Vocal fold bowing in elderly male monozygotic twins: a case study

Quantitative Evaluation of Vocal Bowing Following Bilateral Thyroplasty in Age-Related Vocal Atrophy

OBJECTIVE

Age-related vocal atrophy (ARVA) is associated with vocal fold bowing, persistent glottal gap during phonation, and dysphonia. Bilateral medialization thyroplasty is sometimes performed in patients with ARVA to improve vocal fold closure and voice. We set out to quantify stroboscopic changes in vocal fold bowing, glottal closure, and abduction angle following bilateral thyroplasty and determine how these changes affect voice quality among patients with ARVA.

METHODS

Fifteen individuals with ARVA who underwent bilateral medialization thyroplasty were included in this study. Two independent investigators calculated bowing index (BI), normalized glottal gap area (NGGA), and maximum abduction angle from laryngostroboscopic exams using ImageJ™. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and patient-reported measures were collected before and after thyroplasty.

RESULTS

Thyroplasty resulted in a 10-point improvement in overall CAPE-V (Mean dif -10; 95% CI -17, -3.3, p < 0.01) and VHI-10 (mean dif -3.8; 95% CI -9.8, 2.3, p = 0.19, n = 8). NGGA and BI significantly decreased following surgery (mean dif -78; 95% CI -155, -1.5, p = 0.05; and mean dif -2.1; 95% CI -2.4, -0.84, p < 0.01, respectively). BI correlated with CAPE-V scores (r = 0.66, 95% CI 0.22, 0.87, p < 0.01). When considering the normalized combined contributions of both NGGA and BI, there was a stronger correlation in CAPE-V scores (r = 0.87, 95% CI 0.50, 0.97, p < 0.01) compared with either measure alone.

CONCLUSIONS

Thyroplasty resulted in a decrease in vocal fold bowing, glottal gap area, and CAPE-V scores in patients with ARVA. Correction of vocal bowing and glottal gap, following bilateral thyroplasty, improved voice measures following surgery. Quantitative evaluation of vocal fold morphology may be valuable when assessing the severity and treatment-response in patients with ARVA following bilateral thyroplasty. Laryngoscope, 134:835-841, 2024.

Effect of Clinical Expertise on Efficacy of Vocal Function Exercises in Individuals With Typical Voice

OBJECTIVES/HYPOTHESIS

To determine the effect of clinical expertise on efficacy of Vocal Function Exercises (VFEs) as measured by change in percent of maximum phonation time goal attained. The hypothesis was that clinical expertise would result in greater increases in percent of maximum phonation time goal attained.

STUDY DESIGN

Randomized controlled trial.

METHODS

A convenience sample of 19 individuals with typical voice was recruited in a university academic clinic setting. All participants completed baseline assessment and 17 completed all study procedures. Participants were randomized to receive VFEs from an expert voice clinician with more than 40 years' experience (expert group (EG)) or from a master's student in Communication Sciences and Disorders trained in VFEs (novice group (NG)). The primary outcome measure was change in percent of maximum phonation time goal attained during VFE tasks 1 and 4.

RESULTS

Mean change scores for maximum phonation time were 27.71 (P = 0.001) and 25.31 (P = 0.003) for EG and NG, respectively. Both groups improved significantly on the primary outcome measure, but the difference between groups was not statistically significant (P = 0.759). A Hedges'-g effect size of -0.14 [-1.10, 0.81] was obtained comparing EG and NG groups, indicating a small negative effect of limited clinical expertise on VFE outcomes in individuals with typical voice.

CONCLUSIONS

Speech-language pathologists with varied levels of expertise are capable of efficaciously administering VFEs in individuals with typical voice.

The Effect of Maximum Phonation Time Goal on Efficacy of Vocal Function Exercises

OBJECTIVES/ HYPOTHESIS

To determine the effect of maximum phonation time goal on efficacy of Vocal Function Exercises (VFEs) as measured by percent of maximum phonation time goal attained. The hypothesis was that provision of a maximum phonation time goal would result in greater increases in percent of maximum phonation time goal attained.

