Diagnostic evaluation and management of hoarseness

I-scan combined with laryngovideostroboscopy for predicting malignancy in vocal fold leukoplakia

OBJECTIVE

This study evaluated vocal fold leukoplakia using i-scan combined with laryngovideostroboscopy for risk assessment prediction.

METHODS

A total of 141 patients with 218 lesions were enrolled in this study. Morphological characteristics of leukoplakia, assessment of the vascular pattern using i-scan, and vocal fold vibratory function were analyzed.

RESULTS

The number of patients with no, mild, moderate, severe dysplasia, and invasive carcinoma were 68, 40, 17, 46 and 47, respectively. The sensitivity of morphological characteristic, vascular pattern, vibratory function and predictive model were 77.4%, 72%, 69.9%, and 82.8%, respectively. Receiver operating characteristic curve analysis of morphological characteristic, vascular pattern, vibratory function and predictive model were 0.771, 0.824, 0.769, and 0.923, respectively. The results of logistic regression analysis showed that rough morphological types, perpendicular vascular pattern, severe decrease and absence of mucosal waves increased the risk of malignancy (OR = 5.531, 4.973, and 16.992, respectively; P < 0.001).

CONCLUSIONS

I-scan combined with laryngovideostroboscopy can improve the differential diagnosis of low-risk and high-risk vocal fold leukoplakia.

The Performance of the Acoustic Voice Quality Index and Acoustic Breathiness Index in Synthesized Voices

OBJECTIVE

The aim of the present study was to investigate the performance of the Acoustic Voice Quality Index (AVQI) and the Acoustic Breathiness Index (ABI) in synthesized voice samples.

METHOD

The validity of the AVQI and ABI performances was analyzed in synthesized voice samples controlling the degree of predefined deviations for overall voice quality (G-scale) and breathiness (B-scale). A range of 26 synthesized voice samples with various severity degrees in G-scale with and without prominence of breathiness for male and female voices were created.

RESULTS

ABI received higher validity in the evaluation of breathiness than AVQI. Furthermore, ABI evaluated accurately breathiness degrees without considering roughness effects in voice samples and confirmed the findings of other studies with natural voices. Furthermore, ABI was more robust than AVQI in the evaluation of severe voice-disordered voice samples. Finally, AVQI represented moreover overall voice quality with an emphasis of breathiness evaluation and less roughness although roughness had a necessary component in overall voice quality evaluation.

CONCLUSION

AVQI and ABI are two robust measurements in the evaluation of voice quality. However, ABI received fewer errors than AVQI in the analyses of higher abnormalities in the voice signal. Disturbances of other subtypes of abnormal overall voice quality such as roughness were not demonstrated in the results of ABI.

Accuracy of narrow‐band imaging for diagnosing malignant transformation of vocal cord leukoplakia: A systematic review and meta‐analysis

Objective

To explore whether narrow-band imaging (NBI) endoscopy is accurate in the diagnosis of malignant transformation of vocal cord leukoplakia.

Methods

The PubMed, Embase, Cochrane Library and Web of Science databases were searched to collect data on studies reporting the use of NBI endoscopy as a diagnostic test for diagnosing vocal cord leukoplakia from January 2015 to December 2021. Study design, analysis method, and extraction results were performed according to the PRISMA guidelines. The sensitivity, specificity, pooled positive likelihood ratio (PLR), negative likelihood ratio (NLR) and area under the curve (AUC) were used to summarize the performance metrics of the meta-analysis. Risk of bias data and the quality of the included studies was evaluated according to the Quality Assessment of Diagnostic Accuracy Studies-2 tool (QUADAS-2).

Results

Nine studies were finally included in the analysis. The results of the meta-analysis showed that the pooled sensitivity and specificity of NBI endoscopy for diagnosing leukoplakia lesions were 0.76 (95% CI: 0.72-0.8) and 0.93 (95% CI: 0.91-0.95), respectively. The PLR and NLR were 10.09 (95% CI: 6.53-15.59) and 0.22 (95% CI: 0.13-0.38), respectively. The comprehensive diagnostic odds ratio (DOR) was 54.96 (95% CI: 24.32-124.17), and the area under the curve was 0.9584. The eight articles had a low risk of bias risk and one article was unclear.

Conclusion

NBI likely has good accuracy for diagnosing malignant transformation of vocal cord leukoplakia. However, multicenter studies and large samples are still needed.

