A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia

Factors Predicting Patient Perception of Dysphonia Caused by Benign Vocal Fold Lesions

OBJECTIVES/HYPOTHESIS

To assess factors that may be predictive of patient perception of dysphonia severity, as quantified by the Voice Handicap Index (VHI) score. We hypothesize that 1) level of vocal demand; 2) auditory-perceptual evaluation of dysphonia severity; and 3) vocal function, as defined by phonatory glottal closure and mucosal wave vibration, are the most significant predictors of VHI score.

STUDY DESIGN

: Retrospective review of 100 patients with benign vocal fold lesions.

METHODS

Variables assessed for predictive value to VHI score are level of vocal demands, auditory-perceptual evaluation of dysphonia severity, integrity of mucosal wave vibration and phonatory glottal closure, lesion type, duration of current complaint, smoking, age, and sex. Harmonic to noise ratio was assessed in a subset of 50 patients.

RESULTS

Patients with routine voice use had significantly lower VHI scores than those with more intensive (nonsinging/acting) vocal demands. Patients who quit smoking had greater VHI scores than those who currently smoke or never started. Patients with long-standing dysphonia tended to have lower VHI scores than those with shorter duration vocal complaints. Auditory-perceptual assessment of dysphonia severity and harmonic to noise ratio were weak predictors of VHI score. Age, sex, lesion type, phonatory glottal closure, and mucosal wave vibration were not significant predictors of VHI score.

CONCLUSIONS

Patient perception of dysphonia severity is independent of many factors commonly assessed during the evaluation of voice disorders. It appears to be an important independent element in the assessment of the effect of a benign vocal fold lesion and critical to therapeutic decision-making.

Retrospective study of 116 patients with non-organic voice disorders: efficacy of mental imagery and laryngeal shaking

Objective:

To report the short- and long-term results of two techniques (mental imagery and manual shaking of the larynx) in patients with non-organic dysphonia or aphonia.

Design:

Retrospective review of patient records, plus follow-up survey (questionnaire).

Setting:

Academic teaching hospital.

Patients:

One hundred and sixteen patients with moderate to severe non-organic dysphonia or aphonia.

Outcome:

Cure (i.e. normal voice) and improved voice quality, judged by clinicians and patients.

Results:

One hundred (86 per cent) of the 116 patients were cured. Ninety-four (81 per cent) patients regained their normal voice within one therapy session. The follow-up survey revealed that 43 of the 87 (49 per cent) patients who responded had not had a relapse since therapy ended. Of those patients suffering relapse, 15 successfully applied mental imagery in order to retrieve their voice, compared with three patients who applied shaking of the larynx.

Conclusion:

Mental imagery, combined if necessary with manual therapy, is an effective therapeutic technique in patients with non-organic voice disorders.

Effects of Voice Therapy: A Systematic Review

Medical as well as paramedical treatments should be evaluated by scientific methods. This systematic review focuses on the effects of voice therapy, excluding pharmacological or surgical treatments. In general, statistically significant positive but modest and varying therapy effects are found. Many of these effect studies cope with diverse methodological problems. Furthermore, the conclusions of most studies cannot be generalized easily or compared to one another. As a consequence, many issues in the field of effects of voice therapy have yet been unanswered.

Systematic review of the treatment of functional dysphonia and prevention of voice disorders

Objective

To evaluate the effectiveness of interventions for treating functional dysphonia or preventing voice disorders in adults.

Data Sources

We searched MEDLINE (1950 to 2006), EMBASE (1974 to 2006), CENTRAL (Issue 2 2006), CINAHL (1983 to 2006), PsychINFO (1967 to 2006), Science Citation Index (1986 to 2006), and the Occupational Health databases OSH-ROM (February 2006).

Review Methods

Systematic review and meta-analysis of randomized controlled trials. Included studies evaluated the effectiveness of interventions for 1) treating functional/nonorganic dysphonia or 2) preventing voice disorders. We identified six randomized controlled trials about treatment and two about prevention. Two authors independently extracted data and assessed trial quality.

Results

A combination of direct and indirect voice therapy, compared with no intervention, improves self-reported (standardized mean difference −1.07; 95% CI −1.94 to −0.19), observerrated (weighted mean difference [WMD] −13.00; 95% CI −17.92 to −8.08), and instrumentally assessed vocal functioning (WMD −1.20; 95% CI −2.37 to −0.03) in adults with functional dysphonia. Effects are reported to remain for at least 14 weeks. Effects are similar in patients and in teachers and student teachers screened for voice problems. We found two studies that did not show voice training, compared with no intervention, to have a preventive effective in improving self-reported vocal functioning. Assessment of publication bias showed that the real effect sizes are probably smaller.

Conclusion

Comprehensive voice therapy is effective in improving vocal performance in adults with functional dysphonia. There is no evidence of effectiveness of voice training in preventing voice disorders.

