Correlating Undiagnosed Hearing Impairment with Hyperfunctional Dysphonia

Auditory-Motor Function Pre- and Post-Therapy in Hyperfunctional Voice Disorders: A Case Series

OBJECTIVE/HYPOTHESIS

Behavioral voice therapy is the most common treatment for hyperfunctional voice disorders (HVDs) but has limited long-term effectiveness since the comprehensive mechanisms underlying HVDs remain unclear. Recent work has implicated disordered sensorimotor integration during speech in some speakers with HVDs and suggests that auditory processing is a key factor to consider in HVD assessment and therapy. The purpose of this case-series study was to assess whether current voice therapy approaches for HVDs resulted in improvements to auditory-motor function.

STUDY DESIGN

Longitudinal (pre-post) study.

METHOD

Pre and postvoice therapy for HVDs, 11 speakers underwent an assessment of auditory-motor function via auditory discrimination of vocal pitch, responses to unanticipated auditory perturbations, and responses to predictable auditory perturbations of vocal pitch.

RESULTS

At the post-therapy session, 10 out of 11 participants demonstrated voice therapy success (via self-reported voice problems and/or auditory-perceptual judgements of voice by a clinician) and eight of the 11 participants demonstrated improvements in at least one measure of auditory discrimination and/or auditory-motor control. Specifically, three speakers demonstrated improvements in auditory discrimination, five speakers demonstrated improved (within typical cutoffs) responses to predictable perturbations, and two speakers demonstrated improvements in both auditory discrimination and auditory-motor measures.

CONCLUSIONS

Together, these findings support that voice therapy in individuals with HVDs may impact auditory-motor control and highlight the potential benefit of systematically addressing auditory function in voice therapy and assessment for HVDs.

The Relationship Between Pitch Discrimination and Fundamental Frequency Variation: Effects of Singing Status and Vocal Hyperfunction

PURPOSE

The purpose of this study was to investigate the relationship between pitch discrimination and fundamental frequency (fo) variation in running speech, with consideration of factors such as singing status and vocal hyperfunction (VH).

METHOD

Female speakers (18-69 years) with typical voices (26 non-singers; 27 singers) and speakers with VH (22 non-singers; 30 singers) completed a pitch discrimination task and read the Rainbow Passage. The pitch discrimination task was a two-alternative forced choice procedure, in which participants determined whether tokens were the same or different. Tokens were a prerecorded sustained /ɑ/ of the participant's own voice and a pitch-shifted version of their sustained /ɑ/, such that the difference in fo was adaptively modified. Pitch discrimination and Rainbow Passage fo variation were calculated for each participant and compared via Pearson's correlations for each group.

RESULTS

A significant strong correlation was found between pitch discrimination and fo variation for non-singers with typical voices. No significant correlations were found for the other three groups, with notable restrictions in the ranges of discrimination for both singer-groups and in the range of fo variation values for non-singers with VH.

CONCLUSIONS

Speakers with worse pitch discrimination may increase their fo variation to produce self-salient intonational changes, which is in contrast to previous findings from articulatory investigations. The erosion of this relationship in groups with singing training and/or with VH may be explained by the known influence of musical training on pitch discrimination or the biomechanical changes associated with VH restricting speakers' abilities to change their fo.

Vocal Outcome After Cordectomy by Transoral CO2 Laser Microsurgery in Patients With Laryngeal Intraepithelial Neoplasia and Non-neoplastic Lesions

OBJECTIVES

This study investigates vocal outcome after cordectomy by transoral CO2 laser microsurgery (TLM-cordectomy) in patients with laryngeal intra-epithelial neoplasia (LIN) or non-neoplastic lesions (NNL), for improved individual patient advice and potential adjustment of national treatment strategy by which patients suspected to have glottic LIN or T1a cancer are offered TLM-cordectomy, without prior biopsy.

STUDY DESIGN

Prospective, longitudinal, quasi-experimental time series.

