Multidimensional Analysis on the Effect of Vocal Function Exercises on Aged Vocal Fold Atrophy

Aerodynamic Threshold Measures for Reflecting Glottal Closure in Voice Disorders

PURPOSE

Previous work suggested that phonation threshold pressure (PTP), phonation threshold flow (PTF), and phonation threshold power (PTW) could be effective aerodynamic measures for quantifying glottal incompetence. This study examined how these measures could reflect varying extent of incomplete glottal closure in individuals with voice disorders.

METHOD

Thirty individuals formally diagnosed with glottal incompetence, including 10 with hypofunctional disorders (hypo group) and 20 with hyperfunctional disorders (hyper group), and 30 individuals with normal voice (control group) participated in the study. PTP was measured indirectly by intra-oral pressure during production of bilabial stop consonant-vowel syllables, PTF was measured during the sustained vowel /a/, and PTW was obtained as the product of PTP and PTF. The extent of incomplete glottal closure was quantified by normalized glottal gap (NGG) and normalized glottal gap area (NGGA) based on image analysis of videostroboscopic recordings of sustained /i/.

RESULTS

Significant differences in all threshold measures (p < .05) were found among three participant groups with medium-to-large effect sizes (ηp2 = .128-.220), with significantly higher values for the hypo group than the control group and no significant differences between the hyper and control groups. Receiver operating characteristic (ROC) analysis showed the highest diagnostic or classification accuracy contrasting between the hypo and control groups (area under the ROC curve = .717-.757), with the highest classification accuracy for PTW. There were significant, moderate-to-strong positive correlations with NGG and NGGA for the disorders group (Pearson's r = .4244-.6226) and the hypo group (r = .5689-.8949).

CONCLUSIONS

These measures could be effective for identifying glottal incompetence, especially for hypofunctional disorders. PTW could be more sensitive than PTP and PTF in reflecting the extent of incomplete glottal closure, consistent with theoretical predictions. Their relative sensitivities for quantifying distinct incomplete glottal closures specific to different voice disorders should be evaluated in future studies.

Treating Presbyphonia in 2024: A Scoping Review

Presbyphonia is a multi-dimensional pathology. Therefore, its treatment should address its different affecting factors, including a global health management to fight geriatric frailty, improve overall physical strength, and limit medication side-effects. The specific therapies should address glottal gap closure and vocal folds' pliability. Based on a literature scoping review, we propose to start with voice therapy, combining different exercises and techniques that can improve voice quality. For patients with high vocal demands or larger glottal gaps, a medialization should be performed with an office-based medialization with hyaluronic acid injection as a first line. This can be associated with office-based injection of platelet rich plasma to improve mucosal vibration.

Effect of Voice Therapy as a Supplement After Reinnervation Surgery for Breathy Dysphonia Due to Unilateral Vocal Fold Paralysis

OBJECTIVE

To evaluate whether vocal function exercises (VFE) could be an adjunct treatment for patients with unilateral vocal fold paralysis (UVFP) who were not satisfied with their postoperative voices after reinnervation surgeries.

STUDY DESIGN

Retrospective.

METHODS

Medical records of the patients with UVFP who underwent laryngeal reinnervation between October 2011 and October 2014 were reviewed. Patients were classified into two groups: one received VFE according to patients' desire (VFE group) and the other did not have voice therapy (control group). Effects of VFE were assessed by vocal fold vibration (regularity, amplitude and glottal gap), aerodynamic measurements (maximum phonation time (MPT) and mean airflow rate (MFR)), GRBAS scale, acoustic parameters (pitch range, pitch perturbation and amplitude perturbation quotients (PPQ, APQ), and noise-to-harmonics ratio (NHR)) and subjective evaluation by patients (Voice Handicap Index-10 (VHI-10)). Phonatory function was also compared between the two groups at three time points: before reinnervation surgery, before VFE, and after VFE.

RESULTS

Thirty patients were enrolled (11 men, 19 women). The VFE group included eight patients, and 22 patients served as controls. In the VFE group, several parameters (amplitude, MPT, MFR, pitch range, APQ, and NHR) did not improve significantly after surgery, while all parameters examined improved significantly in the control group. After VFE, amplitude, glottal gap, MFR, B score, pitch range, and PPQ showed significant improvement, while the control group did not show a significant improvement except in VHI-10, during the corresponding period. Significant differences in G and B scores and VHI-10 between the two groups were observed at the third time point.

CONCLUSIONS

VFE may be used as an adjunct treatment for patients with UVFP who are not satisfied with their voices after reinnervation surgery. However, phonatory function after VFE may not reach the same level as for those who are satisfied with their voices after reinnervation surgery.

Endoscopic Distance and its Impact on Quantified Age-related Vocal Fold Atrophy Measures

INTRODUCTION

The bowing index (BI) and normalized glottal gap area (NGGA) are used to quantify vocal fold morphology in ARVA; however, the influence of the distance between the flexible laryngoscope lens and the target area is not known. The goal is to test whether the endoscopic distance impacts vocal fold morphology measurements in patients with ARVA during flexible video laryngostroboscopy (VLS).

METHOD

Patients with ARVA who underwent VLS were included. Images were classified into near (close to the petiole of the epiglottis) and far (below nasopharynx, with tongue base and entire epiglottis visible) conditions. BI was calculated using a mobile application, and NGGA was measured using ImageJ.

RESULTS

This study included 23 patients; the mean age was 77 ± 7 years. Mean BI measured at the near distance was higher than far distances with a mean difference of 1.94 (95% CI: 0.92-2.96, p = 0.001). NGGA showed difference with changed distance -0.24 (95% CI: -0.48 to 0.01, p < 0.05).When stratifying patients into two groups based on median BI measurement, there was a statistically significant difference between near and far conditions, with increased BI in the near condition for patients above the median (p < 0.05), but no difference between the near and far condition for patients with BI below the median.

CONCLUSION

The BI and NGGA were impacted by the endoscopic distance during flexible VLS. BI was significantly higher in the near condition compared with the far condition. The difference in BI between the near and far conditions was more pronounced when the vocal fold bowing was greater. These findings call for heightened awareness of measurement discrepancies secondary to the endoscopic distance during flexible laryngostroboscopy.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:4649-4655, 2024.

Effect of Vocal Function Exercises on the Voice Handicap Index, Vocal Fatigue Index, and Number of Vocal Fatigue Symptoms in Bank Workers: Single-Blinded Randomized Controlled Trial

Vocal fatigue (VF) is a significant portion of occupational voice disorders. Researchers have proposed numerous therapeutic approaches to alleviate VF. However, the efficacy of vocal function exercises (VFEs) as a safe, effective, and simple method is unclear. The current study aims to investigate the effect of VFEs on occupational-related VF in Iranian bank workers. A single-blinded randomized controlled trial with four-level blocking After screening 444 workers, 43 persons with vocal fatigue (VF) were allocated between intervention and control groups. The gender of participants was considered a confounding parameter. Intervention group participants (IGP) (20 males and two females) practiced vocal function exercises (VFEs) (online training) for two weeks, while control group participants (CGP) (20 males and a female) continued their routine lifestyle. The Number of Vocal Fatigue Symptoms (NoVFS), Maximum Phonation Time (MPT), Voice Handicap Index (VHI), and Vocal Fatigue Index (VFI) at pre-intervention and post-intervention levels were gathered and compared. According to the intergroup, pre-/post-intervention differences, and intragroup analysis, the IGP experienced a significant reduction in the NoVFS (P = 0.006, P = 0.009), the mean score VHI (P:0.006, P: 0.001, P: 0.001), the total mean score of VFI (P < 0.001, P < 0.001, P < 0.001), and the first (P = 0.005, P = 0.002, P < 0.001) and second (P = 0.006, P < 0.001) factors' mean score of VFI. Additionally, there was an improvement in the MPT (P < 0.001, P < 0.001, P < 0.001) and the third factor (P = 0.01, P = 0.004, P = 0.021) mean score of VFI. Vocal function exercises can alleviate symptoms, voice handicaps, tiredness, avoidance, and physical discomfort of vocal fatigue in bank workers. Additionally, it can improve glottal (pulmonary) sufficiency and rest recovery of vocal fatigue in this group of workers.

Glottic insufficiency caused by vocal fold atrophy with or without sulcus: systematic review of outcome measurements

PURPOSE

Identifying outcome measurements instruments (OMIs) to evaluate treatment efficacy in patients with vocal fold atrophy and/or sulcus.

METHODS

Systematic review of records published before March 2021 by searching Pubmed and EMBASE. Included studies reported on adults (> 18 year) with dysphonia caused by glottic insufficiency due to vocal fold atrophy with or without sulcus, who were enrolled into a randomized controlled trial, a non-randomized controlled trial, a case-controlled study or a cohort study. All included studies described an intervention with at least one outcome measurement.

