detected in almost one-third of participants. While the instrument was being played, the vocal folds were somewhat adducted, and the vocal tract became more compressed as the task became more demanding. The most frequent observations in the vocal tract examination were hyperemia of the vocal folds or all over the laryngeal and pharyngeal mucosa, excessive secretions over the vocal folds, signs of hyperadduction, arytenoid edema, and phonatory waste.ConclusionWind instrumentalists frequently experience voice disorders, which necessitate further care and investigation.

Wearable Voice Dosimetry System

The objective quantification of voice acoustic parameters is used for the diagnosis, monitoring, and treatment of voice disorders. Such assessments are carried out with specialised equipment within the doctor’s office. The controlled conditions employed are usually not those of the real environment of the patient. The results, although very informative, are specific to those measurement conditions and to the time when they were performed. A wearable voice monitoring system, based on an accelerometer to ensure the message, can overcome these limitations. We present a miniaturised, low-power, and low-cost wearable system to estimate and record voice fundamental frequency (F0), intensity and phonation time for long intervals in the everyday environment of the patient. It was tested on two subjects for up to two weeks of recording time. It was possible to identify distinct periods in vocal activity, such as normal, professional, demanding or hyperfunctional. It provided information on the workload that the vocal cords needed to cope with over time and when and to what extent that workload was concentrated. The proposed voice dosimetry system enables the extraction and recording of voice parameters for long periods of time in the everyday environment of the patient, allowing the objectification of vocal risk situations and personalised treatment and monitoring.

Adaptation and Validation of the Persian Version of the Voice Handicap Index-10 (VHI-10)

ObjectivesVoice disorders can profoundly impact health, quality of life, job performance, and social interactions. Traditional evaluations have expanded to include quality-of-life assessments, emphasizing self-reported outcomes. The Voice Handicap Index (VHI) stands out among relevant questionnaires, with the VHI-10 being a concise derivative. This study was conducted to translate and validate the Voice Handicap Index-10 (VHI-10) questionnaire for Persian speakers, enhancing clinical assessments of voice disorders and quality of life. MethodsThis cross-sectional study, conducted in Iran, involved (1) translating the VHI-10 into Persian, (2) confirming face and content validity using Content Validity Ratio (CVR), and Content Validity Index (CVI), and (3) evaluating its reliability through a survey. A panel of experts confirmed the validity, and reliability of the study, which was assessed using Cronbach's alpha, Spearman-Brown, and Guttman coefficients. The survey involved 225 participants, including 150 healthy people and 75 patients with voice disorders, who were selected using a convenience sampling method. ResultsAll question items demonstrated a CVI greater than 0.79 and a CVR between 0.62 and 1. Reliability analysis yielded high Cronbach's alpha values for functional, physical, and emotional domains (0.909) and total (0.961). The mean overall scores of VHI-10 for healthy and disordered groups were 18.78 and 0.74, respectively. The VHI-10 effectively discriminated between healthy and disordered groups in all domains, with an accuracy of 97.33%. The determined cut-off point was 4.5, with a strong area under the ROC curve (0.989). ConclusionThis study successfully adapted and validated the Persian version of the VHI-10. The questionnaire demonstrated high reliability and validity, distinguishing between individuals with and without voice disorders. This Persian version is now a valuable tool for speech and language pathologists conducting clinical voice evaluations in Iran and also it could be applied in studies to determine the effects of voice problems on participant's quality of life.

From the Expert's Office: Voice disorders after COVID withoutintubation or tracheostomy - fact or fiction?

From the Expert's Office: Voice disorders after COVID withoutintubation or tracheostomy - fact or fiction?