Vocal hygiene education, voice production therapy, and the role of patient adherence: a treatment effectiveness study in women with phonotrauma

PURPOSE

To assess the effectiveness of vocal hygiene education (VHE) and voice production therapy (VP) in altering patient perception of vocal handicap in adult women with benign, bilateral phonotraumatic vocal fold lesions and the role of adherence in that perception.

METHOD

Sixty-two women were randomly assigned to 6 weeks of VP (n = 31) or VHE (n = 31), followed by 4 weeks of self-study. The primary outcome measure was the Voice Handicap Index (VHI) score, assessed at baseline, post-therapy, and post-self-study. Patient adherence was assessed as a cofactor.

RESULTS

Both groups achieved a decrease in VHI scores from baseline to completion of the study, although the improvement was significantly greater for the VP group. The treatment effect size was large for the VP group and small for the VHE group. More participants adhered to VP than to VHE. Only adherent participants achieved significant improvement. Only adherent participants in the VP group improved with self-study. More than two thirds of the VP group achieved final VHI scores within normal limits, compared with approximately one third of those in the VHE group.

CONCLUSIONS

VP therapy may be more effective than VHE in addressing patient perception of vocal handicap in adult women with phonotrauma, and self-study may be an important component of therapy. However, adherence is a critical mediator of outcome.

Articulatory changes following treatment of muscle tension dysphonia: preliminary acoustic evidence

PURPOSE

Primary muscle tension dysphonia (MTD), a voice disturbance that occurs in the absence of structural or neurological pathology, may respond to manual circumlaryngeal techniques, which ostensibly alter the posture of the larynx and/or the configuration of the vocal folds without directly targeting supralaryngeal articulatory structures. Although the phonatory benefits of these techniques have been documented previously, this investigation examined whether acoustic evidence exists for articulatory changes accompanying successful management.

METHOD

In this retrospective study of a clinical database, pre- and post-treatment speech samples from 111 women with MTD were analyzed for acoustic evidence of supraglottal vocal tract changes associated with voice improvement, which was confirmed by perceptual ratings of dysphonia severity. The slopes of the first and second formants in diphthongs, as well as global measures of speech timing were acquired. Twenty younger females with normal voices were recorded twice, across a similar time-span to the disordered speakers, to allow comparisons in performance.

RESULTS

Repeated measures analysis of variance was used to evaluate changes accompanying treatment. Significant time by group interactions for /I/ F2 slope, /eI/ F2 slope, sample duration, and speaking time ratio were observed. As compared to the controls, diphthong second formant transitions increased in slope, and timing measures showed increases in speech continuity for the speakers with MTD.

CONCLUSIONS

Collectively, these preliminary findings suggest that individuals with MTD experience changes in both articulatory and phonatory behavior following successful treatment that targets the larynx.

Assessment and treatment of musculoskeletal tension in hyperfunctional voice disorders

Poorly regulated activity of the perilaryngeal muscles affects phonatory function and contributes to a class of disorders known as hyperfunctional or musculoskeletal tension voice disorders. Recognizing the signs and symptoms of excess or dysregulated laryngeal muscle activity is critical to proper diagnosis and selection of appropriate treatment(s). Although numerous approaches exist to manage such hyperfunctional syndromes, manual circumlaryngeal techniques have recently received attention as valuable tools in both assessment and treatment. Therefore, the purpose of this article is to: (1) describe common phenomenological features of dysregulated laryngeal muscle tension, thereby facilitating its recognition, (2) highlight the role of manual circumlaryngeal techniques in assessment and management, (3) survey additional treatment approaches for laryngeal hyperfunction, and explore the evidence to support their effectiveness, and (4) identify unresolved issues and controversies surrounding tension-based voice disorders. A series of pre- and post-treatment audio examples are provided on the journal website at www.informaworld.com/ijslp .

Interventions for preventing voice disorders in adults

BACKGROUND

Poor voice quality due to a voice disorder can lead to a reduced quality of life. In occupations where voice use is substantial it can lead to periods of absence from work.

OBJECTIVES

To evaluate the effectiveness of interventions to prevent voice disorders in adults.

SEARCH STRATEGY

We searched MEDLINE (PubMed, 1950 to 2006), EMBASE (1974 to 2006), CENTRAL (The Cochrane Library, Issue 2 2006), CINAHL (1983 to 2006), PsychINFO (1967 to 2006), Science Citation Index (1986 to 2006) and the Occupational Health databases OSH-ROM (to 2006). The date of the last search was 05/04/06.

SELECTION CRITERIA

Randomised controlled clinical trials (RCTs) of interventions evaluating the effectiveness of treatments to prevent voice disorders in adults. For work-directed interventions interrupted time series and prospective cohort studies were also eligible.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality. Meta-analysis was performed where appropriate.