RESULTS

A total of 5456 studies were identified. After removing duplicates, screening title and abstract and full text screening of selected records, 34 publications were included in final analysis. From these 50 separate OMIs were recorded and categorized according to the ELS protocol by DeJonckere et al. (Eur Arch Otorhinolaryngol 258: 77-82, 2001). With most OMIs being used in multiple studies the total number of OMIs reported was 265. Nineteen (19) individual OMIs accounted for 80% of reports. The most frequently used OMIs according to category were: VHI and VHI-10 (subjective evaluation); G of GRBAS (perceptual evaluation); F0, Jitter and Shimmer (acoustic evaluation); MPT and MFR (aerodynamic evaluation) and glottic closure and mucosal wave (endoscopic evaluation). Of these OMIs VHI had a high percentage of significance of 90%.

CONCLUSION

This systematic review identifies the most used OMIs in patients with glottic incompetency due to vocal fold atrophy and/or sulcus as a step toward defining a Core Outcome Set (COS) for this population.

PROSPERO REGISTRATION

238274.

Effect of intensive water resistance phonation therapy for people with presbyphonia: A pilot study

Purpose: The aim of this pilot study was to explore the efficacy of an intensive 3 week water resistance phonation (WRP) therapy program for people with presbyphonia.Method: Participants included 13 people with presbyphonia who received intensive WRP therapy. All participants completed eight sessions of therapy over 3 weeks. Auditory perceptual ratings, and acoustic and aerodynamic assessments were performed before and after treatment. Participants also completed the voice-related quality of life questionnaire before and after the treatment.Result: After 3 weeks of intensive voice therapy, significant improvements were demonstrated in acoustic, aerodynamic, and auditory perceptual parameters, as well as patient perceptions of voice-related quality of life. Acoustically, it was found there were significant decreases in shimmer (p = 0.019), noise-to-harmonic ratio (p = 0.016), and smoothed cepstral peak prominence (p = 0.001). Perceptually, the clients with presbyphonia showed significant reductions in the ratings of the overall grade, roughness, asthenia, and strain. Moreover, there was a significant increase in the total score of the Mandarin version of the Voice-Related Quality of Life measure post-therapy.Conclusion: The investigation provides preliminary evidence that people with presbyphonia can improve their vocal function and voice-related quality of life through intensive WRP therapy within a short period of time.

Investigating Acoustic and Psycholinguistic Predictors of Cognitive Impairment in Older Adults: Modeling Study

BACKGROUND

About one-third of older adults aged 65 years and older often have mild cognitive impairment or dementia. Acoustic and psycho-linguistic features derived from conversation may be of great diagnostic value because speech involves verbal memory and cognitive and neuromuscular processes. The relative decline in these processes, however, may not be linear and remains understudied.

OBJECTIVE

This study aims to establish associations between cognitive abilities and various attributes of speech and natural language production. To date, the majority of research has been cross-sectional, relying mostly on data from structured interactions and restricted to textual versus acoustic analyses.

METHODS

In a sample of 71 older (mean age 83.3, SD 7.0 years) community-dwelling adults who completed qualitative interviews and cognitive testing, we investigated the performance of both acoustic and psycholinguistic features associated with cognitive deficits contemporaneously and at a 1-2 years follow up (mean follow-up time 512.3, SD 84.5 days).

RESULTS

Combined acoustic and psycholinguistic features achieved high performance (F1-scores 0.73-0.86) and sensitivity (up to 0.90) in estimating cognitive deficits across multiple domains. Performance remained high when acoustic and psycholinguistic features were used to predict follow-up cognitive performance. The psycholinguistic features that were most successful at classifying high cognitive impairment reflected vocabulary richness, the quantity of speech produced, and the fragmentation of speech, whereas the analogous top-ranked acoustic features reflected breathing and nonverbal vocalizations such as giggles or laughter.

CONCLUSIONS

These results suggest that both acoustic and psycholinguistic features extracted from qualitative interviews may be reliable markers of cognitive deficits in late life.

Cough and Swallowing Therapy and Their Effects on Vocal Fold Bowing and Laryngeal Lesions

OBJECTIVE

Expiratory muscle strength training (EMST) and sensorimotor training of airway protection (smTAP) are two exercises intended to improve cough and swallowing in people with Parkinson's Disease (PwPD). The aims of this study were to (1) examine whether EMST or smTAP elicit changes to vocal fold bowing; and (2) describe the safety of EMST and smTAP as it relates to the development of vocal fold lesions.

METHOD(S)

This was a secondary analysis of data from PwPD who completed EMST or smTAP as part of a prospective randomized controlled trial. Vocal fold bowing (BI) and the presence of laryngeal lesions were blindly analyzed from flexible endoscopic evaluation of swallowing (FEES) using ImageJ software and operational definitions. Linear regression was used to examine the influence time (pre- vs. post-therapy) and therapy (EMST vs. smTAP) on vocal fold bowing. Descriptive statistics were used to describe the presence of laryngeal lesions.

RESULT(S)

Overall, 56 participants were included, 28 per group. The median BI scores pre- and post-therapy were 8.2% and 8.3% for the EMST group and 11.3% and 8.4% for the smTAP group, respectively. Statistical analyses revealed insufficient evidence to suggest an effect of time and treatment type on BI (p > 0.05) or on the presence of vocal fold lesions (p > 0.05).

CONCLUSION

Based on these and previous findings, it appears that changes in vocal fold bowing do not drive treatment effects following EMST and smTAP. Also, this study further supports the safety of smTAP and EMST despite the required forceful exhalation and repetitive coughing.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1127-1132, 2024.

Physiological Effects of Voice Therapy for Aged Vocal Fold Atrophy Revealed by EMG Study

OBJECTIVES

Age-related voice changes are characterized as breathy, weak and strained, and a deterioration in vocal function in the elderly has been putatively linked to a reduced intensity of speech. They contribute to undesirable voice changes known as presbyphonia. These changes are caused by histological alterations in the lamina propria of the vocal fold mucosa and atrophy of the thyroarytenoid muscle, as well as by decreased respiratory support. There are several clinical studies on presbylarynx dysphonia showing the effectiveness of voice therapy. However, physiological changes of the presbylarynx following voice therapy have not been verified. The purpose of this prospective study was to demonstrate the clinical effectiveness of voice therapy for rehabilitating presbylarynx dysphonia, using vocal function assessments and thyroarytenoid muscular activity detection on laryngeal electromyography (LEMG).

METHODS

10 patients who were diagnosed with aged vocal fold atrophy from ages 60 to 87 years (mean age: 72 years) underwent approximately 12 weeks of voice therapy, mainly using forward-focused voice and vocal resistance training. Stroboscopic examination, aerodynamic assessment, acoustic analysis, Voice Handicap Index (VHI)-10, and LEMG were performed pre- and post-voice therapy. Vocal fold vibratory amplitude (VFVA) was measured by image analysis from the stroboscopic examinations. Turns analysis during steady phonation on LEMG was also assessed.

RESULTS

Maximum phonation time, subglottic pressure, jitter, shimmer, VFVA, and VHI-10 significantly improved after voice therapy. The number of turns per second on LEMG also significantly increased.

CONCLUSION

Our data suggest that voice therapy may improve vocal function and thyroarytenoid muscle activity in patients with aged vocal fold atrophy.

Evidence of Long-Term Voice Therapy Effectiveness in Patients With Presbylarynges

Evidence for long-term effectiveness of voice therapy (>2 years from previous clinic visit) is lacking from patients over 60 years who initially presented with voice complaints and subsequently demonstrated videostroboscopic signs of aging leading to voice therapy recommendations. Over the telephone, a certified speech-language pathologist enquired from those compliant and non-compliant, whether their voices were better, stable, or worse since their previous clinic visit, and asked them to rate Voice-Related Quality of Life, voice satisfaction, and Glottal Function Index to compare with their previous clinic visit ratings. Further questions focused on current voice satisfaction, and for those who were compliant, therapeutic experiences including home exercises. Twenty-four participated (16 complied; eight non-compliant), with a mean of 3.7 ± 1.2 years since the previous clinic visit. For those compliant, 0% reported better voices, 69% stable, and 31% worse. Most compliant participants (56%) attended between two and five therapy sessions. The most frequently reported therapy techniques were repeating nasal sounds/words; straw phonation; fewer words/breath group; and increasing pitch range. Eighty-one percent of compliant participants were given home exercises. They stopped regular practice a few months post-therapy but continued using them as rescue techniques. For those non-compliant, 88% reported better voices, 0% stable, and 12% worse. Most non-compliant participants (43%) reported lack of time as their reason for non-compliance. Most compliant participants reported stable voices, supporting voice therapy's role in maintaining voice function over time in the context of progressive aging. However, non-compliant participants were not associated with poorer voice quality over time.