Effect of ketogenic diet versus regular diet on voice quality of patients with Parkinson's disease

Diets that have effects on health problems can vary in their composition. Whilst following a regular diet (RD) a person typically consumes about 30% of calories from fat. Ketogenic diet (KD) is a form of diet whereby a person consumes as much as 90% of calories from fat. KD has been trialed as a treatment for neurological diseases and obesity. Parkinson's disease (PD) is a neurologic disease that impacts the quality of voice. Voice Handicap Index (VHI) is a test that gives information to clinical and physiological assessment about voice. We assessed the impact of KD and RD on voice quality (VQ). Seventy-four patients with PD who reported a voice disorder related to their disease were randomly assigned to the KD or RD groups. We investigated the VHI change of subjects before and 3 months after diet. Sixty-eight PD patients completed the study. Baseline VHI values did not differ significantly between groups. All mean VHI parameters improved in KD group (p˂ 0.001). Currently there are different therapies that address speech and voice disorders in patients with PD. As such KD may be an alternative therapy to improve VQ of patients with PD. A larger sample size is necessary to determine the role and pathophysiology of KD on VQ of PD patients.

Alarming triad of progressive hoarseness in a male smoker

Hoarseness accounts for 1% of all consultations in primary care. Suspicion of malignancy should be considered in individuals with risk factors presenting with unexplained hoarseness lasting more than two weeks. A significant number of patients with laryngeal cancer present at an advanced stage due to lack of awareness regarding vocal health. It is important to educate both the public and primary care health providers concerning laryngeal cancer. We present the case of an 81-year- old male smoker who presented to us with a six-month history of progressive hoarseness. He was initially treated in two primary and one secondary care centres, where a diagnosis of laryngeal cancer was not considered. Careful assessment in our centre managed to determine a diagnosis of T3N0M0 glottic carcinoma. We will discuss this alarming triad of progressive hoarseness in a male smoker to help primary care physicians streamline their thoughts and identify red flags in a hoarse patient.

Diagnostic Accuracies of Laryngeal Diseases Using a Convolutional Neural Network-Based Image Classification System

OBJECTIVES/HYPOTHESIS

There may be an interobserver variation in the diagnosis of laryngeal disease based on laryngoscopic images according to clinical experience. Therefore, this study is aimed to perform computer-assisted diagnosis for common laryngeal diseases using deep learning-based disease classification models.

STUDY DESIGN

Experimental study with retrospective data METHODS: A total of 4106 images (cysts, nodules, polyps, leukoplakia, papillomas, Reinke's edema, granulomas, palsies, and normal cases) were analyzed. After equal distribution of diseases into ninefolds, stratified eightfold cross-validation was performed for training, validation process and remaining onefold was used as a test dataset. A trained model was applied to test sets, and model performance was assessed for precision (positive predictive value), recall (sensitivity), accuracy, F1 score, precision-recall (PR) curve, and PR-area under the receiver operating characteristic curve (PR-AUC). Outcomes were compared to those of visual assessments by four trainees.

RESULTS

The trained deep neural networks (DNNs) outperformed trainees' visual assessments in discriminating cysts, granulomas, nodules, normal cases, palsies, papillomas, and polyps according to the PR-AUC and F1 score. The lowest F1 score and PR-AUC of DNNs were estimated for Reinke's edema (0.720, 0.800) and nodules (0.730, 0.780) but were comparable to the mean of the two trainees' F1 score with the best performances (0.765 and 0.675, respectively). In discriminating papillomas, the F1 score was much higher for DNNs (0.870) than for trainees (0.685). Overall, DNNs outperformed all trainees (micro-average PR-AUC = 0.95; macro-average PR-AUC = 0.91).

CONCLUSIONS

DNN technology could be applied to laryngoscopy to supplement clinical assessment of examiners by providing additional diagnostic clues and having a role as a reference of diagnosis.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Diagnostic Value and Pathological Correlation of Narrow Band Imaging Classification in Laryngeal Lesions

OBJECTIVES

To explore the diagnostic value and pathological correlation of narrow band imaging (NBI) classification in laryngeal lesions.

METHODS

A total of 112 patients (123 lesions) with laryngeal lesions from July 2018 to May 2019 were selected in this study. All patients were examined by NBI and white light imaging endoscopy. The NBI endoscopy was applied to classify the observed lesion sites according to intraepithelial papillary capillary loop pattern. The gold standard of diagnosis was pathological results. To evaluate the consistency of NBI classification and pathological results.

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of the diagnosis for benign, precancerous, and malignant lesions under the NBI endoscopy were 90.91%, 81.19%, 74.07%, 85.42%; 41.67%, 92.93%, 58.82%, 86.79%; and 93.51%, 65.22%, 91.14%, 68.18%, respectively. There was a high consistency between NBI classification and pathological results (κ = 0.679, P < .001).

CONCLUSIONS

The NBI classification can improve the accuracy of the diagnosis of laryngeal lesions. It is important for early diagnosis and treatment of vocal cord leukoplakia and laryngeal cancer.

An Open-Source Computer Vision Tool for Automated Vocal Fold Tracking From Videoendoscopy

OBJECTIVES

Contemporary clinical assessment of vocal fold adduction and abduction is qualitative and subjective. Herein is described a novel computer vision tool for automated quantitative tracking of vocal fold motion from videolaryngoscopy. The potential of this software as a diagnostic aid in unilateral vocal fold paralysis is demonstrated.