MAIN RESULTS

We identified two randomised controlled trials including a total of 53 participants in intervention groups and 43 controls. One study was conducted with teachers and the other with student teachers. Both trials were poor quality. Interventions were grouped into 1) direct voice training, 2) indirect voice training and 3) direct and indirect voice training combined.1) Direct voice training: One study did not find a significant decrease of the Voice Handicap Index for direct voice training compared to no intervention.2) Indirect voice training: One study did not find a significant decrease of the Voice Handicap Index for indirect voice training when compared to no intervention.3) Direct and indirect voice training combined: One study did not find a decrease of the Voice Handicap Index for direct and indirect voice training combined when compared to no intervention. The same study did however find an improvement in maximum phonation time (Mean Difference -3.18 sec; 95 % CI -4.43 to -1.93) for direct and indirect voice training combined when compared to no intervention. No work-directed studies were found. None of the studies found evaluated the effectiveness of prevention in terms of sick leave or number of diagnosed voice disorders.

AUTHORS' CONCLUSIONS

We found no evidence that either direct or indirect voice training or the two combined are effective in improving self-reported vocal functioning when compared to no intervention. The current practice of giving training to at-risk populations for preventing the development of voice disorders is therefore not supported by definitive evidence of effectiveness. Larger and methodologically better trials are needed with outcome measures that better reflect the aims of interventions.

Interventions for treating functional dysphonia in adults

BACKGROUND

Poor voice quality due to functional dysphonia can lead to a reduced quality of life. In occupations where voice use is substantial it can lead to a loss of employment.

OBJECTIVES

To evaluate the effectiveness of interventions to treat functional dysphonia in adults.

SEARCH STRATEGY

We searched MEDLINE (PubMed, 1950 to 2006), EMBASE (1974 to 2006), CENTRAL (The Cochrane Library, Issue 2 2006), CINAHL (1983 to 2006), PsychINFO (1967 to 2006), Science Citation Index (1986 to 2006) and the Occupational Health databases OSH-ROM (to 2006). The date of the last search was 5(th) April 2006.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions evaluating the effectiveness of treatments targeted at adults with functional dysphonia. For work-directed interventions interrupted time series and prospective cohort studies were also eligible.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality. Meta-analysis was performed where appropriate.

MAIN RESULTS

We identified six randomised controlled trials including a total of 163 participants in intervention groups and 141 controls. One trial was high quality. Interventions were grouped into 1) Direct voice therapy 2) Indirect voice therapy 3) Combination of direct and indirect voice therapy and 4) Other treatments: pharmacological treatment and vocal hygiene instructions given by phoniatrist. No studies were found evaluating direct voice therapy on its own. One study did not show indirect voice therapy on its own to be effective when compared to no intervention. There is evidence from three studies for the effectiveness of a combination of direct and indirect voice therapy on self-reported vocal functioning (SMD -1.07; 95% CI -1.94 to -0.19), on observer-rated vocal functioning (WMD -13.00; 95% CI -17.92 to -8.08) and on instrumental assessment of vocal functioning (WMD -1.20; 95% CI -2.37 to -0.03) when compared to no intervention. The results of one study also show that the remedial effect remains significant for at least 14 weeks on self-reported vocal functioning (SMD -0.51; 95% CI -0.87 to -0.14) and on observer-rated vocal functioning (Buffalo Voice Profile) (WMD -0.80; 95% CI -1.14 to -0.46). There is also limited evidence from one study that the number of symptoms may remain lower for a year. The combined therapy with biofeedback was not shown to be more effective than combined therapy alone in one study nor was pharmacological treatment found to be more effective than vocal hygiene instructions given by phoniatrist in one study. Publication bias may have influenced the results.

AUTHORS' CONCLUSIONS

Evidence is available for the effectiveness of comprehensive voice therapy comprising both direct and indirect therapy elements. Effects are similar in patients and in teachers and student teachers screened for voice problems. Larger and methodologically better studies are needed with outcome measures that match treatment aims.

Outcome of Resonant Voice Therapy for Female Teachers With Voice Disorders: Perceptual, Physiological, Acoustic, Aerodynamic, and Functional Measurements

Teachers have a high percentage of voice problems. For voice disordered teachers, resonant voice therapy is hypothesized to reduce voice problems. No research has been done on the physiological, acoustic, and aerodynamic effects of resonant voice therapy for school teachers. The purpose of this study is to investigate resonant voice therapy outcome from perceptual, physiological, acoustic, aerodynamic, and functional aspects for female teachers with voice disorders. A prospective study was designed for this research. The research subjects were 24 female teachers in Taipei. All subjects received resonant voice therapy in groups of 4 subjects, 90 minutes per session, and 1 session per week for 8 weeks. The outcome of resonant voice therapy was assessed from auditory perceptual judgment, videostroboscopic examination, acoustic measurements, aerodynamic measurements, and functional measurements before and after therapy. After therapy the severity of roughness, strain, monotone, resonance, hard attack, and glottal fry in auditory perceptual judgments, the severity of vocal fold pathology, mucosal wave, amplitude, and vocal fold closure in videostroboscopic examinations, phonation threshold pressure, and the score of physical scale in the Voice Handicap Index were significantly reduced. The speaking Fo, maximum range of speaking Fo, and maximum range of speaking intensity were significantly increased after therapy. No significant change was found in perturbation and breathiness measurements after therapy. Resonant voice therapy is effective for school teachers and is suggested as one of the therapy approaches in clinics for this population.

