Toward a more quantitative measure to assess severity of dysphonia: preliminary observations

Rating scales to determine the severity of dysphonia have shown considerable inter-rater variability. The objective of this study, therefore, was to investigate a more quantitative measure to perceptually rate the severity of dysphonia. The study was conducted on 10 participants with abuse-related dysphonia in two conditions, spontaneous speech, and paragraph reading. Four speech-language pathologists, who had experience with voice disorders, and one trained student counted the frequency of the nondysphonic syllables during the above two conditions. The voice samples were both recorded and transcribed for simultaneous analysis. All the recordings were randomized when presented to the raters. The raters circled the nondysphonic syllables while listening to each participant's recording. The nondysphonic syllables were counted, and a percentage of dysphonic severity was calculated for each participant to obtain a dysphonic severity percentage. Specific characteristics (eg, breathiness, noise, strain) were not specifically addressed, as they were components of the percentage of dysphonia obtained. The Cronbach's alpha revealed very high inter-rater reliability and high correlations among the raters for both spontaneous speech and paragraph reading, indicating reduced variability in raters' perceptions. This method appeared to be a more quantitative measure of perceptual ratings than current scales, which use general gradations of dysphonic severity. In addition, a naïve rater was successfully trained to use this method. This technique has the potential to be used in both pre- and posttherapy analysis, as well as during therapy, to determine progress.

Exploring genetic and environmental effects in dysphonia: a twin study

PURPOSE

To explore the existence of genetic effects as well as the interaction between potential genetic effects and a voice-demanding occupation on dysphonia.

METHOD

One thousand seven hundred and twenty-eight Finnish twins (555 male; 1,173 female) born between 1961 and 1989 completed a questionnaire concerning vocal symptoms and occupation. The zygosity determination resulted in 125 monozygotic and 108 dizygotic full twin pairs. A composite variable called dysphonia was formed by summing 6 vocal symptoms based on the results of a factor analysis. Twin model fitting was used to explore the contribution of genetic and environmental effects on the dysphonia variable.

RESULTS

Individual differences in dysphonia were explained by genetic effects (35%) and nonshared environmental effects (65%). Shared environmental effects were estimated at 0%. Also, the authors found that for the participants who worked in voice-demanding occupations, the causes of dysphonia were more environmental, whereas the etiology of the symptoms was more strongly affected by genes in the participants with less voice-demanding occupations. However, this gene-environment interaction was not statistically significant.

CONCLUSION

Both genetic and environmental factors have an impact on the etiology of voice problems. Environmental factors, either independently or interacting with genetic factors, seem to play the key role, especially if the person has a voice-demanding occupation.

Ehlers-Danlos syndrome presenting as dysphonia and manifesting as tongue hypermobility: Report of 2 cases

Ehlers-Danlos syndrome (EDS) comprises a group of related hereditary connective tissue diseases. EDS manifests as joint hypermobility, tissue elasticity, and easy bruising. Although affected patients typically present to primary care physicians, orthopedists, and rheumatologists, some head and neck symptoms (e.g., dysphonia, dysphagia, and/or temporomandibular joint complaints) may direct some to an otolaryngologist. We describe the cases of 2 patients who presented to our otolaryngology clinic for evaluation of dysphonia. On physical examination, both exhibited tongue hypermobility, and both were subsequently diagnosed with EDS. We also review the results of our comprehensive literature search, in which we found only 3 articles that specifically described tongue hypermobility; in each case, the hypermobility was related to EDS. Finally, we discuss presentations of EDS that otolaryngologists might encounter.

Usefulness of assessment of voice capabilities in female patients with reflux-related dysphonia

OBJECTIVES

To analyze vocal capabilities in patients diagnosed with reflux related dysphonia versus controls with healthy voice with selection of the most informative discriminating quantitative parameters and to assess voice changes following treatment.

MATERIAL AND METHODS

Six parameters of voice range profile (VRP) and five parameters of speech range profile were taken and analyzed from 60 dysphonic outpatient females with laryngopharyngeal reflux (LPR) diagnosed by reflux-related atypical and typical symptoms, videolaryngoscopic findings, upper gastrointestinal endoscopy, and positive response to empiric 3-month omeprazole treatment. Seventy-six females with healthy voice served as controls.