STUDY DESIGN

Randomized controlled trial.

METHODS

A convenience sample of individuals with normal voice were recruited in a university academic clinic setting. Of 34 participants who volunteered for the study, 28 completed baseline assessment and 19 completed all study procedures. Participants were randomized to complete VFEs with knowledge of their maximum phonation time goal (standard goal, SG), with knowledge of their maximum phonation time goal after three weeks (delayed goal, DG), or without knowledge of their maximum phonation time goal (no goal, NG). The primary outcome measure was percent of maximum phonation time goal obtained during VFE tasks one and four.

RESULTS

Mean change scores for maximum phonation time were 32.50 (SG), 34.55 (DG), and 21.02 (NG). Hedges' g effect sizes of -0.10 (-1.19, 0.99) and 0.56 (-0.55, 1.67) were obtained comparing DG and SG groups, and NG and SG groups, respectively.

CONCLUSIONS

Absence of maximum phonation time goal attenuates VFE efficacy; maximum phonation time goal is an active ingredient within VFEs.

Vocal Function Exercises With and Without Maximally Sustained Phonation: A Randomized Controlled Trial of Individuals With Normal Voice

OBJECTIVES

To determine the effect of maximally sustained phonation on efficacy of Vocal Function Exercises as measured by percent of maximum phonation time goal attained. The hypothesis was that maximally sustained phonation would result in greater improvements in percent of maximum phonation time goal attained.

STUDY DESIGN

Randomized controlled trial.

METHODS

A convenience sample of individuals with normal voice were recruited in a university academic clinic setting. Of 34 participants who volunteered for the study, 31 completed baseline assessment and 23 completed all study procedures. Participants were randomized to complete Vocal Function Exercises (traditional group TG), modified Vocal Function Exercises with reduced requirement for maximally sustained phonation (midpoint group MG), or modified Vocal Function Exercises with removed requirement for maximally sustained phonation (baseline group BG). The primary outcome measure was percent of maximum phonation time goal obtained during Vocal Function Exercises.

RESULTS

The MG (p = 0.008) and TG (p = 0.001) groups significantly improved percent of maximum phonation time goal attained after six weeks of exercise, while the BG group (p = 0.0202) did not (ɑ = 0.0125). Difference among groups was not statistically significant (p = 0.67, ɑ = 0.0125). Hedges' g effect sizes of 0.29 (-0.66, 1.25) and 0.51 (-0.57, 1.58) were obtained comparing MG and TG groups, and BG and TG groups, respectively.

CONCLUSIONS

Greater requirements for maximally sustained phonation improved efficacy of Vocal Function Exercises in enhancing normal voice as measured by percent of maximum phonation time goal attained. Maximally sustained phonation may be modified to some extent while preserving efficacy of Vocal Function Exercises, however complete elimination of maximally sustained phonation may attenuate improvement. Additional research in a clinical population is warranted.

Objective Laryngoscopic Measures From Older Patients With Voice Complaints and Signs of Aging

PURPOSE

The purpose of this study was to use objective measures of glottal gap, bowing, and supraglottic compression from selected images of laryngoscopic examinations from adults over 60 years of age with voice complaints and signs of aging to test current hypotheses on whether degree of severity impacts treatment recommendations and potential follow-through with treatment.

METHOD

Records from 108 individuals 60 years or older with voice complaints and signs of aging were reviewed. Three objective measures (normalized glottal gap area [NGGA], total bowing index, and normalized true vocal fold width) were derived. Each measure was subsequently divided into three categories by severity: absence, small degree, or large degree. Nonparametric statistics tested associations between severity and treatment recommendations as well as potential follow-through.

RESULTS

Noninvasive treatments (observation/voice therapy) were marginally associated with no glottal gap (p = .09). More invasive treatments (injection/bilateral thyroplasty) were associated with glottal gaps being present (p = .026), but bilateral thyroplasty recommendations were not significantly associated with the largest gaps. Treatment modalities were not characterized by specific severity categories for any of the objective measures. No significant differences were found for any of the three objective measures between those who followed through with recommended treatment and those who did not.