METHODS

Consecutively included patients (n = 155) with LIN (n = 84) or NNL (n = 71) who underwent voice assessments before and after TLM-cordectomy. The multi-dimensional voice assessment protocol comprised voice and speech range profiles, aerodynamics, acoustic analysis, self-evaluated voice handicap, and perceptual auditory voice ratings.

RESULTS

Median follow-up time was 195 (range 50-1121) days for patients with LIN and 193 (range 69-1294) days for patients with NNL. Statistically significant changes, LIN: in voice handicap index (VHI) and breathiness after TLM-cordectomy. Statistically significant changes, NNL: voice range profile (voice range area, intensity range, and frequency range) and VHI after TLM-cordectomy. All group-wise changes were to less disordered voices. Previous smokers had the largest decreases in VHI and breathiness. Patients with baseline VHI scores >65 had smaller increases in VHI, however 13-19% of the patients had increases in VHI above the clinically relevant threshold after TLM-cordectomy.

CONCLUSION

Overall, TLM-cordectomy in patients with LIN and NNL improved vocal outcome and our study thus supports the current Danish treatment strategy and improves the basis for proper patient advice. Multi-dimensional voice assessment is suggested preoperatively and six-nine months postoperatively, with focus on individual vocal differences and voice demands.

Integrative Review and Framework of Suggested Mechanisms in Primary Muscle Tension Dysphonia

PURPOSE

Despite the high prevalence of primary muscle tension dysphonia (MTD-1), its underlying mechanisms and their interrelationships have yet to be fully identified. The objectives of this integrative review were (a) to describe and classify the suggested underlying mechanisms for MTD-1, (b) to appraise the empirical evidence supporting each of the proposed mechanisms, and (c) to summarize the information in an integrative model.

METHOD

PubMed, Scopus, and CINAHL were searched for all publications pertaining to muscle tension dysphonia. Papers were retained if they included theoretical or empirical data pertaining to underlying mechanisms of MTD-1. A total of 921 papers initially qualified for screening, of which 100 remained for consideration in this review. Underlying mechanisms of MTD-1 were extracted using a consensus approach.

RESULTS

Seven broad categories of putative mechanisms involved in MTD-1 were identified: psychosocial, autonomic, sensorimotor, respiratory, postural, inflammatory, and neuromuscular. These categories were further divided into 19 subcategories detailed in the body of this review article. Based on the reviewed evidence, our proposed integrative model presents MTD-1 as an idiosyncratic motor adaptation to physiological perturbation or perceived threat. Under this model, physiologically or psychologically aversive stimuli can instigate a series of motor adaptations at multiple levels of the nervous system, ultimately disturbing muscle activation patterns and their biomechanical outcomes. Importantly, these adaptations appear to have the potential to become chronic even after threatening stimuli are withdrawn.

CONCLUSIONS

The proposed model highlights the importance of personalized rehabilitation in MTD-1 treatment. Limitations of the literature are discussed to provide guidance for future research aimed at improving our understanding of MTD-1.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19586065.

Assessment of auditory processing in childhood dysphonia

INTRODUCTION

Clinical experience shows that children with functional dysphonia often present disorders that are associated with abnormal auditory and emotional development. These children also struggle with voice therapy, perhaps because of difficulties with auditory control during speech. It has been hypothesized that difficulties in auditory processing in children may be an important factor in the pathogenesis of childhood dysphonia.

OBJECTIVE

The study aimed to assess selected auditory functions in children with hyperfunctional dysphonia.

MATERIALS AND METHOD

The study group consisted of 331 children aged from 7 to 12 years suffering from hyperfunctional dysphonia. The control group consisted of 213 children aged 7-12 years. All patients underwent ENT and phoniatric examination. All children underwent two standardized psychoacoustic tests: the Frequency Pattern Test (FPT) and the Duration Pattern Test (DPT).

RESULTS

In the examined material, 223 children had edematous vocal fold nodules. The largest statistically significant differences were seen in the acoustic parameters describing relative frequency changes. FPT and DPT showed statistically significant differences in children with hyperfunctional dysphonia compared to the control group. At all ages the percentage of correctly identified tone sequences was significantly lower in children with dysphonia.