STUDY DESIGN

Case-control.

METHODS

A deep-learning algorithm was trained for vocal fold localization from videoendoscopy for automated frame-wise estimation of glottic opening angles. Algorithm accuracy was compared against manual expert markings. Maximum glottic opening angles between adults with normal movements (N = 20) and those with unilateral vocal fold paralysis (N = 20) were characterized.

RESULTS

Algorithm angle estimations demonstrated a correlation coefficient of 0.97 (P < .001) and mean absolute difference of 3.72° (standard deviation [SD], 3.49°) in comparison to manual expert markings. In comparison to those with normal movements, patients with unilateral vocal fold paralysis demonstrated significantly lower maximal glottic opening angles (mean 68.75° ± 11.82° vs. 49.44° ± 10.42°; difference, 19.31°; 95% confidence interval [CI] [12.17°-26.44°]; P < .001). Maximum opening angle less than 58.65° predicted unilateral vocal fold paralysis with a sensitivity of 0.85 and specificity of 0.85, with an area under the receiver operating characteristic curve of 0.888 (95% CI [0.784-0.991]; P < .001).

CONCLUSION

A user-friendly software tool for automated quantification of vocal fold movements from previously recorded videolaryngoscopy examinations is presented, termed automated glottic action tracking by artificial intelligence (AGATI). This tool may prove useful for diagnosis and outcomes tracking of vocal fold movement disorders.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E219-E225, 2021.

Vocal cord paralysis following general anesthesia with endotracheal intubation: a clinical review on 43 cases

Background

Vocal cord paralysis (VCP) is one of the most stressful experiences for patients undergoing general anesthesia. Moreover, it is a risk factor for aspiration pneumonia and may increase morbidity and mortality. We examined several clinical features of the condition by reviewing the medical records of patients who experienced VCP following general anesthesia.

Methods

We reviewed the medical records of 321 patients who consulted an otolaryngologist owing to hoarseness, sore throat, throat discomfort, or dysphagia after general anesthesia. Among these, we included in the present study 43 patients who were diagnosed with VCP by laryngoscopy, who did not have symptoms of suspected VCP before surgery, who had no past history of VCP, and for whom endotracheal intubation was not continued after surgery.

Results

The mean age of patients with VCP was 51.3 years. With respect to surgical site, the most common was upper limb surgery, performed in 12 cases (9 cases were performed in sitting posture. With respect to surgical duration, only 11 cases lasted less than 3 h, whereas 32 cases required a surgical duration longer than 3 h. The most common symptom of VCP was hoarseness. Nine of the patients with VCP recovered spontaneously, but VCP persisted in 13 cases until the final follow-up examination.

Conclusions

We hope that this study might call attention to the occurrence of VCP following general anesthesia. Moreover, it is necessary to further evaluate the reasons for the higher incidence of VCP in upper limb surgery performed in sitting posture.

Development of three-dimensional laryngostroboscopy for office-based laryngeal diagnostics and phonosurgical therapy

OBJECTIVE

To develop a three-dimensional (3D) laryngostroboscopic examination unit, compare the optic playback quality in relation to established 2D procedures, and report the first case series using 3D rigid laryngostroboscopy for diagnosis and management of laryngotracheal diseases.

STUDY DESIGN

Laboratory study, prospective case series.

METHODS

The optical efficacy of newly developed rigid 3D endoscopes was examined in a laboratory setting. Diagnostic suitability was investigated in 100 subjects (50 male, 50 female) receiving 2D high-definition (HD) and 3D laryngostroboscopy. Two of the subjects subsequently underwent 3D-assisted office-based transoral phonosurgery under local anesthesia. Main outcome measures were comparative visualization of laryngotracheal pathologies, influence on preoperative planning, and evaluation of prognostic factors for the outcome of phonosurgical interventions.

RESULTS

Three-dimensional endostroboscopic procedures were effectively optimized to establish an examination protocol for all-day clinical use. Office-based 3D laryngostroboscopy was successfully applied in subjects with normal anatomy (n = 10) and various laryngotracheal findings (n = 90). In comparison to 2D HD videolaryngostroboscopy, the 3D view offered enhanced visualization of laryngotracheal anatomy, with qualitatively improved depth perception and spatial representation. In organic pathologies, this resulted in a more precise indication of phonosurgical procedures, increased accuracy in surgical planning, facilitated office-based endoscopic surgery, and better evaluation of prognostic factors for the outcome of phonosurgical interventions.

CONCLUSION

Three-dimensional laryngostroboscopy proved to increase the understanding of functional and surgical anatomy. Its application has enormous potential for improving the diagnostic value of laryngoscopy, surgical precision in laryngotracheal interventions, tissue preservation, and methods of teaching.