Optimising outcome assessment of voice interventions, I: reliability and validity of three self-reported scales

Background:

There is an increasing choice of voice outcome research tools, but good comparative data are lacking.

Objective:

To evaluate the reliability and validity of three voice-specific, self-reported scales.

Design:

Longitudinal, cohort comparison study.

Setting:

Two UK voice clinics: the Freeman Hospital, Newcastle upon Tyne, and the Glasgow Royal Infirmary.

Participants:

One hundred and eighty-one patients presenting with dysphonia.

Main outcome measures:

All patients completed the vocal performance questionnaire, the voice handicap index and the voice symptom scale. For comparison, each patient's voice was recorded and assessed perceptually using the grade–roughness–breathiness–aesthenia–strain scale. The reliability and validity of the three self-reported vocal performance measures were assessed in all subjects, while 50 completed the questionnaires again to assess repeatability.

Results:

The results of the 170 participants with completed data sets showed that all three questionnaires had high levels of internal consistency (Cronbach's alpha = 0.81–0.95) and repeatability (voice handicap index = 0.83; vocal performance questionnaire = 0.75; voice symptom scale = 0.63). Concurrent and criterion validity were also good, although, of the grade–roughness–breathiness–aesthenia–strain subscales, roughness was the least well correlated with the self-reported measures.

Conclusion:

The vocal performance questionnaire, the voice handicap index and the voice symptom scale are all reliable and valid instruments for measuring the patient-perceived impact of a voice disorder.

Is laryngopharyngeal reflux related to functional dysphonia?

OBJECTIVES

Laryngopharyngeal reflux (LPR) may be a contributing factor in chronic hoarseness. The association of LPR with functional dysphonia (FD), the most common voice clinic diagnosis, is unknown. We attempted to determine whether patients with FD have a higher rate of laryngeal exposure to acidic stomach contents than do healthy volunteers.

METHODS

We recruited through the voice clinic 23 patients who had had persistent dysphonia for 3 months. Pregnancy, major structural laryngeal abnormality, and vocal fold paralysis were exclusion criteria. Eight healthy volunteers were recruited. The subjects gave informed consent to enter the study, which had the approval of our hospital ethics committee. The patients and control subjects underwent 24-hour dual-probe pH-metry.

RESULTS

Twenty-two patients and 6 control subjects completed the study. Overall, there seemed to be no statistical differences between patients and controls on all but 2 channel 1 pH-metry parameters. These were the longest reflux episode (seconds) in a supine position, and the fraction of time the pH was less than 4 in a supine position. Both of these time periods were longer in patients than in the controls (p < .05).

CONCLUSIONS

Our study demonstrated an association between LPR and FD for 2 pH parameters. Larger studies are required to assess the potential relationship between nonorganic dysphonias and reflux. Furthermore, the presence of a multifactorial causation of FD, including "medical" and psychological causes, should be addressed in future studies.

Long-Term Outcome of Hyperfunctional Voice Disorders Based on a Multiparameter Approach

SUMMARY

The purpose of this study is to determine the long-term voice outcome (6.1 years after a well-defined voice treatment program) of hyperfunctional voice disorders in 27 subjects. All patients showed a muscle tension pattern type I (MTP I). Perceptual ratings, aerodynamic and acoustical analyses, Voice Handicap Index (VHI) value, and a determination of the Dysphonia Severity Index (DSI) were performed. The laryngovideostroboscopic images indicated that 51% of the subjects still show pathological laryngological findings. The negative evolution of the DSI from -1 to -3.2 is in agreement with this finding. Analysis of the components of the DSI shows that the main responsible variable for this negative change is the lowest intensity (I-low) that increased with 8.1 dB, indicating that subjects generally speak too loud, which is a typical problem for vocal hyperfunction. The VHI-score indicates an unimportant psychosocial impact of the voice disorder. The more objective and laryngostroboscopic findings indicate a chronic situation for a substantial part of the subjects and even a worse situation for some of them. Whether the long-term voice outcome results can be changed with the insertion of several follow-up voice rehabilitation sessions over the years remains unanswered and is a subject for further research.