DISCUSSION

Results demonstrated some support for current hypotheses on how degrees of severity of objective measures relate to treatment recommendations. Of the three measures, NGGA appears to be more informative regarding treatment recommendations and follow-through, but due to low power, larger sample sizes are needed to confirm clinical relevance.

Rehabilitation Treatment Specification System: Methodology to Identify and Describe Unique Targets and Ingredients

Although significant advances have been made in measuring the outcomes of rehabilitation interventions, comparably less progress has been made in measuring the treatment processes that lead to improved outcomes. A recently developed framework called the Rehabilitation Treatment Specification System (RTSS) has potential to identify which clinician actions (ie, ingredients) actively improve specific patient functions (ie, targets). However, the RTSS does not provide methodology for standardly identifying specific unique targets or ingredients. Without a method to evaluate the uniqueness of an individual target or ingredient, it is difficult to know whether variations in treatment descriptions are synonymous (ie, different words describing the same treatment) or meaningfully different (eg, different words describing different treatments or variations of the same treatment). A recent project used vocal rehabilitation ingredients and targets to create RTSS-based lists of unique overarching target and ingredient categories with underlying dimensions describing how individual ingredients and targets vary within those categories. The primary purpose of this article is to describe the challenges encountered during the project and the methodology developed to address those challenges. Because the methodology was based on the RTSS's broadly applicable framework, it can be used across all areas of rehabilitation regardless of the discipline (speech-language pathology, physical therapy, occupational therapy, psychology, etc) or impairment domain (language, cognition, ambulation, upper extremity training, etc). The resulting standard operationalized lists of targets and ingredients have high face and content validity. The lists may also facilitate implementation of the RTSS in research, education, interdisciplinary communication, and everyday treatment.

Quantitative Assessment of Learning and Retention in Virtual Vocal Function Exercises

Purpose Successful voice therapy requires the patient to learn new vocal behaviors, but little is currently known regarding how vocal motor skills are improved and retained. To quantitatively characterize the motor learning process in a clinically meaningful context, a virtual task was developed based on the Vocal Function Exercises. In the virtual task, subjects control a computational model of a ball floating on a column of airflow via modifications to mean airflow (L/s) and intensity (dB-C) to keep the ball within a target range representing a normative ratio (dB × s/L). Method One vocally healthy female and one female with nonphonotraumatic vocal hyperfunction practiced the task for 11 days and completed retention testing 1 and 6 months later. The mapping between the two execution variables (airflow and intensity) and one error measure (proximity to the normative ratio) was evaluated by quantifying distributional variability (tolerance cost and noise cost) and temporal variability (scaling index of detrended fluctuation analysis). Results Both subjects reduced their error over practice and retained their performance 6 months later. Tolerance cost and noise cost were positively correlated with decreases in error during early practice and late practice, respectively. After extended practice, temporal variability was modulated to align with the task's solution manifold. Conclusions These case studies illustrated, in a healthy control and a patient with nonphonotraumatic vocal hyperfunction, that the virtual floating ball task produces quantitative measures characterizing the learning process. Future work will further investigate the task's potential to enhance clinical assessment and treatments involving voice control. Supplemental Material https://doi.org/10.23641/asha.13322891.

Effectiveness of a physiologic voice therapy program based on different semioccluded vocal tract exercises in subjects with behavioral dysphonia: A randomized controlled trial

PURPOSE

The present study aimed to assess the effectiveness of a physiologic voice therapy program based on different semioccluded vocal tract exercises in subjects with behavioral dysphonia.

METHODS

Thirty-four participants with behavioral dysphonia were randomly assigned to one of two treatment groups: 1) voice treatment with physiologic voice therapy plus vocal hygiene program (n=20), and 2) vocal hygiene program only (n=14). Laryngoscopic assessment was performed in all subjects. Before and after voice therapy, participants underwent aerodynamic, electroglottographic, and acoustic assessment. The Voice Handicap Index (VHI), Voice symptom scale (VoiSs), Vocal tract discomfort scale (VTDS), and self-assessment of resonant voice quality were also performed. The treatment included eight voice therapy sessions. For the experimental group, the exercises consisted of a sequence of seven phonatory tasks performed with four different semioccluded vocal tract exercises (SOVTE). Comparison for all variables were performed between experimental group and control group.