RESULTS

All six parameters of voice range profile and three of 5 parameters of speech range profile showed significant differences comparing LPR patients with controls before omeprazole treatment (P<0.05). Logistic regression analysis revealed VRP maximum-minimum intensity range to be the most informative parameter for discrimination between reflux-related dysphonic and healthy voices (overall prediction accuracy, 86.8%). A threshold value of significant parameter was stated using the receiver operating characteristic curve. Treatment with omeprazole significantly improved voice quality showing the greatest changes in the mean scores of majority of voice range profile parameters.

CONCLUSIONS

Vocal capabilities, especially evaluated by voice range profile, are restricted in LPR female patients in comparison to subjects with healthy voice. Quantitative voice assessment with voice range profile may add more objective aspect for screening dysphonia and could be used as a criterion of evaluation of treatment efficacy in such patients.

Electroglottography in the follow-up of bilateral vocal fold palsy

Electroglottography in the follow-up of bilateral vocal fold palsy.

OBJECTIVES

The aim of the study was to determine if electroglottography provides useful information concerning vocal perturbations within the glottis in the follow-up of patients with bilateral vocal fold palsy.

METHODOLOGY

Electroglottography was performed in 8 patients with bilateral vocal fold palsy (aged 43-77 years; mean, 62.6; standard deviation, 3.8; median, 66) and 8 healthy age-matched controls. Percent (%) irregularity, jitter, and shimmer were calculated by Speech Studio. The patients' severity of dysphonia was rated by experts on a four-point scale.

RESULTS

Percent irregularity was significantly higher in patients with vocal cord palsy than in controls (p < 0.05). There was strong correlation between percent irregularity, jitter, and shimmer, and perceptual degree of dysphonia in all examinations during 6-month follow-up.

CONCLUSIONS

Electroglottographic recordings can give an objective measure of glottal disturbances in patients with bilateral vocal fold palsy. It is possible to track improvement in vocal fold contact due to return of vocal fold mobility and functional compensation in consecutive examinations. Percent irregularity, jitter, and shimmer adequately represent changes in glottal function in individuals with bilateral vocal fold palsy during 6-month follow-up.

Dysphonia, dysphagia, and esophageal injuries after anterior cervical spine surgery

Anterior cervical spine surgery is commonly used by spine surgeons to treat numerous pathologic entities. The most common procedures involve decompression of the cervical spine through either diskectomy or corpectomy. Procedures that involve anterior dissection of the neck can lead to various complications, including dysphonia, dysphagia, and esophageal injuries.

An unusual cause of dysphonia: laryngeal verruca vulgaris

PROBLEMS/OBJECTIVES

Verruca vulgaris of the larynx (VVL) is an uncommon lesion with clinical and histopathological features that are easily misdiagnosed as verrucous carcinoma, and thus may lead to unnecessary surgery. This case study investigated clinical and pathological features that might distinguish VVL from other keratotic laryngeal lesions.

METHODOLOGY

A 35-year-old man presented with a 3-month history of progressive hoarseness and superficial, keratotic, vocal cord lesions. The verrucoid configuration of the surface and lack of nuclear atypia enabled treatment by local excision. The biopsied lesion was sectioned and examined by immunohistochemistry, and in situ hybridization.

RESULTS

The patient was disease-free up to 1 year and 6 months after surgery. The exophytic, keratotic lesions of the larynx had features of cutaneous verruca vulgaris. No human papilloma virus was detected.

CONCLUSIONS

We described histopathological features of VVL that will facilitate its distinction from laryngeal keratosis, squamous papillomas, verrucous hyperplasia, and verrucous carcinoma.

[The smokers voice self assessment based on Voice Handicap Index (VHI)]

Complex voice assessment due to European Laryngeal Society proposals (2000) contains voice self estimation based on the Polish version of the Voice Handicap Index (VHI). This study focuses on the relation between voice handicap and smoking in dysphonic patients, who are using voice professionally. Thirty outpatient (25 female and 5 male, aged 40 to 55 years) voice department attendees suffering from professional dysphonia took part in this study. All patients after phoniatric examination completed the Polish version of the Voice Handicap Index (VHI). The questions concern functional, emotional and physical complains due to dysphonia. Most of smokers did not complain of dysphonia related problems comparing to non smokers. Even the scores of functional and emotional scales of VHI in smokers shown better results (less handicap) than in nonsmokers. Smoking does not affect patients handicap due to dysphonia measured in the Voice Handicap Index.