The Effectiveness of a Voice Treatment Approach for Teachers With Self-Reported Voice Problems

SUMMARY

Teachers are considered the professional group most at risk of developing voice-problems, but limited treatment effectiveness evidence exists. We studied prospectively the effectiveness of a 6-week combined treatment approach using vocal function exercises (VFEs) and vocal hygiene (VH) education with 20 teachers with self-reported voice problems. Twenty subjects were randomly assigned to a no-treatment control (n = 11) and a treatment group (n = 9). Fibreoptic endoscopic evaluation was carried out on all subjects before randomization. Two self-report voice outcome measures were used: the Voice-Related Quality of Life (VRQOL) and the Voice Symptom Severity Scale (VoiSS). A Voice Care Knowledge Visual Analogue Scale (VAS), developed specifically for the study, was also used to evaluate change in selected voice knowledge areas. A Student unpaired t test revealed a statistically significant (P < 0.05) improvement in the treatment group as measured by the VoiSS. There was not a significant improvement in the treatment group as measured by the V-RQOL. The difference in voice care knowledge areas was also significant for the treatment group (P < 0.05). This study suggests that a voice treatment approach of VFEs and VH education improved self-reported voice symptoms and voice care knowledge in a group of teachers.

Cross-cultural Adaptation and Validation of the Chinese Voice Handicap Index-10

OBJECTIVES/HYPOTHESIS

Recent developments in voice assessment propose the use of quality of life measurements. The Voice Handicap Index (VHI) is one of the most psychometrically robust and well-studied instruments among the various instruments for measuring quality of life. Two versions of VHI (VHI-30 and VHI-10) have been shown to be valid instruments for distinguishing dysphonic from nondysphonic individuals and also for documenting treatment effect for dysphonic patients. The VHI has been used worldwide; however, the psychometric properties of the Chinese version of VHI remains untested. This study aimed to investigate such properties of the Chinese VHI-30 and VHI-10 in the Hong Kong Chinese population.

STUDY DESIGN

Psychometric analysis of the Chinese VHI-30 and VHI-10 in dysphonic patients and control subjects.

METHODS

The original VHI-30 was translated into Chinese and was completed by 131 dysphonic patients and 54 nondysphonic individuals. The dysphonic patients also self-rated their dysphonic severity.

RESULTS

Results showed high test-retest reliability and high item-total correlation for both Chinese VHI-30 and VHI-10. Both Chinese versions could be used to distinguish different dysphonic groups and between dysphonic and nondysphonic groups. Significant correlation was found between the VHI scores and the patients' self-rated dysphonic severity.

CONCLUSION

The present study supported the original three-factorial structures of the VHI-30 and the use of the VHI for the Chinese population. It is shown that the Chinese VHI-10 is a strong representation of VHI-30 and is recommended for use in clinics because of its validity and ease of use by patients.

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

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

The efficacy of voice therapy in patients after treatment for early glottic carcinoma

BACKGROUND

After treatment for early glottic carcinoma, a considerable number of patients end up with voice problems that interfere with daily life activities. The objective of this randomized and controlled study was to assess the efficacy of voice therapy in these patients.

METHODS

Of 177 patients, 6-120 months after treatment for early glottic carcinoma, 70 patients (40%) suffered from voice impairment based on a 5-item screening questionnaire. Approximately 60% of those 70 patients were not interested in participating in the current study. Twenty-three patients who were willing to participate were assigned randomly either to a voice therapy group (n = 12 patients) or to a control group (n = 11 patients). Multidimensional voice analyses (the self-reported Voice Handicap Index [VHI], acoustic and perceptual voice quality analysis, videolaryngostroboscopy, and the Voice Range Profile) were conducted twice: before and after voice therapy or with 3 months in between for the control group.

RESULTS

Statistical analyses of the difference in scores (postmeasurement minus premeasurement) showed significant voice improvement after voice therapy on the total VHI score, percent jitter, and noise-to-harmonics ratio in the voice signal and on the perceptual rating of vocal fry.

CONCLUSIONS

Voice therapy proved to be effective in patients who had voice problems after treatment for early glottic carcinoma. Improvement not only was noticed by the patients (VHI) but also was confirmed by objective voice parameters.

Puberphonia: A novel approach to treatment

Puberphonia affects the adolescent males. Authors have used a novel approach by using a Macintosh laryngoscope for stretching of vocal cords, which gives immediate and permanent relief. This procedure, which was incidentally found to be useful, while doing a laryngoscopic examination of a puberphonic patient, was effective and superior to any method used in the past 26 cases treated during 1991 to 2005 had been followed with the excellent results.

Common Practices of Voice Therapists in the Evaluation of Patients

This study surveys voice therapists regarding common diagnostic practices in patients referred for therapy with the diagnosis of muscle tension dysphonia (broadly defined as the "hyperfunctional" component of the dysphonia). Through postings on the e-mail list of the ASHA special interest division on voice, speech pathologists with at least 3 years' experience in stroboscopy and acoustic instrumentation were invited to complete the survey. Results from 53 completed surveys demonstrated that voice quality and patient self-perception are the sole assessments performed by all therapists. Voice quality, observation of body posture and movement, and probing the patient's ability to alter voice production are each significantly more likely to be performed than the more objective stroboscopic, acoustic, aerodynamic, and EGG assessments. Further, the tasks of defining specific therapy session goals and helping the patient to achieve a particular target skill are considered best served by measures of vocal quality, observation of body position and movement, and judging the patient's ability to alter voice production. For definition of the overall therapy goal, stroboscopy and patient perception scales are added to all of the subjective assessment measures as being important. Acoustic data are considered most important for patient reinforcement and outcomes assessment. Implications of these findings are discussed, and topics for further exploration are identified.