RESULTS

Wilcoxon test showed significant improvements for experimental group for VHI, VoiSs, VTDS (decrease), and self-perception of resonant voice quality (increase). Significant decrease for experimental groups was observed on subglottic pressure, phonation threshold pressure, and glottal airflow across the implemented tasks.

CONCLUSION

Physiologic voice therapy based on semioccluded vocal tract exercises seems to be an effective tool to improve voice in subjects diagnosed with behavioral dysphonia. Apparently, most changes should be expected in variables related to physical and functional aspects compared to objective variables. Subglottic pressure and phonation threshold pressure seem to be the most change-sensitive parameters and they may reflect a reduction in phonatory effort reported by patients after voice therapy.

Does a Systematic Vocal Exercise Program Enhance the Physiologic Range of Voice Production in Classical Singing Graduate-Level Students?

Purpose The purpose of this study was to assess the effects of vocal function exercises (VFEs) on the physiologic range of the operatic voice. The primary outcome measure was total voice range profile (VRP) area. Method Forty graduate-level opera majors were randomly assigned to experimental (training with VFE + vocal hygiene) and control (vocal hygiene only) groups. All participants underwent an acoustic voice assessment (modified VRP) pre and post 10 weeks of the assigned intervention. VRP total area was calculated and compared between and within the two groups. The total VRP area was subsequently divided into three area thirds (low, medium, and high). Results A significant improvement (increase) was observed in the VFE group for the primary outcome measure of VRP area when pre- and postvoice conditions were compared for total area, upper third, and middle third. No significant improvement was found in the vocal hygiene-only group. Conclusion Vocal training with VFEs over a 10-week period demonstrated positive effects on physiologic voice range as evidenced by an increase in the total VRP area and therefore may enhance the potential of those who already have professional voice training.

Efficacy of Voice Therapy in Improving Vocal Function in Adults Irradiated for Laryngeal Cancers: A Pilot Study

BACKGROUND

Radiation therapy (XRT) for laryngeal cancers causes acute and chronic vocal dysfunction. Although these deleterious effects of XRT are well-established, there is a dearth of research with respect to effective voice rehabilitation following XRT for laryngeal cancers.

OBJECTIVE

To obtain preliminary data on the efficacy of voice rehabilitation, using vocal function exercises (VFEs) in improving vocal function in adults irradiated for laryngeal cancer. The comparison treatment group (VH) received vocal hygiene counseling.

STUDY DESIGN

Randomized clinical trial.

METHODS

Participants were randomized to the VFE + VH or VH group. Both interventions lasted 6 weeks. The primary outcome measure was improvement in VHI scores. Secondary outcome measures included auditory-perceptual assessments, acoustic and aerodynamic measures, and laryngeal imaging.

RESULTS

Ten participants were recruited for the study. The VFE + VH (n = 6) group demonstrated a statistically significant improvement in the primary outcome measure (P = 0.03), as well as select parameters of all secondary outcome measures. The VH (n = 4) group did not demonstrate a statistically significant improvement in primary or secondary outcome measures.

CONCLUSIONS

This study offers preliminary data for the utility of VFEs in the irradiated laryngeal cancer population. However, findings in the VFE + VH group lack generalizability, secondary to sample heterogeneity, and limited sample size.

Vocal function exercises for normal voice: With and without semi-occlusion

PURPOSE

This study examined the effect of varying degrees of vocal tract (VT) occlusion used during Vocal Function Exercises (VFEs) on attainment of maximum phonation time (MPT) goals in normal voice. Greater VT occlusion was expected to result in increased MPT. The overarching goal was to determine whether the semi-occluded vocal tract (SOVT) posture used during VFEs could be modified while preserving efficacy.