[Glomus tumor with diplopia]

This paper highlights the case of a 46-year-old female patient who seeks ophthalmic medical advice for her complaint about double vision on right gaze. Patient's medical history reveals several symptoms like headaches, progressive hearing loss on right side and dysphonia for which all investigations proved irrelevant. Thourough clinical examination, lab exams and imaging techniques revealed the cause for this symptoms i.e. glomic tumour with middle ear extention. We find this case to be exceptional as ocular symptoms led to the diagnose of a non-ocular serious, possible life threatening condition, bearing in mind that previously occured non-ocular symptoms couldn't elucidate the cause.

Voice Change Following Thyroid and Parathyroid Surgery

Voice complications following thyroid and parathyroid procedures have long been recognized in the literature. However, there is little clear data on the nature, severity, and duration of any changes. No single previous study has comprehensively addressed the multiple issues involved. Most studies have been retrospective, preventing control over extraneous variables, or are small prospective studies using limited assessment measures. Emphasis has been on damage (paralysis) to the recurrent laryngeal nerve (RLN). The effects of surgery on the more subtle (but equally important) aspects of voice disorders have received little attention. This prospective study of 67 participants used multidimensional voice outcomes measures to assess changes in voice following thyroid and parathyroid surgery. Strict exclusion criteria minimized the effects of extraneous variables. Participants were assessed preoperatively to establish a baseline and at least twice more postoperatively. Generally speaking, the patient vocal performance and expert perceptual rating data suggest an incidence of 0% for all operation types. Mild changes at the early postoperative stages had settled in all cases by the 3-month postoperative assessment. Videostroboscopic evaluation revealed an interesting picture of six patients who appeared to have improved vocal function postsurgery, 15 patients who showed signs of neurological damage at their first postoperative examination, and only five "permanent" RLN paralyses at 12 months postsurgery. The potential for improvement in voice quality postsurgery has not previously been reported in the literature as far as we are aware. Symptoms consistent with RLN and superior laryngeal nerve palsy were present both pre- and postoperatively. Apparent nerve damage did not necessarily result in dysphonia. The potential for undiagnosed nerve damage preoperatively has rarely been reported in the literature. These results may have medico-legal implications, in addition to influencing surgical risk management and informed patient consent.

A longitudinal study of voice before and after phonosurgery for removal of a polyp

The aim of the present investigation was to evaluate the acoustic parameters, perceptual estimation, and self-estimation of voice before, 1 month after, and 6 years after surgical removal of a vocal fold polyp. Subjects were five male patients who came to the Phoniatric Clinic because of breathiness. For all patients, a polyp of one vocal fold was diagnosed. The operation was performed using cold instruments based on the principles of contemporary phonosurgery aiming maximally at preserving the phonatory bridge of the vocal fold. The subjects were recorded in a sound-proof booth three times: before surgery, 1 month post-, and 6 years post-operation. The patients read a short tale and they pronounced a sustained vowel /a/. The following variables were measured: clinical (the distance of the polyp from the anterior commissure, the width of the polyp base and the size of the polyp), and acoustic (F0, jitter, shimmer, harmonic-to-noise ratio, voice turbulence index, degree of voice breaks, and long-term average spectrum). Acoustic variables were measured using the program Praat, while the estimation of voice quality was completed using the GRBAS scale and self-estimation questionnaire of the voice quality, which were answered by the patients. The results showed significant improvement in the variables investigated and improved patients satisfaction with their vocal health after the surgery.

[Orthodontics, orthognatic surgery and their functional environment]

Dento-dental and dento-maxillary dysharmonies and maxillo-mandibular dysmorphologies are impairments that can be treated either by orthodontics and surgery, or with a combination of orthodontics and orthognatic surgery. Respiration, deglutition, phonation and succion play a predominant role in the occurrence of maxillofacial dysmorphologies. Contributing factors to such impairments include upper airway function disorders such as respiration, deglutition, phonation, sucking. Abnormal functions must be extensively studied in management of maxillofacial patients in order to achieve stable results and to avoid relapses.