The reliability and validity of patient self-rating of their own voice quality

OBJECTIVES

To provide preliminary data on the reliability and validity of dysphonic patients rating their own voice quality.

DESIGN

Prospective reliability/validity assessment of voice ratings in dysphonic patients.

SETTING

The Royal Free Hampstead NHS Primary Care Trust.

PARTICIPANTS

Thirty-five adult dysphonia patients recruited from ENT referrals to a speech and language therapy department. Exclusion criteria were (i) a hearing impairment which may affect auditory discrimination and (ii) a diagnosis of cognitive impairment which may affect task comprehension.

MAIN OUTCOME MEASURES

Patient intra-rater reliability was assessed by test-retest ratings, using G (Grade), R (Rough), B (Breathy), A (Asthenic), S (Strained) (GRBAS). Validity was assessed by comparing (i) patient-clinician inter-rater reliability, (ii) patients' GRBAS ratings with their Vocal Performance Questionnaire (VPQ) responses.

RESULT

(i) Patients had lower intrarater reliability than clinicians (for G of GRBAS, kappa = 0.51 versus 0.74); (ii) patients consistently rated their voices more severely than clinicians (for G of GRBAS, mean rating = 1.4 versus 1.0); (iii) clinician-patient inter-rater agreement was no better than chance (paired t-test, all P < 0.05); (iv) patient ratings correlated significantly with vocal performance scores (r > 0.4, P < 0.05).

CONCLUSIONS

Patients appear to have good validity and consistency using GRBAS as a self-perception tool. However, validity measured in terms of agreement with clinician ratings is poor. Voice patients may rate what they perceive rather than what they hear. Disagreement between patient and clinician ratings has implications for therapy aims, prognosis, patient expectations and outcomes. Where disagreement persists, the clinician may have to determine whether therapy priorities need redesigning to reflect patients' perceived needs, or to evaluate whether patient perceptions and expectations are unrealistic.

Quality of life and voice following endoscopic resection or radiotherapy for early glottic cancer

OBJECTIVES

To assess whether proposed voice and quality of life (QoL) outcome measures were likely to be acceptable to patients previously treated for early glottic cancer by either radiotherapy or endoscopic resection, as well as looking for differences in QoL and voice between treatments.

DESIGN

Questionnaire-based cohort study.

SETTING

Secondary care, three centres.

PARTICIPANTS

All patients treated for T1a or in situ glottic carcinoma between 1997 and 2003. Fifty-three patients were identified; those who had undergone salvage surgery or radiotherapy were excluded. A proportion refused to participate or could not be contacted and two patients had died of unrelated causes. Thirty-six patients completed the trial with 18 from each treatment arm.

MAIN OUTCOME MEASURES

Quality of voice as assessed by three questionnaires, Voice Handicap Index (VHI), Vocal Performance Questionnaire (VPQ), Voice Symptom Score (VoiSS) and perceptual analysis of voice by Grade, Roughness, Breathiness, Asthenia and Strained (GRBAS) assessment of vocal recordings. Quality of life as assessed by the Hospital Anxiety and Depression Scale (HADS), University of Washington Quality of Life Questionnaire (UW-QoL), and the Functional Assessment of Cancer Therapy (FACT) questionnaire.

RESULTS

All patients included in the trial were able to complete the questionnaires; however, 19% required assistance of some kind. GRBAS assessment showed no difference between groups for any criteria. All QoL questionnaires gave equivalent good scores. All of the voice questionnaires showed no statistical difference between groups except for the emotional subscale of the VoiSS which showed a significantly better score for the radiotherapy arm (P = 0.04).

CONCLUSION

All outcome measures were applicable and acceptable to the patient group. Overall QoL and voice appears similar despite treatment arm, apart from the emotional subscale of the VoiSS. A randomized controlled trial is required to further assess this question.

Outcome of vocal hygiene in singers

PURPOSE OF REVIEW

In this article, we illustrate the evolution of studies that contribute to a better understanding of vocal care for professional voice users and singers in particular.

RECENT FINDINGS

Research on vocal hygiene is specific, focusing on concrete solutions. It has commonly been believed that hydration and vocal rest are beneficial; recent research proves this supposition. An exhaustive medical diagnosis and careful therapy is stressed to detect and treat any micro-organic lesions caused by reflux, infection, allergy and environmental circumstances, which can harm a singer's voice. The use of medication is reviewed and side effects are evaluated.

SUMMARY

Vocal coaches, speech therapists and otolaryngologists need to focus more specifically on the management of vocal care. Accurate medical diagnosis and specific guidelines for singers must be provided as higher voice demands imply more profound and structured voice care. In the past, vocal hygiene had a negative connotation; a more positive and supporting approach to voice care, with more attention to the singer, is recommended.