METHOD

Twenty-six females ages 18-30 participated in this pre-post longitudinal group study. Participants were randomly assigned to three experimental groups and completed a six-week VFE protocol. The first group performed exercises using the prescribed SOVT posture; the second group used the vowel /o/; group three used the vowel /a/. The primary outcome measure was MPT as performed on the exercise tasks using the assigned vocal tract posture.

RESULT

MPT significantly improved in the prescribed SOVT group, but did not significantly improve in the modified /o/ and /a/ groups.

CONCLUSION

The SOVT posture used during VFEs is modifiable to a small extent without significantly undermining efficacy. Changes in MPT are less robust with reduced VT occlusion. Research in a clinical population is warranted.

Vocal function exercises for normal voice: The effects of varying dosage

PURPOSE

This study examined the effect of varying dosage of vocal function exercise (VFE) home practice on attainment of pre-established maximum phonation time (MPT) goals in individuals with normal voice. High dosage VFE practice was expected to result in greatest MPT. The overarching goal of this study was to contribute to a VFE dosage-response curve, potentially including a point of observable toxicity.

METHOD

Twenty-eight females ages 18-25 with normal voice participated in this pre-post longitudinal group study. Participants were randomly assigned to one of three experimental groups and completed a six-week VFE protocol with practice twice daily. The low dosage group performed each exercise once, the traditional group twice, and the high dosage group four times. The primary outcome measure was MPT as performed on the fourth VFE using the prescribed semi-occluded vocal tract posture.

RESULT

No toxic effects were observed. MPT increased for all participants, with significant improvement for traditional and high dosage groups.

CONCLUSION

High dosage VFEs may yield more rapid improvement in MPT, however benefits must be weighed against the risk of increased attrition. Low dosage VFEs insufficiently improved MPT. Further research on dosage is warranted, and should include individuals with disordered voice.

Immediate Effects of the Semi-Occluded Ventilation Mask on Subjects Diagnosed With Functional Dysphonia and Subjects With Normal Voices

PURPOSE

The present study was designed to assess the immediate effects of the semi-occluded ventilation mask (SOVM) in subjects with functional dysphonia and subjects with normal voice.

METHODS

Sixty-four participants were included in this study (48 women and 16 men). Thirty-one of them were diagnosed with functional dysphonia and 33 with normal voice. All subjects were randomly assigned to one of two conditions: an experimental condition using the SOVM (n = 33) and a control condition with participants not using the SOVM (n = 31). Thus, within both conditions, participants could be either dysphonic or normal-voiced. This produced a total of four different groups: (1) subjects with normal voice with SOVM (n = 17), (2) subjects with normal voice without SOVM (n = 16), (3) dysphonic subjects with SOVM (n = 16), and (4) dysphonic subjects without SOVM (n = 15). All participants underwent aerodynamic, electroglottographic (EGG), and acoustic assessments, and were also asked to assess their own voice, before and after voice exercises.

RESULTS

Significant differences were found for aerodynamic, EGG, and acoustic variables when comparing SOVM conditions (dysphonic and normal) against control. Cepstral peak prominence and EGG contact quotient showed an increase among dysphonic participants with SOVM. L1-L0 showed an increase for all participants in SOVM condition (dysphonic and normal). Self-perceived resonant voice quality showed an increase for both groups in SOVM condition. Glottal airflow showed a decrease for the dysphonic participants in SOVM condition. Phonation threshold pressure and subglottic pressure showed a decrease for both groups in SOVM condition.

CONCLUSION

The present study suggests that immediate positive effect could be produced by connected speech phonatory tasks using the SOVM in both dysphonic subjects and subjects with normal voice, the change being greater among the former. SOVM seems to promote an easy voice production and a more efficient phonation.

Vocal Dose in Older Adults with Presbyphonia: An Analytic, Cross-Sectional Study

PURPOSE

Older patients with age-related voice changes (presbyphonia) are considered vocal under-doers due to a reportedly low a amount and intensity of voice use (ie, low vocal dose). This low voice use may be consequential to negative effects of presbyphonia like throat discomfort, as well as anxiety and frustration from difficulty communicating. Causally speaking, vocal fold atrophy (presbylaryngis) may indicate inadequate intrinsic laryngeal muscle loading with low voice use, though research is lacking. As a first step, this study examined voice use objectively using vocal dosimetry in older adults with presbyphonia. We hypothesized participants, especially if retired, would exhibit low vocal doses, and lower than reported for other populations.