CONCLUSION

Children with hyperfunctional dysphonia have difficulties in judging the pitch and duration of auditory stimuli. Difficulties in auditory processing appear to be important in the pathomechanism of functional voice disorders. Impaired hearing processes in children with hyperfunctional dysphonia can make it difficult to obtain positive and lasting effects from voice therapy.

Impaired auditory discrimination and auditory-motor integration in hyperfunctional voice disorders

Hyperfunctional voice disorders (HVDs) are the most common class of voice disorders, consisting of diagnoses such as vocal fold nodules and muscle tension dysphonia. These speech production disorders result in effort, fatigue, pain, and even complete loss of voice. The mechanisms underlying HVDs are largely unknown. Here, the auditory-motor control of voice fundamental frequency (f_o) was examined in 62 speakers with and 62 speakers without HVDs. Due to the high prevalence of HVDs in singers, and the known impacts of singing experience on auditory-motor function, groups were matched for singing experience. Speakers completed three tasks, yielding: (1) auditory discrimination of voice f_o; (2) reflexive responses to sudden f_o shifts; and (3) adaptive responses to sustained f_o shifts. Compared to controls, and regardless of singing experience, individuals with HVDs showed: (1) worse auditory discrimination; (2) comparable reflexive responses; and (3) a greater frequency of atypical adaptive responses. Atypical adaptive responses were associated with poorer auditory discrimination, directly implicating auditory function in this motor disorder. These findings motivate a paradigm shift for understanding development and treatment of HVDs.

Fundamental Frequency and Jitter Percent in MDVP and PRAAT

PURPOSE

This study initially investigated the relationship between Fundamental Frequency and Jitter Percent across and within MDVP and PRAAT. Subsequently, it explored if the measured acoustic signal's Length or the analysis temporal segment selection impacts potential correlation across the tools' measures.

METHODS

We collected forty-two Maximum Phonation Time acoustic signals from 10 participants with Healthy Voices in a standardized setting. We excluded from enrollment any potential participants having a history of voice disorders or showing an abnormality in a pre-study assessment.

RESULTS

There is no correlation between Jitter percent's values and Fundamental Frequency within either Tool in our healthy voice samples. The Length of the acoustic signal and temporal analysis selection impact the correlation between Jitter Percent measurements across the two tools; The correlation between Fundamental Frequency measurements across the devices was not affected. Means of Fundamental Frequency did not differ across the two devices but show a persistent pattern of greater values in MDVP. Jitter Percent measurements were significantly higher in MDVP CONCLUSIONS: There is a potential for clinicians using PRAAT assessments in the clinic to make inferences from research using MDVP as an analysis tool. Further work is needed in patients with Voice disorders to explore that possibility.

Vocal Pitch Discrimination in Children with and without Vocal Fold Nodules

Vocal pitch discrimination abilities were compared in sixteen children with vocal fold nodules (CwVN) and sixteen matched controls with typical voices (CwTV). Vocal pitch discrimination was also evaluated in thirty-five vocally healthy children and twenty adults to examine potential changes as a function of maturation. CwTV were categorized as either younger (N = 15, 5.6-7.7 years) or older (N = 20, 8.2-11.7 years). Participants completed two-alternative, forced choice listening tasks in which they judged whether pairs of sustained /α/ tokens were different in pitch. Each pair consisted of a base token with a fundamental frequency fo ) of 216.2 Hz and a test token with a fo that was adaptively modified, according to the participant's prior judgments. There were no significant differences in pitch discrimination abilities between CwVN and CwTV. Pitch discrimination abilities were significantly poorer in younger and older CwTV as compared to adults. Additionally, younger CwTV had significantly poorer discrimination abilities than older CwTV. Findings from this study suggest that CwVN do not have differences in pitch discrimination abilities, yet, therapies designed for CwVN should consider this developmental trend in perceptual abilities.