[Rehabilitation of voice at paralytic dysphonia--case report]

Paralytic dysphonia is a voice disorder created as a result of neurogenic injury of the neuromuscular larynx organ, owing to the laryngeal nerves paralysis or paresis. It is of the most serious voice producing larynx organ lesions. The paper presents the case of 53-year-old patient with a total neurogenic traumatic left vocal cord paralysis. The usefulness of an early phoniatric and logopedic rehabilitation by means of breathing and kinetic exercises, mechanotherapy and a vocalistic and phonetic method in order to obtain the improvement of the quality of voice in paralytic dysphonia was analysed. The complex subjective and objective foniatric assessment of the voice quality before and after the rehabilitation indicated the usefulness of applied methods and the improvement of all parameters of the voice quality in the analyzed case.

Vocal Pathologies of Difficult Diagnosis

The objective of this study was to review four vocal pathologies difficult to diagnose (vocal sulci, submucosal cysts, pseudocysts, and mucosal bridges) seen in the Principe de Asturias University Hospital Voice Unit (Alcalá de Henares, Madrid, Spain) over a 9-year period. This study was to show the prevalence of these pathologies out of the total number of benign vocal pathologies, basing our findings on clinical and stroboscopic criteria; and to analyze the stroboscopic-surgical correlation of the series over the last 3 1/2 years. This study was a retrospective review of the stroboscopies carried out between 1993 and 2002, of the suspected diagnoses offered by three ENT specialists. The data were based on the video archives of the unit and surgical notes. We reviewed 4206 stroboscopies, 189 (4.5%) corresponded to new cases. Within this group, we found the following distribution: 48% of vocal sulci, 42% of submucosal cysts, 10% of pseudocysts, and 0% of mucosal bridges. Seventy-nine percent showed unilateral pathology. The sulci showed the highest percentage of bilaterality (33%). The stroboscopic-surgical correlation (1999-2002) was positive in 69% of the sulci, 78% of the cysts, and 100% of the pseudocysts. In our series, 4.5% of the stroboscopies were performed on these groups of difficult diagnosis. For these pathologies, the stroboscopy is the exploratory method that offers more information and that allows us to obtain an optimal correlation between diagnostic suspicion and surgical evidence.

A rare cause of dysphonia

Although dysphonia is a common complaint among patients seen in an otolaryngology clinic, an autoimmune cause of the problem is less common. Autoimmune disease can be the source of various laryngologic manifestations, but diagnosis depends on a high index of suspicion, careful patient evaluation and testing, and videolaryngoscopy (videostroboscopy if available) to uncover specific identifying findings. This report describes a patient presenting with upper-range vocal difficulties who was found to have early systemic lupus erythematosus.

[Voice quality evaluation in patients with obstructive sleep apnea syndrome treated with uvulopalatopharyngoplasty (UPPP)]

MATERIAL AND METHODS

The evaluation of voice quality of 22 patients with obstructive sleep apnea syndrome (OSAS), who underwent uvulopalatopharyngoplasty (UPPP), was performed. The voice quality was assessed before the operation, and 1 month and 6-months after the procedure. The grade of dysphonia was determined on a six-grade dysphonia scale according to the Union of European Phoniatricians. Maximum phonation time (MPT) was analyzed. The acoustic examination of voice was performed determining fundamental frequency (F0) value and shimmer, jitter and NHR acoustic parameters. Formants analysis of voice was made estimating the level of F1, F2, F3 and F4 formants.

RESULTS

Registered hearing dysphonia directly after the surgery was transient. The surgery did not significantly change F0 and jitter parameters that decrease the grade intensification of dysphonia. The reduction of maximum phonation time, changes in jitter and NHR acoustic parameters as well as the reduction of F3 and F4 formants confirmed the occurrence of open nasality directly after UPPP.

CONCLUSION

Registered voice quality and timbre disturbance after UPPP were periodic.