METHOD

This research used an analytic, cross-sectional design with subgroup analyses to determine feasibility of vocal dosimetry in older adults with presbyphonia. Thirteen older adults with presbyphonia (7 males) completed vocal dose monitoring using an ambulatory phonation monitor (APM). The APM measured vocal parameters over a day of monitoring, from which time, cycle, and distance doses were calculated. Data also were gathered on demographics, vocal handicap, and vocal effort.

RESULTS

Descriptively, the group showed a low mean time dose as compared to published vocal dose data from other populations. Females exhibited significantly higher mean values of time dose, cycle dose, and fundamental frequency than males. Time dose for males was negatively correlated with vocal effort. Subgroup analyses failed to detect an effect of age group, but found significantly a higher mean value for time dose in employed, compared to retired, participants.

CONCLUSIONS

Consistent with self-report, we found older adults with presbyphonia exhibit low time doses, which were in contrast to high vocal doses published on teachers, patients with dysphonia, and even office workers. We found differences in vocal dose as a function of sex and employment status. Though a limited sample, findings suggest patients with presbyphonia may demonstrate low vocal dose, which may be a useful target in treatment.

Immediate Effects of the Vocal Function Exercises Semi-Occluded Mouth Posture on Glottal Airflow Parameters: A Preliminary Study

OBJECTIVES

The study aimed to quantify immediate alterations in the airflow glottogram between the Vocal Function Exercises semi-occluded mouth posture (/ol/ with lip buzz) and the sustained vowel /o/ in individuals with normal voices, and to determine if noted changes were in agreement with established semi-occluded vocal tract aerodynamic theory. Based on semi-occluded vocal tract aerodynamic theory, we hypothesized the following immediate changes in the flow glottogram during the /ol-buzz/ condition: a greater open quotient, a greater skewing quotient, a greater maximum flow declination rate, increased average airflow, decreased peak airflow, and increased minimum airflow.

METHODS

A cohort of eight men with normal voices produced the sustained vowel /o/ and the Vocal Function Exercises semi-occluded mouth posture (/ol-buzz/). Flow glottograms for both conditions were obtained from the inverse-filtered oral airflow signal via a circumferentially vented pneumotachograph mask.

RESULTS

Data revealed that open quotient and minimum airflow rates increased significantly between conditions. All other measures trended in the directions predicted by aerodynamic theory, but were not statistically significant.

CONCLUSIONS

The Vocal Function Exercises semi-occluded mouth posture appeared to provide an effective vocal tract semi-occlusion that immediately altered the flow glottogram in accordance with predictions made by computer-modeled aerodynamic theory.

Effect on long-term average spectrum of pop singers' vocal warm-up with vocal function exercises

Abstract This case-control study aimed to investigate if there is any change on the spectral slope declination immediately after vocal function exercises (VFE) vs traditional vocal warm-up exercises in normal singers. Thirty-eight pop singers with perceptually normal voices were divided into two groups: an experimental group (n = 20) and a control group (n = 18). One single session with VFE for the experimental group and traditional singing warm-up exercises for the control group was applied. Voice was recorded before and after the exercises. The recorded tasks were to read a phonetically balanced text and to sing a song. Long-term average spectrum (LTAS) analysis included alpha ratio, L1-L0 ratio, and singing power ratio (SPR). Acoustic parameters of voice samples pre- and post-training were compared. Comparison between VFE and control group was also performed. Significant changes after treatment included the alpha ratio and singing power ratio in speaking voice, and SPR in the singing voice for VFE group. The traditional vocal warm-up of the control group also showed pre-post changes. Significant differences between VFE group and control group for alpha ratio and SPR were found in speaking voice samples. This study demonstrates that VFE have an immediate effect on the spectrum of the voice, specifically a decrease on the spectral slope declination. The results of this study provide support for the advantageous effect of VFE as vocal warm-up on voice quality.