Trust Development Between Speech-Language Pathologists and Laryngologists: A Thematic Analysis

ObjectivesSpeech language pathologists (SLPs) and laryngologists often work closely in interdisciplinary settings evaluating and treating patients with voice, swallowing, and airway disorders. This collaboration is integral to providing optimum patient care. We theorize that trust is an essential component of this relationship and contributes to effective patient care and professional satisfaction. There is currently no literature that explores the development and role of trust in this unique interprofessional relationship. We aim to explore the SLP and laryngologist interprofessional relationship and the development and role of trust in that relationship. Study DesignQualitative Realist Thematic Analysis MethodsThematic analysis of semi-structured qualitative interviews was performed to explore the relationship between SLPs and laryngologists. Through purposive sampling from November 2022 – January 2023, we recruited SLPs (n=10) and laryngologists (n=10) from 12 centers with varying years of practice, practice setting (academic or private), geographic location, and team structures. ResultsTrust between SLPs and laryngologists is comprised of confidence in 1) ability (clinical judgment, technical skill), 2) benevolence, and 3) integrity. Trust formation is enhanced by frequency and quality of communication, physical proximity, and reduction of practical barriers (scheduling, billing, departmental structure). Role negotiation was not identified as a factor. The presence of all three components of trust contributes to job satisfaction, perceptions of patient experience and care outcomes, and the willingness to collaborate in academic areas beyond clinical care. ConclusionsAll three elements (ability, benevolence, integrity) must be present for trust in an interprofessional relationship between SLPs and laryngologists, and formation of trust is facilitated by robust communication, physical proximity, and reduction of practical barriers to collaboration. The lack of these elements and lack of trust between the two professions can negatively impact collaboration, job satisfaction, and patient care outcomes, contributing to inefficiencies in patient care.

Speak Up for Teachers Health: The Importance of Vocal Care in Education Settings

This article reviews the elevated prevalence and complex nature of voice complaints among teachers, highlighting their profound impact on students’ academic performance, teachers’ well-being, and overall school productivity. The text discusses the significance of teachers as occupational voice users, provides statistics on the prevalence, summarizes work-related factors and occupational policy contributing to the issue, and presents a comprehensive approach to intervention. This article facilitates recognizing and addressing work-related voice disorders among teachers while enhancing communication between educators and healthcare professionals.

Connecting Auditory-Perceptual Prompts Used in Voice Therapy to Anatomy and Physiology: Application to the Estill Voice Model and the Rehabilitation Treatment Specification System

PurposeThis clinical tutorial will present the concept of applying auditory-perceptual prompts (implicit instruction) typically used in voice therapy to anatomy and physiology of the voice production system (explicit instruction) via the Estill Voice Model (EVM) and the Rehabilitation Treatment Specification System (RTSS). MethodsEVM offers an integrated implicit-explicit instructional approach to voice training allowing for isolated practice of vocal structures (explicit) that interact to produce functional voice qualities (implicit) such as modal speech and louder projected voice qualities. In EVM, voice quality is correlated with the specific anatomy and physiologic adjustments via 13 Estill Figures and options (e.g., Larynx Figure has three options: High, Mid, and Low). RTSS provides a framework to connect client change in functioning (i.e., target) with clinician action (i.e., ingredients). Mechanisms of action connect the target to the ingredients by hypothesizing how the treatment is expected to work. ResultsEvidence is provided for connecting auditory-perpetual voice prompts with anatomy and physiology of voice and supporting an integrated implicit-explicit approach to voice therapy. The concept of linking commonly used implicit auditory-perceptual prompts used in voice therapy (e.g., humming, loud “aahh”) to explicit anatomy and physiology training (e.g., 13 Estill Figures and options) is demonstrated using EVM and the RTSS framework with case studies and video examples. ConclusionsClinicians may choose to use anatomy and physiology of voice to define and provide explicit instruction for typically used implicit auditory-perceptual prompts. Future research is warranted to test the concept applied to voice therapy models in the literature across prevention and treatment of voice disorders.

Integrating Psychotherapy in the Treatment of Functional Voice Disorders: Addressing the Role of Morbid Gain

Integrating Psychotherapy in the Treatment of Functional Voice Disorders: Addressing the Role of Morbid Gain

Phonation threshold pressure in inspiratory vs expiratory phonation

Inspiratory or reverse phonation refers to the production of voice when air is inhaled from the mouth and nostrils into the lungs. This way of phonation occurs naturally during laughter, sighs, and crying [1]. It has also been used to achieve special vocal effects by singers, shamans, and ventriloquists, and is common in the vocalizations of other mammals and birds. Furthermore, it is a useful treatment exercise in voice therapy for several voice disorders [2]. However, despite its relevance, few physical studies of inspiratory phonation have been conducted, and its underlying physics still needs further clarification.