Sensitivity of Videolaryngostroboscopic Rating Tools to Differences in Dysphonia Severity

OBJECTIVES

This study evaluated the validity of two videolaryngostroboscopic (VLS) rating tools to detect differences in VLS ratings between normophonic speakers, mild, and moderate-severely dysphonic speakers.

METHODS

Sixteen rigid VLS exams were obtained from four normophonic controls and 12 speakers with dysphonia (8 =mild, 4 =moderate-severe) secondary to laryngeal pathology. Eight clinicians rated nine vibratory VLS parameters for each exam using both the Voice-vibratory Assessment of Laryngeal Imaging (VALI) tool and a 100 mm visual analog scales (VAS). Ratings obtained for both right and left vocal folds (eg, mucosal wave, amplitude of vibration, nonvibrating portion) were averaged. One rating of overall severity of laryngeal function using a 100 mm VAS also was obtained. ANOVAs were used to evaluate differences in VLS parameters between three speaker groups (normophonic, mildly dysphonic, moderate-severely dysphonic) using these two rating tools.

RESULTS

There were statistically significant differences between controls and moderate-severely dysphonic speakers and for all VLS parameters except phase symmetry (P < 0.05) for both VALI and VAS ratings. Differences between mildly dysphonic and moderate-severely dysphonic and speakers were observed for 4/6 VALI ratings (mucosal wave, nonvibratory portions, phase closure, and regularity) and 5/6 parameters (mucosal wave, amplitude of vibration, nonvibratory portions, phase closure, and regularity) for VAS ratings. Significant differences between controls and mildly dysphonic speakers were not observed for VLS parameter rated using the VALI. There were significant differences between controls and mildly dysphonic speakers for 3/6 parameters (mucosal wave, amplitude of vibration, nonvibratory portion) using a VAS. Ratings of overall severity of laryngeal function differed between all levels of dysphonia severity.

CONCLUSIONS

Significant differences in VLS ratings were observed for comparisons of normophonic and moderate-severely dysphonic speakers and mild to moderately dysphonic speakers using the VALI and the VAS. However, the VAS scale appeared to better differentiate differences in VLS measures between normophonic speakers and those with mild dysphonia. Future studies should consider rating scale sensitivity when VLS rating tools are selected for clinical and research purposes.

Geriatric Voice: Distinctive Clinical Profiles of Working Seniors in a Tertiary Laryngology Clinic

OBJECTIVES

Voice disorders have been reported in up to 47% of the geriatric population. Few studies have assessed dysphonia in the elderly, with none examining vocal function in working seniors. This study aims to profile the clinical characteristics of individuals aged 65 years and older, comparing working and non-working seniors.

STUDY DESIGN

Retrospective cohort study.

METHODS

Medical charts were reviewed for patients aged 65 years and older referred to the McGill University Health Centre Laryngology Clinic (January 2018-March 2020). Variables studied included sociodemographics, comorbidities, voice complaints, lifestyle factors, diagnoses, voice acoustics [maximum phonation time (MPT), S/Z ratio, F0], GRBAS scale, Voice Handicap Index-10 (VHI-10), Reflux Symptom Index (RSI), and treatment modalities.

RESULTS

A total of 267 patients were included, with a mean [standard deviation (SD)] age of 74.2 (6.6) years and 61% of female patients. Occupation information was available in 148 cases, of which 31.1% were still working and 12.8% were professional voice users. The predominant voice complaint was dysphonia/hoarseness (48.8%) and the most prevalent diagnosis was presbyphonia (31.8%). The mean (SD) VHI-10 and RSI scores were 19.8 (9.0) and 18.7 (9.4) points, respectively. Voice therapy was prescribed for 155 patients (58.7%): 124 attended at least one session with significant post-treatment improvements in the GRBAS and VHI-10 scores (P < 0.01). In the univariate analysis, working seniors had a significantly more prevalent singing habit (P = 0.04) and laryngopharyngeal reflux diagnosis (P = 0.01), displaying a significantly longer MPT (P < 0.001) and lower G-B-S scores (P < 0.05). After adjusting mean differences, only MPT and the G-S scores were significantly different between both groups.

CONCLUSIONS

The predominant diagnosis in elders with voice complaints was presbyphonia. Voice therapy proved effective in improving the VHI-10 and GRBAS scores for geriatric patients. Almost one-third of seniors remained in the workforce, demonstrating superior vocal profiles, specifically in the MPT and the grade and strain of perceptual voice quality.

A Systematic Review of Speech-Language Pathology Interventions for Presbyphonia Using the Rehabilitation Treatment Specification System

BACKGROUND

The prevalence of voice disorders for people aged >65 years is four times higher than for the population at large. The most common cause of dysphonia in this group is presbyphonia, the preferred first-line treatment for which is voice therapy with a speech-language pathologist. This systematic review seeks to identify how voice therapy affects multidimensional voice outcomes in people with presbyphonia.

METHODS

A systematic search of CINAHL, Embase, Emcare, MEDLINE, and Google Scholar was conducted in March 2023. Comparative and noncomparative studies of voice therapy in participants aged >50 years with presbyphonia were considered for inclusion. No limitations were placed on date or language of publication. Study quality and risk of bias were assessed with the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies. Subgroup analysis was used to compare studies based on participant sex, intervention duration, study design, and intervention content. Interventions were specified using the Rehabilitation Treatment Specification System (RTSS) employing a consensus methodology among reviewers. The results were synthesized utilizing meta-analysis when outcomes were adequately specified and narrative analysis when they were not.

RESULTS

Twenty-three studies were included with 1050 subjects (mean age: 72.5 ± 8.6 years; 51% female). The most reported intervention was vocal function exercises. Per the RTSS, 14 interventions employed a predominantly Organ Functions approach, and the 14 remaining interventions employed a Skills & Habits approach. Meta-analysis confirmed posttherapy improvement in patient-related outcome measures of 0.93 standard mean difference (P < 0.00001, 95% confidence interval [CI]: 0.70-1.17); studies with predominantly males and with longer treatment periods were associated with larger improvements, while randomized controlled trials reported more modest improvements. Meta-analysis also identified a mean posttherapy increase in maximum phonation time (MPT) of 5.37 seconds (P < 0.00001, 95% CI: 3.52-7.22). Treatments with an Organ Functions focus resulted in greater gains in MPT than those with a Skills & Habits focus (7.52 seconds versus 2.90 seconds). Finally, meta-analysis identified reductions in acoustic perturbation measures (jitter: 0.62%, P < 0.001, 95% CI: 0.26%-0.97%; shimmer 1.05%, P < 0.00001, 95% CI: 0.67%-1.44%). Narrative synthesis further identified improvement in auditory-perceptual voice quality in all active treatment groups as well as improved glottal function in most studies that reported this.

CONCLUSIONS

Despite the uncertainty around internal validity introduced by the inclusion of a wide range of study designs, there is convincing evidence that voice therapy for presbyphonia results in significant improvement in patient-reported, aerodynamic, acoustic, and expert-rated voice outcomes. Treatments with an Organ Functions focus may better address the underlying physiological deficits of presbyphonia, although future comparative studies with multidimensional voice assessment are warranted.

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.

Treatments for Age-related Vocal Atrophy: A Systematic Review

OBJECTIVE

Age-related vocal atrophy (ARVA) can dramatically affect voice, communication, and quality of life. The objectives of this systematic review were to (1) determine whether treatments for ARVA were superior to controls (2) compare the relative efficacy of procedural and behavioral treatments (3) review the various types of outcome measures, and (4) evaluate the quality of studies.

REVIEW METHODS

The literature was searched using strategies designed by a medical librarian (2/18/21, updated 3/9/22). Studies investigating treatments for bilateral vocal atrophy were included. Studies involving unilateral atrophy, presbyphonia (without endoscopic findings), or an absent comparator group were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was used to guide this study.

RESULTS

After applying the inclusion/exclusion criteria, 8 articles remained, including 4 randomized trials and 4 cohort studies, and a narrative synthesis was performed. Surgical and behavioral treatments for ARVA appeared to be superior to control groups, based on specific outcome measures. However, the superiority of these treatments over controls was not uniformly observed across multiple outcome measures. When comparing different treatments, superiority could not be established based on the quality and completeness of the studies included in the systematic review. Outcome measures also varied between individual studies. Finally, the risk of bias was analyzed and scored. Consistent point deductions among reviewed studies were noted.

CONCLUSIONS

When comparing treatments for ARVA. Surgery and voice therapy were both superior to control groups based on specific outcome measures from different domains. Superiority of one treatment could not be established.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:2846-2855, 2023.