Comparing Outcomes of Voice Therapy: A Benchmarking Study Using the Therapy Outcome Measure

The quality cycle requires clinicians to assess the outcomes of interventions. Benchmarking is an approach that has been advocated to compare current performance across different services to identify commonalities and significant differences. This article gives the results of a study of outcomes in speech and language therapy (SLT) using the therapy outcome measure (TOM) for patients with voice disorder (dysphonia) comparing outcomes of seven separate speech and language therapy services. The study aimed to identify the similarities and differences in outcomes of care provided by different services. Two hundred and forty patients with dysphonia (age range 3-87.5 years, average 51.9 years) were treated. The results indicated that although there was no significant difference in the profile of the severity of symptomology of patients referred to speech and language therapy in different geographical areas, there was a significant difference in the treatment outcomes across the services and in the stated reason for discharge from treatment. Nevertheless, most patients with dysphonia had a good outcome and this was associated with completion of the course of treatment. There were significant differences in the number of treatment contacts provided by the different services and in the duration (between admission and discharge) of treatment across the services. Benchmarking can provide useful information through use of routinely collected clinical data.

Evaluating the effectiveness and efficiency of voice therapy using transnasal flexible laryngoscopy: a randomized controlled trial

Transnasal flexible laryngoscopy (TFL) is an examination of laryngeal anatomy and physiology using continuous light. TFL is being used increasingly by voice pathologists in treatment but with little scientific evidence to support it. The purpose of this study was to evaluate the effectiveness and efficiency of TFL as a therapeutic tool. The study used a prospective randomized controlled trial. Fifty dysphonic subjects were recruited and randomly assigned to either a traditional treatment group or a TFL-assisted treatment group. The effectiveness of voice therapy in both treatment groups was measured with a package of voice outcome measures. Subjects in both treatment groups demonstrated statistically significant improvements after voice therapy (perceptual auditory rating of voice quality measurement p < 0.01; instrumental electroglottographic measurement p < 0.01; patient questionnaire measurement p < 0.01). The time taken to complete treatment in both groups was recorded. The average (median) time taken to complete voice therapy in the TFL-assisted treatment group was 2 hours less than in the traditional treatment group (p < 0.01). Voice therapy with TFL as a therapy tool was effective and more efficient than traditional voice therapy.

Perceptual evaluation of voice quality and its correlation with acoustic measurements

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

The Voice Symptom Scale (VoiSS) and the Vocal Handicap Index (VHI): a comparison of structure and content

Self report measures of voice function are in frequent use, but have had inadequate psychometric evaluation. We aimed to perform a substantial factor analysis of two measures of voice impairment, the Voice Symptom Scale (VoiSS) and the Voice Handicap Index (VHI). Both the 30-item questionnaires were completed by 319 dysphonic voice clinic attenders (99M, 220F). Principal components analysis confirmed that both instruments reflected general voice abnormality. The VoiSS comprised three factors - impairment (15 items), emotional (8 items) and related physical symptoms (7 items) - each with a good internal consistency. Analysis of the VHI suggested that it contains only two subscales. When a three-factor solution was imposed on the data, analysis failed to support the currently advised three 10-item subscale interpretations. Instead, we found a physical (voice impairment) domain (8 items), a psychosocial domain (14 items) and a factor with 8 items related to difficulty in being heard. The VHI requires further statistical refinement to identify its subscale structure. The VoiSS was developed from 800 subjects and is psychometrically the most robust and extensively validated self report voice measure available.

Evidence-based treatment of paralytic dysphonia: making sense of outcomes and efficacy data

The criteria used to determine the success or failure of a given treatment for vocal fold paralysis are fundamental components of routine clinical practice and treatment outcomes research for the surgeon and voice therapist. The purpose of this article is to offer a guide to the critical interpretation of available measures of out-come and efficacy for this patient population. Such data form the basis for the practice of evidence-based medicine and voice therapy,essential if the standard of care is to evolve to the benefit of the patient. A better understanding of the potentials and limitations of each measure is important for treatment planning and patient counseling and, ultimately, for the conception of future well-designed clinical research. The complex issues regarding outcomes measurement are addressed here within the context of current treatment literature on vocal fold paralysis. Particular emphasis is placed on realistic data gathering within clinical practice.

Functional dysphonia

Functional dysphonia-a voice disturbance in the absence of structural or neurologic laryngeal pathology-is an enigmatic and controversial voice disorder that is frequently encountered in multidisciplinary voice clinics. Poorly regulated activity of the intrinsic and extrinsic laryngeal muscles is cited as the proximal cause of functional dysphonia, but the origin of this dyregulated laryngeal muscle activity has not been fully elucidated. Several causes have been cited as contributing to this imbalanced muscle tension; however, recent research evidence points to specific personality traits as important contributors to its development and maintenance. Voice therapy by an experienced speech-language pathologist remains an effective short-term treatment for functional dysphonia in the majority of cases, but less is known regarding the long-term fate of such intervention. Further research is needed to better understand the pathogenesis of functional dysphonia, and factors contributing to its successful management.