[Respiratory symptoms of gastroesophageal reflux in children]

In the current pediatric practice, respiratory symptoms are one of the most common reasons that lead to referral to a pediatric specialist. Although most such symptoms are generated by respiratory causes, mainly infectious ones, sometimes extra-respiratory pathogenesis is involved. In the last twenty years, pediatric gastroesophageal reflux (GER) has been more frequently recognized both because the increased awareness of the disease and the progresses concerning the diagnostic techniques. The reflux-related complications and not necessarily the number and severity of reflux episodes are the features which help distinguishing between functional or physiologic and pathologic GER. The actual gold standard for gastro-esophageal reflux disease (GERD) diagnosis is the twenty-four-hour pH monitoring of the distal esophagus. Real time ultrasound examination of the eso-gastric junction might also raise the suspicion of GERD. We report three clinical cases of GERD with distinct respiratory complications and non specific clinical picture in which anti-reflux therapy have successfully contributed symptoms remission.

Unilateral vocal fold agenesis: an unusual cause of dysphonia

Unilateral vocal fold agenesis: an unusual cause of dysphonia. Unilateral vocal fold agenesis is a rare congenital laryngeal anomaly. To our knowledge, there have been no published reports about this clinical entity to date. A 6-year-old female patient was referred to our practice for persistent hoarseness of voice since birth. On physical examination, her voice was hoarse and reduced in volume. She had facial features typical of Down syndrome and macroglossia. Laryngeal examination revealed the absence of the right vocal fold. She had no further evaluation or treatment.

Perineurioma originating from the recurrent laryngeal nerve, and the phonochirurgical treatment of the developed vocal fold palsy

Perineurioma is a rare, benign tumour of the perineurium, which develops mostly on the nerves of the extremities. The neoplasm related to a genetic mutation on the 22nd chromosome, is a rarity on the vagal nerve branches. Authors report the case of a 15-year-old female with an immunhistochemically verified (focal EMA positive, vimentin, CD56 positive) perineurioma originating from the left recurrent laryngeal nerve. After the removal of the tumour together with the involved 2-cm-long part of the nerve, vocal fold palsy developed with aphonia (left vocal fold was in intermedian position). The treatment had to be chosen carefully as the larynx was still in growth. In our case there was no possibility of spontaneous regeneration, thus we chose lipoaugmentation of the left vocal fold, which does not affect the laryngeal framework, so causes the least harm to the larynx. Following surgery the patient's voice reached the normal range (before lipoaugmentation perception (0-100): G40 B80 R40 Acoustics: Ji 1.1%, Shi 10.8% Harmonicity: 13.9 dB maximum phonation time (MPT) 5 s after augmentation, Perception: G10 B10 R20, Acoustics: Ji 0.3 %, Shi 2.6%, Harmonicity: 21.2 dB MPT 22 s). This result was permanent, as the regularly performed objective voice evaluations confirmed during the 2-year follow-up.

[Clinical characteristics of myasthenia gravis with dysphonia as the initial symptom]

OBJECTIVE

To identify clinical features and diagnostic tests that would alert the otolaryngologist to consider myasthenia gravis (MG) in the differential diagnosis of dysphonia, we reviewed the clinical characteristics of MG whose initial symptom is dysphonia.

METHODS

31 patients who presented with dysphonia as their initial and primary complaint are reported, their symptoms and signs are observed and analyzed.

RESULTS

Patients with dysphonia as their initial symptom of MG may complain of vocal fatigue, difficulty sustaining or projecting their voices, breathy voice or intermittent hoarseness. These symptoms are characterized by fluctuating weakness and abnormal fatigability. Flexible fibroendoscopic examination revealed that patients had incomplete adduction of the vocal folds, fatigue of the tensors of the vocal fold, incomplete glottic closure, vocal cord paralysis, saliva pooling over the bilateral or unilateral pyriform sinus. Neostigmine test revealed dramatic improvement in all patients. Serum levels of anti-Ach-R antibodies were tested in 19 cases, only 5 cases were abnormality. All patients had improved after treatment

CONCLUSIONS

Voice changes can be the first sign of early MG. Based on fluctuating weakness or weak voice at the end of the day, a positive neostigmine test, significantly higher circulating antibody to acetylcholine receptor, a diagnosis of MG could definitively be made.