Recurrent laryngeal motor nerve conduction studies in a rat model: Establishing an objective measure for investigating laryngeal innervation

INTRODUCTION/AIMS

Disease or injury can cause neuromuscular changes to the larynx that can affect voice, breathing, and swallowing. Motor nerve conduction studies have had limited use in the study of laryngeal neurophysiology, despite their importance in other anatomic sites. The aim of this study was to explore the feasibility of performing recurrent laryngeal motor nerve conduction studies (rlMNCS) in a rat model.

METHODS

rlMNCS were performed in 15 rats under anesthesia. A bipolar stimulating electrode was placed on the recurrent laryngeal nerve (RLN) 5 mm below the cricoid cartilage. Via direct laryngoscopy, a recording electrode was placed transorally into the thyroarytenoid muscle. The RLN was maximally stimulated to determine the compound muscle action potential (CMAP). Three consecutive trials were averaged.

RESULTS

The mean stimulating threshold to the RLN to achieve a CMAP from the thyroarytenoid was 1.7 ± 0.6 mA. RLN stimulation caused a visible adductor twitch of the vocal fold in all animals. The mean negative amplitude was 2.0 ± 0.8 mV, and the total area was 1.0 ± 0.4 mV ms. The CMAP latency and negative duration were 1.0 ± 0.1 ms and 0.9 ± 0.2 ms, respectively.

DISCUSSION

rlMNCS are feasible and may be useful in understanding laryngeal neurophysiology with disease or injury. This work could provide a tractable animal model for studying and monitoring treatment of neuromuscular conditions affecting voice, breathing, and swallowing.

A 4-Week Straw Phonation in Water Exercise Program for Aging-Related Vocal Fold Atrophy

PURPOSE

This study evaluated the efficacy of a 4-week straw phonation in water (SPW) exercise program on aging-related vocal fold atrophy (VFA), with a secondary objective to examine the immediate effects of SPW exercises.

METHOD

Thirty-eight older adults aged 60 years and above formally diagnosed with aging-related VFA were randomly assigned into an experimental group undergoing SPW exercises with an 8-cm depth of straw submersion into water for 4 weeks plus vocal hygiene practice (n = 20), and a control group with only vocal hygiene practice (n = 18). Outcome measures included laryngeal endoscopic measures of glottal gap, auditory-perceptual ratings of voice quality, acoustic measures, aerodynamic measures, and standardized self-assessment questionnaire scores. An additional round of acoustic and aerodynamic assessment following 20 min of SPW exercises was conducted to examine the immediate effects.

RESULTS

Significant improvements in normalized glottal gap area, perceptual rating of breathiness, smoothed cepstral peak prominence, harmonics-to-noise ratio (HNR), mean oral airflow, subglottal pressure and laryngeal airway resistance at comfortable loudness, Voice-related Quality of Life scores, and Chinese Vocal Fatigue Index Factor 3 scores were observed in the experimental group relative to the control group. There were also significant immediate effects for HNR, mean oral airflow, subglottal pressure, and laryngeal airway resistance.

CONCLUSIONS

These findings suggested significant immediate improvements in vocal function following SPW exercises, with additional significant improvements in vocal function as well as significant improvements in quality of life following the 4-week SPW exercise program. Further studies with more long-term follow-up are recommended to better understand the efficacy of SPW exercises with deep levels of straw submersion into water as an effective clinical option for the management of hypofunctional dysphonia associated with aging-related VFA.

Nonlinear analysis by phase space reconstruction of healthy elderly voices

PURPOSE

To compare the results of the non-linear acoustic analysis of elderly male and female voices, speakers of Brazilian Portuguese.

METHODS

Recordings of 14 men and 15 women were used. The voices were consensually judged to be vocally healthy by three trained speech therapists. The non-linear acoustic analysis was performed by the Phase Space Reconstruction (PSR) analysis using the Voice Analysis program.

RESULTS

A significant difference was observed in the parameter irregularity (p = 0.001) and spacing (p = 0.005), with worse results for the male group. While 93% of male voices presented degrees 2 or 3 of irregularity, these degrees were observed in 53% of female voices. In 78.6% of male voices, medium to large spacing was observed, a fact observed only in 26.7% of women.

CONCLUSION

The results of the non-linear analysis, through the Phase Space Reconstruction, using the CIS Protocol, in the voices of the elderly, showed the best result in terms of the number of curves (four or more). Regarding the irregularity of the tracing, in men, the majority presented grades 2 and 3 and in women, half presented grade 1. Regarding the spacing, 78.6% of the male voices had medium to large spacing, a fact observed only in 26.7% of women.There was a difference between the sexes in the vocal findings of the elderly by the CIS protocol with the PSR, pointing out worse results irregularity and spacing in the male population, which suggests greater vocal aperiodicity in elderly men.

Utilizing novel recurrent laryngeal motor nerve conduction studies to characterize the aging larynx: A pilot study

Objectives

Age-related changes to the larynx are associated with dysphonia and contribute to reduced quality of life. This study utilizes recurrent laryngeal motor nerve conduction studies (rlMNCS) to determine if neurophysiologic changes occur in the aging larynx using an aging rat model.

Study Design

Animal study.

Methods

In vivo rlMNCS were performed in 10 young hemi-larynges (3-4 months) and 10 aged hemi-larynges (18-19 months) rats (Fischer 344 × Brown Norway F344BN). Recording electrodes were placed into the thyroarytenoid (TA) muscle through direct laryngoscopy. Recurrent laryngeal nerves (RLNs) were directly stimulated with bipolar electrodes. Compound motor action potentials (CMAPs) were obtained. RLN cross-sections were stained with toluidine blue. Axon count, myelination, and g-ratio were quantified utilizing AxonDeepSeg analysis software.

Results

rlMNCS were successfully obtained in all animals. Mean CMAP amplitude and negative durations in young rats were 3.58 ± 2.20 mV and 0.93 ± 0.14 mS (mean dif: 0.17; 95% CI: -2.21 to 2.54), respectively, and 3.74 ± 2.81 mV and 0.98 ± 0.11 mS (mean dif: 0.050; 95% CI: -0.07 to 0.17). No significant differences in onset latency or negative area were observed. Mean axon count in young rats (176 ± 35) was comparable to that in old rats (173 ± 31). Myelin thickness and g-ratio did not differ between groups.

Conclusions

There were no statistically significant differences in RLN conduction or axon histology between young and aged rats in this pilot study. This work provides a basis for future, adequately powered studies, and may lead to a tractable animal model to study the aging larynx.

Level of Evidence

5.

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.

The maximum phonation time as marker for voice treatment efficacy: A network meta-analysis

PURPOSE

There is a diversity in treatment approaches for voice therapy in which aerodynamic treatment effects between the approaches are lacking. The evidence of voice treatments on the maximum phonation time (MPT) was quantified using the statistical approach of a network meta-analysis (NMA).

DATA SOURCES

Three databases and manual search from inception to November 2021 were evaluated.

STUDY SELECTION

Studies were considered which were reports of randomised controlled/clinical trials (RCT) evaluating the efficacy of a specific voice therapy treatment using MPT as an outcome measure in adult participants with voice disorders. Studies were excluded if participants had been diagnosed with neurological-motor-speech disorders or who were vocally healthy. Furthermore, no medical, pharmacological, or technical instrumental treatments were used.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for systematic reviews and meta-analyses extension statement guidelines were followed. Two reviewers independently screened citations, extracted data, and assessed risk of bias using PEDro scale. Random effects model was used for meta-analysis.

RESULTS

We identified finally 12 RCT studies (treatment groups n = 285, and control group without an intervention n = 62). Eight interventions were evaluated. The only effective intervention with a significant effect was vocal function exercises (VFE) (mean pre-post difference 6.16 s, 95% confidence interval, 1.18-11.13 s).

CONCLUSIONS AND RELEVANCE

VFE effectively improved MPT from pre- to post-treatment in comparison with other voice interventions which were identified in the present NMA. Further high-quality intervention studies with large samples sizes, multidimensional measures, and homogeneous groups of dysphonia are needed to support evidence-based practice in laryngology.

Physiologic Voice Rehabilitation Based on Water Resistance Therapy With Connected Speech in Subjects With Vocal Fatigue

PURPOSE

The present study aimed to assess the effectiveness of a physiologic voice therapy program based on water resistance therapy (WRT) exercises including connected speech in a group of subjects with voice complaints (vocal effort and fatigue).