VoiSS: a patient-derived Voice Symptom Scale

OBJECTIVE

Many voice-rating tools are either physician-derived, disease-specific measures or they merely combine general quality-of-life domains with vocal symptoms. The aim of this series of studies was to devise and validate a patient-derived inventory of voice symptoms for use as a sensitive assessment tool of (i) baseline pathology and (ii) response to change in adult dysphonia clinics.

METHOD

Three stages in the development of the instrument are described. First, an initial exploratory, open-ended questionnaire study was used to compile a prototype list of voice complaints [Clin Otolaryngol 22 (1997) 37]. Second, the prototype list was administered to 168 subjects with dysphonia and underwent principal components analysis. Qualitatively, it was also assessed at this stage for its ability to capture voice-related impairment, disability and handicap. Third, a modified 44-item scale was administered to 180 new subjects.

RESULTS

The symptoms were highly endorsed. Principal components analysis with oblique rotation yielded a Voice Symptom Scale (VoiSS); 43 of the items comprise a 'general voice pathology' scale. More specifically, five oblique components provided assessments of: 'communication problems,' 'throat infections,' 'psychosocial distress,' 'voice sound and variability' and 'phlegm.'

CONCLUSION

The VoiSS is simple for patients to complete and easy to score. It is sensitive enough to reflect the wide range of communication, physical symptoms and emotional responses implicit in adult dysphonia.

Comparisons between therapists' and patients' views of dysphonia: a survey study

Speech and language therapists (SLTs) recognise the need to involve patients in the design and implementation of services. The present study describes the results of a questionnaire survey undertaken among SLTs working with patients with voice disorders to determine whether patients' and therapists' views on issues around dysphonia were in harmony. The SLTs' views of patients' disabilities and handicaps associated with dysphonia are reported and compared with those of an earlier survey of patient-reported difficulties (Scott et al. Clin Otolaryngol 1997; 22: 37-40). A close, but incomplete, match of therapists' and patients' views of dysphonia is reported and discussed.

Vocal loading among day care center teachers

Day care center teachers suffer from voice disorders more often than nurses do. Several risk factors may increase voice disorder prevalence of day care center teachers. The risk factors can be bound to their job content and manner of working i.e. having to raise their voice to attract the attention of the children and to offer them the possibility to perceive spoken information, or to the environment i.e. poor acoustics and excess background noise. The purpose of this study was to measure some of the risk factors for voice disorders of day care center teachers and of a control group (nurses); these were speaking times and speech levels. The background noise levels during activities and RASTI-values (Rapid Speech Transmission Index), i.e. measures of the acoustics of rooms, were also measured at the day care centers. It was found that day care center teachers use their voices more and with higher levels than nurses do. It was also found that the background noise levels are high, which is partly due to the poor acoustics (lack of sufficient attenuation) of the rooms. Control of excess background noise is of utmost importance both for speakers' speech production as well as children's speech recognition.

Formal perceptual evaluation of voice quality in the United Kingdom

This document is a position statement on the formal perceptual evaluation of voice quality in the United Kingdom (UK). It addresses a number of clinical issues pertaining to the complexity of voice quality analysis. There is also a brief description of the three formal perceptual protocols most commonly used in the UK: The Vocal Profile Analysis (VPA), GRBAS and The Buffalo III Voice Profile. Potential clinical problems with perceptual voice quality evaluation are highlighted. Problems associated with the lack of defined terminology, limitless variety of voice quality, general lack of reliability data and difficulties in determining specificity and sensitivity are discussed. A practical guide for selecting an evaluation scheme is described. The conclusion is that the GRBAS scheme should be recommended as the absolute minimum standard for practising UK voice clinicians. However, there is a clear need to develop a more satisfactory perceptual rating scheme that is clinically realistic, theoretically sound, internationally acceptable and has proven reliability.

The effect of Isshiki type 1 thyroplasty on quality of life and vocal performance

Type 1 thyroplasty for unilateral vocal cord palsy improves many vocal outcome measures but there is little information on quality of life despite its increasingly recognized importance. Our prospective study examined its effect on a range of subjective and objective measures and quality of life. Twenty-seven patients underwent thyroplasty. Before and after surgery they completed a vocal performance questionnaire and the Nottingham Health Profile (NHP); instrumental analyses of jitter, shimmer and noise-harmonic ratio (NHR); and perceptual analyses of grade, roughness, breathiness, aesthenia and strain (GRBAS) were also performed. Significant improvements were found in instrumental, perceptual and self-assessment of voice and the energy, social and emotional dimensions of the NHP. Three patients had initially poor results but were successfully revised. These results of type 1 thyroplasty compare favourably with those previously published. The improvement in quality of life appears to result directly from improved voice. Many thyroplasty patients have limited life expectancy: early surgical intervention should be considered.