METHODS

Twenty-four participants with behavioral dysphonia were randomly assigned to one of two treatment groups: (1) voice treatment with WRT plus vocal hygiene program (n = 12), and (2) vocal hygiene program only (n = 12). Laryngoscopic assessment was performed in all subjects. Before and after voice therapy, participants underwent aerodynamic and electroglottographic assessment. The Voice Handicap Index (VHI) and self-assessment of resonant voice were also performed. The treatment included six voice therapy sessions. For the experimental group, the exercises consisted of a sequence of seven phonatory tasks performed with two different voice training devices (PocketVox and MaskVox). Comparison for all variables was performed between experimental group and control group.

RESULTS

Significant differences were found for experimental group for VHI physical subscale, and self-perceived resonant voice when comparing pre-post conditions. A strong negative correlation between self-perceived resonant voice and VHI physical sub-score was also reported. No significant differences were found for instrumented variables.

CONCLUSION

Physiologic voice therapy based on WRT exercises including connected speech seems to be an effective tool to improve self-perceived voice in subjects diagnosed with voice complaints. Apparently, changes are more prone to occur in perceptual variables related with physical discomfort associate with voice production. A reduction in phonatory effort and perceptual aspects of vocal fatigue are the main improvements.

Effects of Mechanical Vibration Stimulation of the Larynx on Voice Production

INTRODUCTION

Combining mechanical vibration stimulation with resistance training to improve neuromuscular performance is a method that has gained popularity in the field of sports sciences.

PURPOSE

To evaluate the immediate and mid-term effects of mechanical vibration stimulation (G-Life NL3000) of the larynx associated to vocal exercises.

METHOD

Fourteen professional voice users divided into: Experimental Group - Seven participants who performed a 20-minute exercise protocol with humming applying mechanical vibration stimulation (G-Life NL3000) of the larynx once a day for 30 days; Control Group - Seven participants who performed only the 20-minute exercise protocol with humming. For comparison purposes, the evaluation was carried out pre-stimulation, immediately after simulation (post) and 30 days after stimulation (late-post).

RESULTS

The Experimental Group showed a statistically significant progress in the post-immediate evaluation and in the post-treatment evaluation for maximum phonation time (*P = < 0.001), Jitter (*P = 0.008), Shimmer (*P = 0.005), noise-to-harmonics ratio (*P = 0.005). In the GRBASI scale, the Experimental Group showed significant results in the post-treatment evaluation for Grade (*P = 0.005), Roughness (*P = 0.008), Breathiness (*P = 0.018) and Instability (*P = 0.018). A self-perception voice questionnaire showed better voice quality (*P= 0.031) and easier phonation (*P = 0.005) in the Experimental Group.

CONCLUSION

Mechanical vibration stimulation of the larynx associated to humming produced positive changes in the vocal pattern and significantly improvement in short and mid-term vocal quality for participants in this study.

A Voice Rehabilitation Protocol With the Semioccluded Ventilation Mask in Subjects With Symptoms of Vocal Fatigue and Phonatory Effort

PURPOSE

The present study was designed to assess the efficacy of a six-session physiologic voice therapy program with the semioccluded ventilation mask (SOVM) in a group of subjects with voice complaints (vocal effort and fatigue).

METHODS

Thirty-four participants with functional dysphonia were randomly assigned to one of two treatment groups: (1) voice treatment with physiologic voice therapy plus vocal hygiene program (n = 17), and (2) vocal hygiene program only (n = 17). Laryngoscopic assessment was performed in all subjects to confirm laryngeal diagnosis. Before and after voice therapy, participants underwent aerodynamic assessment. The Voice Handicap Index (VHI), Vocal Tract Discomfort Scale (VTDS), and self-assessment of resonant voice were also performed. The treatment included six voice therapy sessions. For the experimental group, the exercises consisted of a sequence of seven phonatory tasks performed with the SOVM. Comparison for all variables was performed between experimental group and control group.

RESULTS

Statistical analysis showed significant improvements for experimental group for VHI (decrease), VTDS (decrease), and self-perception of resonant voice quality (increase). Significant decrease for experimental group was observed in subglottic pressure and phonation threshold pressure.

CONCLUSION

Physiologic voice therapy based on the SOVM with connected speech exercises seems to be an effective tool to improve voice in subjects diagnosed with voice complaints. Apparently, improvements are reflected in both subjective and objective outcomes. A reduction in phonatory effort and perceptual aspects of vocal fatigue are the main subjective improvements. A decrease in air pressure-related variables seems to be the most important objective change after voice therapy.

Finger Kazoo Intensive Short-term Vocal Therapy: Vocal and Aerodynamic Measurements in Female Teachers

OBJECTIVE

to verify the effect after short-term intensive therapy with the Finger Kazoo technique on vocal and aerodynamic measures of dysphonic female teachers.

METHOD

blind randomized clinical trial. Fifteen female teachers without structural disorders of vocal folds and nine with vocal nodules participated in the study groups. Yet, nine female teachers without structural disorders and eight with vocal nodules in the control groups. The following variables were measured pre and post-therapy: minimum and maximum fundamental frequency: forced vital capacity; simple phonic coefficient; compound phonic coefficient; ratio between maximum phonation time of /a/ and expected maximum phonation time.

RESULTS

no statistical significance was observed in the intra and intergroup analyses in any of the measures.

CONCLUSION

in this group of female teachers, it was not possible to show a positive effect of short-term and intensive therapy with the Finger Kazoo technique on the vocal measures of minimum and maximum fundamental frequency, forced vital capacity, simple phonic coefficient, compound phonic coefficient, and the relationship between maximum phonation time of /a/ and expected maximum phonation time.

The Additive Effectiveness of Inspiratory Muscle Training on Glottic Closure and Subjective Voice Outcomes of Patients With Benign Lesion After Hyaluronic Acid Laryngoplasty

OBJECTIVES

For patients with glottic insufficiency disease, injection laryngoplasty is a rapid and efficient management option that complements voice therapy. Some studies have indicated that respiratory muscle training may also show promise in patients with voice disorders. However, the effect of respiratory muscle training in patients with glottic insufficiency was reported to be limited, and whether it provides additional benefit after standard management requires further evaluation. We aimed to investigate the effectiveness of inspiratory muscle training on glottis closure and patient-reported voice quality in glottic insufficiency patients who had been treated with hyaluronic acid injection.

STUDY DESIGN

Retrospective observational study.

METHODS

We included 46 patients with glottic insufficiency who had undergone hyaluronic acid injection. Twenty of them had undergone inspiratory muscle training during three months. We measured patients' changes in glottic status according to the normalized glottal gap area and bowing index, as well as voice quality of life according to the voice handicap index 10 and the voice outcome survey, before and after training.

RESULTS

Patients who underwent inspiratory muscle training had higher odds of experiencing better improvement in all scores. The range of odds ratios ranged from 2.5 to 6.3 for changes in scores, and from 3.8 to 22.2 for changes in score percentages. Of note, the effect of training on percentage changes in the normalized glottal gap area score was significant (P= 0.0127) after adjustment for the duration of vocal disease, body mass index and BMI, and history of gastroesophageal reflux disease.

CONCLUSIONS

Inspiratory muscle training can improve the glottal gap after injection laryngoplasty, and may be applied in clinical practice.

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.

Recognition of the Effect of Vocal Exercises by Fuzzy Triangular Naive Bayes, a Machine Learning Classifier: A Preliminary Analysis

OBJECTIVES

Machine learning (ML) methods allow the development of expert systems for pattern recognition and predictive analysis of intervention outcomes. It has been used in Voice Sciences, mainly to discriminate between healthy and dysphonic voices. Parameter patterns of vocal acoustic analysis and vocal perceptual assessment can be evaluated by ML classifiers, such as the Fuzzy Triangular Naive Bayes (FTriangNB), after using techniques that improve the vocal quality of individuals with healthy or dysphonic voices. Thus, the goal of this study was to analyze the performance of the FTriangNB to detect patterns in the acoustic parameters and the auditory-perceptual assessment of 12 women with dysphonia and 12 vocally healthy women, after performing three vocal exercises (tongue trills, semi-occluded vocal tract exercise with a high-resistance straw - SOVTE, and over-articulation).

METHODS

The FTriangNB classifier contained in the Fuzzy Class package was implemented in the data analysis software R Studio version 1.4.1106 for Macintosh. The confusion matrix was extracted, as well as the accuracy, the Kappa coefficient, and the class statistics. The final result was compared with those generated by FTriangNB with the same variables from the preapplication database of the exercises.

RESULTS

The FTriangNB presented good accuracy (87.5%) and Kappa coefficient (81.3%), and showed almost perfect agreement after application of the exercises, while the results before the application of the exercises demonstrated accuracy without acceptable discrimination capacity (33.3%) and Kappa coefficient with a poor agreement (-6.67%). The Semioccluded Vocal Tract Exercises (SOVTE) with high strength straw presented with a sensitivity and Negative Predictive Value (NPV) of value 1 (one), and the over-articulation's specificity and Positive Predictive Value (PPV) also showed a value of 1 (one).

CONCLUSIONS

The FTriangNB showed great accuracy in recognizing the effect of vocal exercises. Exploratory studies with larger samples using FTriangNB, as well as other Machine Learning classifiers should be further carried out for this purpose in the Voice Science to enable inferences.

Efficacy of Voice Therapy With Acapella Choice ® Device in Subjects With Vocal Fatigue Delivered Via Telepractice

PURPOSE

The present study aimed at assessing the effectiveness of remote voice therapy (telepractice) implemented with Acapella Choice device in subjects with vocal fatigue.

METHODS

Thirty participants with vocal fatigue were randomly assigned to one of two treatment groups: (1) voice treatment with acapella Choice device plus vocal hygiene program (n=15), and (2) voice treatment with Water resistance therapy plus vocal hygiene program (n=15). Laryngoscopic assessment was conducted in all subjects to confirm diagnosis. Before and after voice therapy, participants underwent self-assessment of voice. Vocal Fatigue Index (VFI), Voice Handicap Index (VHI), and Vocal tract discomfort scale (VTDS) were used. Treatment period included six voice therapy sessions within 3 weeks, with a frequency of two therapy sessions per week. Each session lasted 30 minutes. For both groups, exercises consisted of a sequence of nine phonatory tasks performed with Acapella Choice (experimental group) and WRT (control group). Comparison for all variables were performed between experimental group and control group.

RESULTS

Significant improvements were found when comparing Pre and Post measures for both groups. No significant differences were found when comparing Acapella Choice group and WRT group.

CONCLUSION

Remote physiologic voice therapy with Acapella Choice device and water resistance therapy seem to be both effective to improve voice in subjects diagnosed with vocal fatigue. No differences should be expected between these therapeutic protocols when treating patients with vocal fatigue. Moreover, both are effective at reducing tiredness of voice, voice avoidance, physical discomfort associated with voicing, subjective perception of sensory discomfort in throat, and reduction of physical, emotional, and functional impact of voice problems.

Quantification of Vocal Fold Atrophy in Age‐Related and Parkinson's Disease‐Related Vocal Atrophy

OBJECTIVE

Vocal fold atrophy (VFA) is associated with aging and Parkinson's disease (PD). Clinical diagnosis of VFA depends on several visual-perceptual laryngostroboscopy findings that are inherently subjective. The purpose of this study was to use quantitative measurements to; (1) examine the relationships between VFA and dysphonia severity and (2) evaluate differences in VFA in patients with age-related VFA versus PD.

METHODS

Thirty-six patients >60 years of age with VFA were included in this retrospective cohort study. Demographic information, medical history, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), Voice Handicap Index-10 (VHI-10), and still images from the stroboscopic exam were obtained. Image J™ was used to measure VFA, including bowing index (BI), normalized glottal gap area, and normalized mucosal wave amplitude. Pearson's correlation was used to evaluate the relationship between VFA, CAPE-V, and VHI-10. t-Tests and multivariate linear regression were used to compare VFA measures by dysphonia severity (CAPE-V <30 vs. >30) and diagnosis (age-related vocal atrophy [ARVA] and PD).

RESULTS

BI was positively correlated with CAPE-V. Patients with CAPE-V >30 had a significantly larger BI compared to those with CAPE-V <30. Patients with PD had significantly larger BI than those with ARVA. Diagnosis of PD also predicted a larger BI after controlling for age and CAPE-V.

CONCLUSION

Quantitative measures supported an association between bowing severity and dysphonia severity in patients with PD and ARVA. A PD diagnosis significantly predicted more severe BI. These findings demonstrate the potential utility of BI. Quantitative VFA measures might also provide insight into the mechanisms of ARVA and dysphonia.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:1462-1469, 2023.

Effectiveness of Breath-holding Pulling Exercise in Patients with Vocal Fold Atrophy

OBJECTIVE

In recent years, the incidence of vocal fold atrophy has increased among the elderly. Vocal function exercises (VFE) are performed in patients with age-related vocal fold atrophy; however, treatment could be challenging if the patient is unable to go to the hospital or in hospitals that do not have a speech pathologist. Breath-holding pulling exercises are simple and can be performed anywhere for the management of such patients. This study aimed to examine the effectiveness of breath-holding pulling exercises in patients with vocal fold atrophy.

STUDY DESIGN

Retrospective study METHODS: With the hands folded in front of the chest, the patients were instructed to take a deep breath, pull their hands to the left and right, and then hold their breath for 5 seconds. The physician instructed the patients to do this 10 times each morning, afternoon, and evening. Speech function, acoustic analysis, pitch range, and Voice Handicap Index-10 (VHI-10) were evaluated and compared before and 4-8 weeks after treatment.

RESULTS

Maximum phonation time (MPT), the primary endpoint, significantly improved after treatment from 14.2 ± 6.6 to 20.3 ± 9.3 seconds. Among the secondary endpoints, mean flow rate (207.5 ± 104.4 to 165.1 ± 66.5 mL/s), pitch range (22.9 ± 8.3 to 26.2 ± 8.1 semitones), VHI-10 (18.1 ± 7.2 to 12.5 ± 6.3 points) jitter (2.5±1.6 to 1.7±1.2%), and shimmer (5.9±3.5 to 4.8±3.3%) showed significant improvement.

CONCLUSION

Breath-holding pulling exercises were found to be effective in patients with vocal fold atrophy. These can be performed in hospitals with no speech pathologists, in patients who are unable to go to the hospital, and in patients who are hospitalized or unable to speak loudly. Moreover, as with conventional VFE, the training method achieves a high level of patient satisfaction.

What Can Altered Auditory Feedback Paradigms Tell Us About Vocal Motor Control in Individuals With Voice Disorders?

Purpose

The goal of this review article is to provide a summary of the progression of altered auditory feedback (AAF) as a method to understand the pathophysiology of voice disorders. This review article focuses on populations with voice disorders that have thus far been studied using AAF, including individuals with Parkinson's disease, cerebellar degeneration, hyperfunctional voice disorders, vocal fold paralysis, and laryngeal dystonia. Studies using AAF have found that individuals with Parkinson's disease, cerebellar degeneration, and laryngeal dystonia have hyperactive auditory feedback responses due to differing underlying causes. In persons with PD, the hyperactivity may be a compensatory mechanism for atypically weak feedforward motor control. In individuals with cerebellar degeneration and laryngeal dystonia, the reasons for hyperactivity remain unknown. Individuals with hyperfunctional voice disorders may have auditory-motor integration deficits, suggesting atypical updating of feedforward motor control.

Conclusions

These findings have the potential to provide critical insights to clinicians in selecting the most effective therapy techniques for individuals with voice disorders. Future collaboration between clinicians and researchers with the shared objective of improving AAF as an ecologically feasible and valid tool for clinical assessment may provide more personalized therapy targets for individuals with voice disorders.

Terapia vocal com abordagem respiratória em idosos: revisão integrativa da literatura

RESUMO Objetivo: caracterizar a terapia vocal com abordagem respiratória em idosos disfônicos. Métodos: a busca foi realizada nas bases PubMed, BVS, Scopus, Web of Science e Embase. Foram incluídos estudos originais, nos idiomas inglês, espanhol e português, que tratassem sobre terapia vocal associada à abordagem respiratória na população idosa. Foram analisadas as variáveis gênero, faixa etária, etiologia associada, frequência e duração da sessão, dosagem de exercícios, intervenção e benefícios. Resultados: foram encontrados 1.425 artigos, porém, apenas nove foram incluídos na revisão. Na terapia vocal para idosos, destacaram-se as estratégias do Exercício de Função Vocal e o Método Lee Silverman®, além de outras, como o ParkinSong e o uso do tubo submerso em água. Tais abordagens modificam a função da musculatura laríngea, o impulso e o suporte respiratório, bem como o treino para aumento da intensidade vocal. Os principais resultados terapêuticos foram: melhora nos parâmetros perceptivo-auditivos, acústicos, aerodinâmicos, tempo máximo de fonação, nível de esforço fonatório e qualidade vocal. Conclusão: a terapia vocal com abordagem respiratória caracterizou-se pelo uso de estratégias direcionadas tanto à população idosa de forma geral, quanto a populações com disfonia neurológica, cujos resultados mostraram melhoria no controle de intensidade, frequência, ressonância e coordenação pneumofônica.

Voice therapy with a respiratory approach in older people: an integrative literature review

ABSTRACT Purpose: to characterize voice therapy with a respiratory approach in dysphonic older people. Methods: a search made in PubMed, VHL, Scopus, Web of Science, and EMBASE. Original studies in English, Spanish, and Portuguese, addressing voice therapy in combination with a respiratory approach in the older population, were included. The analysis encompassed sex, age, associated etiology, session frequency and duration, exercise dosage, intervention, and benefits. Results: altogether, 1,425 articles were found, of which only nine were included in the review. In voice therapy for older people, the following strategies stood out: Vocal Function Exercises, Lee Silverman Voice Treatment®, ParkinSong, and tubes immersed in water. These approaches change the laryngeal muscle function and respiratory impulse and support and increase vocal intensity. The main therapeutic findings included improved auditory-perceptual, acoustic, and aerodynamic parameters, maximum phonation time, phonatory effort level, and voice quality. Conclusion: voice therapy with a respiratory approach characteristically used strategies aimed at both the general older population and those with neurological dysphonia. Their results showed improvement in frequency, resonance, intensity control, and breathing/phonation coordination.

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.

Active Ingredients of Voice Therapy for Muscle Tension Voice Disorders: A Retrospective Data Audit

Background: Although voice therapy is the first line treatment for muscle-tension voice disorders (MTVD), no clinical research has investigated the role of specific active ingredients. This study aimed to evaluate the efficacy of active ingredients in the treatment of MTVD. A retrospective review of a clinical voice database was conducted on 68 MTVD patients who were treated using the optimal phonation task (OPT) and sob voice quality (SVQ), as well as two different processes: task variation and negative practice (NP). Mixed-model analysis was performed on auditory–perceptual and acoustic data from voice recordings at baseline and after each technique. Active ingredients were evaluated using effect sizes. Significant overall treatment effects were observed for the treatment program. Effect sizes ranged from 0.34 (post-NP) to 0.387 (post-SVQ) for overall severity ratings. Effect sizes ranged from 0.237 (post-SVQ) to 0.445 (post-NP) for a smoothed cepstral peak prominence measure. The treatment effects did not depend upon the MTVD type (primary or secondary), treating clinicians, nor the number of sessions and days between sessions. Implementation of individual techniques that promote improved voice quality and processes that support learning resulted in improved habitual voice quality. Both voice techniques and processes can be considered as active ingredients in voice therapy.

Does Voice Therapy Improve Vocal Outcomes in Vocal Fold Atrophy?

OBJECTIVES

Vocal fold atrophy is increasingly identified in the geriatric population. Current literature shows varying outcomes with voice therapy. Our goal was to analyze multidimensional vocal outcomes of these patients who underwent voice therapy. Secondary aims included determining compliance and analyzing differences in patients who undergo surgery.

METHODS

197 patients with vocal fold atrophy were included and reviewed. Patients were categorized by treatment received. Patient-reported, perceptual, aerodynamic, and acoustic voice outcomes were analyzed before and after therapeutic intervention. Changes were calculated and significance determined using Wilcoxon signed-rank and rank-sum tests.

RESULTS

89(45%) received no therapy, 43(22%) incomplete therapy, 51(26%) complete therapy, 8(4%) surgery only, and 6(3%) therapy followed by surgery. Those who completed voice therapy showed significant improvement in voice related quality of life (VRQOL) (P = .0225), glottal function index (GFI) (P < .001), grade, roughness, breathiness, asthenia, strain (GRBAS) (P < .001), maximum phonation time (MPT) (P = .0081), and fundamental frequency in women (P = .0024). No significant changes were found in mean airflow. When comparing patients who underwent surgery versus voice therapy, statistically significant differences were present between pre-treatment VRQOL (P = .0269) and GFI (P = .0166).

CONCLUSIONS

Only 29% of patients with vocal atrophy completed voice therapy when recommended. Within this patient cohort, voice therapy results in significant improvement in multidimensional voice outcomes. Patients with vocal atrophy that undergo surgical treatment differ from those treated with voice therapy alone in their pre-treatment patient-reported measures.

The effect of nasal septum deviation on voice aging

PURPOSE

The aging process of the voice differs among individuals, and the factors that affect age-related changes in voice are not well-defined. In this study, we investigated the difference between older people with nasal septum deviation (NSD) and older people without NSD in terms of degree of aging voice using objective and subjective voice assessment tools.

METHODS

The study included 94 patients (47 women, 47 men) aged >65 years. Nasal septum deviation was determined in 45 patients (NSD group), and 49 patients had no nasal pathology (control group). Maximum phonation time (MPT), GRBAS scale, and acoustic voice analysis parameters were compared between the NSD and control groups; sub-group analysis disaggregated by sex was also performed.

RESULTS

No significant difference was observed between the NSD and control groups with respect to MPT, GRBAS scale, and acoustic voice analysis parameters in the total study population and among male subjects. The only parameter that showed a significant difference between sub-groups of female subjects was soft phonation index (SPI) (p=.03).

CONCLUSIONS

To the best of our knowledge, this is the first study to analyze the effect of NSD on the voice aging. With the findings of the present study, NSD does not seem to have an effect on voice aging, and also it can be suggested that septoplasty will not have an effect on preventing presbyphonia. Further studies on larger groups of patients are required to provide more definitive evidence on this subject.

Phonation Resistance Training Exercises (PhoRTE) With and Without Expiratory Muscle Strength Training (EMST) For Patients With Presbyphonia: A Noninferiority Randomized Clinical Trial

OBJECTIVES

Presbyphonia negatively impacts quality of life in patients with age-related voice changes. A proof-of-concept study showed promise for high vocal intensity exercise to treat presbyphonia, which became the basis for a novel intervention for age-related voice changes known as Phonation Resistance Training Exercises (PhoRTE). Expiratory Muscle Strength Training (EMST) has also been proposed as an additional intervention to target and strengthen the aging respiratory system; however, EMST has undergone limited evaluation as an adjunct treatment for elderly patients undergoing voice therapy for presbyphonia. This study determined if the addition of EMST to PhoRTE voice therapy (PhoRTE + EMST) is at least as effective at voice improvement as PhoRTE alone.

STUDY DESIGN

Prospective, randomized, controlled, single-blinded, non-inferiority.

MATERIALS AND METHODS

Participants aged 55 years or older with a diagnosis of vocal fold atrophy were randomized to complete PhoRTE therapy or PhoRTE + EMST. The primary outcome was change in Voice Handicap Index-10 (VHI-10). Secondary outcomes included the Aging Voice Index, maximum expiratory pressure, and acoustic and aerodynamic measures of voice. Repeated measures linear mixed models were constructed to analyze outcomes at a significance level of α = 0.10.

RESULTS

Twenty-six participants were recruited for the study, and 24 participants were randomized to either treatment arm. Sixteen participants completed the entire study. Both treatment arms showed statistically significant and clinically meaningful improvements in VHI-10 (PhoRTE mean [M] = -8.20, P < 0.001; PhoRTE + EMST M = -9.58, P < 0.001), and PhoRTE + EMST was noninferior to PhoRTE alone (P = 0.069). Both groups experienced a statistically significant pre-post treatment decrease (improvement) in AVI scores (PhoRTE M = -18.40, P = 0.004; PhoRTE + EMST M = -16.28, P = 0.005). PhoRTE+EMST had statistically significantly greater changes in maximum expiratory pressure compared to PhoRTE alone (PhoRTE M = 8.24 cm H₂O, PhoRTE + EMST M = 32.63 cm H₂O; P= 0.015). Some secondary acoustic and aerodynamic outcomes displayed trends toward improvement.

CONCLUSION

This study demonstrates that voice therapy targeting high vocal intensity exercise (eg, PhoRTE) and EMST can play a role in improving voice outcomes for patients with presbyphonia.

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.

Phonation Threshold Pressure/Flow for Reflecting Glottal Closure in Unilateral Vocal Fold Paralysis

OBJECTIVE

Previous theoretical analysis predicted that phonation threshold flow (PTF) could be a more sensitive aerodynamic measure than phonation threshold pressure (PTP) for reflecting glottal incompetence. This study investigated the feasibility of whether PTP and PTF may differentiate subjects with unilateral adductor vocal fold paralysis and paresis (UAVFP) from those without, and whether PTP and PTF could reflect the extent of incomplete glottal closure associated with UAVFP.

METHODS

PTP and PTF were quantified for 13 subjects with UAVFP and 21 control subjects with normal voice, and the normalized glottal gap area (NGGA) based on videostroboscopic image analysis was quantified for subjects with UAVFP.

RESULTS

Significant differences in both PTP and PTF were found between subjects with UAVFP and control subjects. Receiver operating characteristic analysis indicated a higher discriminatory ability of PTP for differentiating subjects with UAVFP from those without (area under the curve of 0.905 for PTP, 0.678 for PTF), yet a significant positive correlation was found between PTF and NGGA (Spearman's ρ = 0.571) but not between PTP and NGGA (ρ = -0.364).

CONCLUSION

Results supported the feasibility of using PTP and PTF as potential diagnostic indicators for reflecting glottal closure in UAVFP, with PTP potentially more sensitive for differentiating subjects with and without incomplete glottal closure. These preliminary findings were limited by the small sample size, with further studies needed to verify whether PTF could be more sensitive for reflecting the extent of incomplete glottal closure, as predicted theoretically.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1598-E1604, 2021.

Voice and Respiratory Characteristics of Men and Women Seeking Treatment for Presbyphonia

BACKGROUND AND OBJECTIVES

Impaired respiratory function could potentially explain why some older speakers experience voice-related handicap whereas others do not, despite presenting with similar age-related laryngeal characteristics. The objectives of this study were therefore to (1) describe voice and respiratory function across men and women in a sample of treatment-seeking patients with presbyphonia; (2) assess how respiratory function differed from the general elderly population, based on normative data; and 3) discuss how respiratory function may play a role in the development of voice symptoms across men and women.

METHODS

Twenty one participants with presbyphonia underwent respiratory assessments (spirometry and respiratory muscle strength testing) in addition to standard of care voice assessments. Respiratory variables included forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), FEV₁/FVC, maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP).

RESULTS

Voice features were consistent with the diagnosis of presbyphonia and values did not different significantly between males and females, although some trends were noted. Regarding respiratory variables, one-third of the participants (n = 7) presented with FVC and FEV₁ less than 80% of predicted, and 57% (n = 12) were <90% of predicted. Nine percent of the males (n = 1) and none of the females had a MIP below the lower limit of normal (LLN) expected for their age, sex, and weight. Eighteen percent of the males (n = 2) and 20% of the females (n = 2) fell below the LLN for MEP.

CONCLUSION

Our sample of participants with presbyphonia included a non-negligible proportion of patients with decreased percent predicted values of FVC and FEV₁, and with respiratory muscle strength (MEP) below the LLN. Standardized values of pulmonary function were not different across sexes, indicative of a similar respiratory health. However, a lower raw pulmonary function and respiratory muscle strength in women may compound laryngeal changes and have an impact on perceived voice-related handicap. Together, findings warrant further studies to explore the impact of decreased respiratory function on voice and, ultimately, on the response to voice therapy in patients with presbyphonia.

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.

Respiratory Muscle Strength Training to Improve Vocal Function in Patients with Presbyphonia

BACKGROUND AND OBJECTIVE

The effects of presbyphonia are compounded by the decline in respiratory function that occurs with age. Commonly recommended exercises to optimize the use of respiratory muscles during speech, such as diaphragmatic breathing, are unlikely to be intensive enough to induce respiratory changes and impact vocal function. The objective of this study was to assess the effect of adding a targeted intervention, respiratory muscle strength training, to voice exercises in a sample of patients with presbyphonia.

METHODS/DESIGN

In this prospective, randomized-controlled trial, 12 participants received either (1) vocal function exercises (VFE), (2) VFE combined with inspiratory muscle strength training (IMST), or (3) VFE combined with expiratory muscle strength training (EMST). Data collected prior to and following 4 weekly intervention sessions included respiratory measures (pulmonary function and respiratory muscle strength) and voice measures (videostroboscopy, acoustic, auditory-perceptual, aerodynamic, and self-assessment measures).

RESULTS

Participants who received IMST improved their voice quality during connected speech (smoothed cepstral peak prominence and ratings of overall voice quality) and their scores on the three self-assessment questionnaires with large to very large within-group effect sizes (|d| = 0.82-1.61). In addition, participants in the IMST group reduced their subglottal pressure with a large effect size (d = -0.92). Participants who received EMST improved their maximum expiratory strength and smoothed cepstral peak prominence with large effect sizes (d = 0.80 and 0.99, respectively) but had limited improvements in other outcomes. Participants who received only VFE decreased their amount of vocal fold bowing, improved their voice quality on a sustained vowel (amplitude perturbation quotient), and improved their Glottal Function Index score with large effect sizes (|d| = 0.74-1.00).

CONCLUSION

Preliminary data indicate that adding IMST to voice exercises may lead to the greatest benefits in patients with presbyphonia by promoting improved subglottal pressure control as well as increasing air available for phonation, resulting in improved self-assessment outcomes.

The Impact of Respiratory Function on Voice in Patients with Presbyphonia

BACKGROUND AND OBJECTIVE

Presbyphonia is an age-related voice disorder characterized by vocal fold atrophy and incomplete glottal closure during phonation. The extent to which the effects of presbyphonia may be compounded by age-related declines in the respiratory system and further impact communication and quality of life remains unknown. Therefore, the objective of this study was to determine how variations in respiratory function impacts voice measures in a sample of participants with presbyphonia.

METHODS

In this pilot study, 21 participants with presbyphonia underwent respiratory assessments (spirometry and respiratory muscle strength testing) and voice assessments (videostroboscopy, acoustic analysis, auditory-perceptual ratings, aerodynamic assessment, and self-assessments). Factor and cluster analyses were conducted to extract voice and respiratory constructs and to identify groups of participants with similar profiles. Correlations and regression analyses were conducted to better describe the relationships between voice and respiratory function.

RESULTS

Respiratory function was found to impact voice via two main pathways: through its physiological effect on voice and through its impact on general health and impairment. A lower respiratory function was associated with a lower vocal fold pliability and regularity of vibration and with an elevated aerodynamic resistance accompanied by laryngeal hyperfunction. Standardized measures of respiratory function were associated with perceived voice-related handicap. Respiratory function did not associate with voice quality, which was mostly influenced by the severity of vocal fold atrophy.

CONCLUSION

Poor respiratory health exacerbates the burden of vocal fold atrophy and, therefore, implementation of respiratory screening prior to starting voice therapy may significantly affect the treatment plan and consequently the outcomes of voice therapy in this patient population.

Effects of a 6-Week Straw Phonation in Water Exercise Program on the Aging Voice

Purpose Semi-occluded vocal tract (SOVT) exercises with tubes or straws have been widely used for a variety of voice disorders. Yet, the effects of longer periods of SOVT exercises (lasting for weeks) on the aging voice are not well understood. This study investigated the effects of a 6-week straw phonation in water (SPW) exercise program. Method Thirty-seven elderly subjects with self-perceived voice problems were assigned into two groups: (a) SPW exercises with six weekly sessions and home practice (experimental group) and (b) vocal hygiene education (control group). Before and after intervention (2 weeks after the completion of the exercise program), acoustic analysis, auditory-perceptual evaluation, and self-assessment of vocal impairment were conducted. Results Analysis of covariance revealed significant differences between the two groups in smoothed cepstral peak prominence measures, harmonics-to-noise ratio, the auditory-perceptual parameter of breathiness, and Voice Handicap Index-10 scores postintervention. No significant differences between the two groups were found for other measures. Conclusions Our results supported the positive effects of SOVT exercises for the aging voice, with a 6-week SPW exercise program being a clinical option. Future studies should involve long-term follow-up and additional outcome measures to better understand the efficacy of SOVT exercises, particularly SPW exercises, for the aging voice.

Vocal fold medialization-A 5-year series of single surgeon consecutive medialization with review of literature

INTRODUCTION

ENT UK released guidelines in 2010 detailing the requisite structure for the creation of a laryngeal intervention clinic. The senior author's practice is the only one regionally that offers this service, and our objective was to review this to determine whether vocal cord medialization injections were showing an improvement in quality of voice for patients.

MATERIALS AND METHODS

Patients were reviewed in a specialist voice clinic prior to being offered vocal cord injection under local anaesthetic in a separate dedicated weekly clinic. They would be assessed by the senior author and a dedicated voice specialist speech and language therapist (SALT). This would include a preinjection grade, roughness, breathiness, asthenia, and strain (GRBAS), Voice Handicap Index (VHI)-10, and the measuring of maximum phonation time (MPT) with the aid of Opera Vox Apple iPad application.

RESULTS

Data were available for 186 injections, on patients with a median age of 66 years (interquartile range [IQR]: 51-75), of whom 61% were male. VHI-10 score improved significantly, from a mean of 26.7 to 12.5 (P < .001). A significant improvement in MPT was also observed, from a median of 3.0 to 6.3 (N = 66, P < .001). Improvements in all components of the GRBAS score were also observed (all P < .001), with between 43% and 88% of cases reporting reductions after the procedure. Patients receiving a repeat procedure saw a significantly smaller improvement in VHI-10 than those where it was the primary treatment (mean reduction: 9.8 vs 15.5, P = .018). Analysis of MPT found a significant correlation between the quantity of injection material used and the degree of improvement observed (rho = 0.355, P = .004).

CONCLUSION

Vocal Cord local anaesthetic medialization injection is a swift, safe, and effective short-term method of improving dysphonia.