LEVEL OF EVIDENCE

NA Laryngoscope, 128:2823-2831, 2018.

Evaluation of the Correlation Between Turkish Voice Handicap Index-10 and Turkish Voice-Related Quality of Life Scale

OBJECTIVE

Aim of this sudy was to evaluate the correlation between Turkish Voice Handicap Index-10 (TVHİ-10) and Turkish Voice-Related Quality of Life Questionnaries (TV-RQOL) on patients with dysphonia.

METHODS

Two different groups were formed with patients with dysphonia and healthy individuals between February and July 2016. After medical history and otorhinolaringologic and phoniatric examinations all the subjects completed TVHI-10 and TV-RQOL questionnaries. The correlation between scores of parameters of questionnaries were evaluated.

RESULTS

Data of 104 patients (59 women, 45 men) with a mean age of 46±15 years in dysphonia group and 75 individuals (38 women, 37 men) with a mean age of 45±13.8 years in healthy group were evaluated. TVHI-10 and TV-RQOL parameters' scores were significantly higher in dysphonia group than healthy group. There were positive and significant correlations between scores of TVHI-10 and TV-RQOL parameters of all 179 individuals. There was significant positive correlation between total scores of TVHI-10 and TV-RQOL values of all individuals (r=0.949, p<0.001).

CONCLUSION

There is positive significant correlation between validated Turkish versions of VHI-10 and V-RQOL questionnaries as a self-assessment measurement tools. The results of studies which use TV-RQOL can be compared with the results of the studies using TVHI-10.

An unusual cause of hoarseness and recurrent laryngeal nerve palsy

Recurrent laryngeal nerve palsy and thyroid disease suggest locally invasive thyroid malignancy. In contrast, recurrent laryngeal nerve palsy caused by benign multinodular goiters or ectopic thyroid tissue accounts for only 1% of cases. This article describes an unusual case of recurrent laryngeal nerve palsy secondary to a benign ectopic retrosternal thyroid tissue mass. Recurrent laryngeal nerve palsy should be considered in the differential diagnosis of patients presenting with progressive voice weakness and hoarseness.

Collinearity and Sample Coverage Issues in the Objective Measurement of Vocal Quality: The Case of Roughness and Breathiness

PURPOSE

The aim of the study was to address the reported inconsistencies in the relationship between objective acoustic measures and perceptual ratings of vocal quality.

METHOD

This tutorial moves away from the more widely examined problems related to obtaining the perceptual ratings and the acoustic measures and centers in less scrutinized issues regarding the procedure to establish the correspondence. Expressions for the most common measure of association between perceptual and acoustic measures (Pearson's r) are derived using a multiple linear regression model. The particular case where the multiple linear regression involves only roughness and breathiness is discussed to illustrate the issues.

RESULTS

Most problems reported regarding inconsistent findings in the relationship between given acoustic measures and particular perceptual ratings could be linked to sample properties not directly related to the actual relationship. The influential sample properties are the collinearity between the regressors in the multiple linear regression and their relative variances. Recommendations on how to rule out this possible cause of inconsistency are given, varying in scope from data collection, reporting, manipulation, and results interpretation.

CONCLUSIONS

The problems described can be extended to more general cases than the exemplified roughness and breathiness sample's coverage. Ruling out this possible cause of inconsistency would increase the validity of the results reported.

Speaker-Independent Silent Speech Recognition from Flesh-Point Articulatory Movements Using an LSTM Neural Network

Silent speech recognition (SSR) converts non-audio information such as articulatory movements into text. SSR has the potential to enable persons with laryngectomy to communicate through natural spoken expression. Current SSR systems have largely relied on speaker-dependent recognition models. The high degree of variability in articulatory patterns across different speakers has been a barrier for developing effective speaker-independent SSR approaches. Speaker-independent SSR approaches, however, are critical for reducing the amount of training data required from each speaker. In this paper, we investigate speaker-independent SSR from the movements of flesh points on tongue and lip with articulatory normalization methods that reduce the inter-speaker variation. To minimize the across-speaker physiological differences of the articulators, we propose Procrustes matching-based articulatory normalization by removing locational, rotational, and scaling differences. To further normalize the articulatory data, we apply feature-space maximum likelihood linear regression and i-vector. In this paper, we adopt a bidirectional long short term memory recurrent neural network (BLSTM) as an articulatory model to effectively model the articulatory movements with long-range articulatory history. A silent speech data set with flesh points was collected using an electromagnetic articulograph (EMA) from twelve healthy and two laryngectomized English speakers. Experimental results showed the effectiveness of our speaker-independent SSR approaches on healthy as well as laryngectomy speakers. In addition, BLSTM outperformed standard deep neural network. The best performance was obtained by BLSTM with all the three normalization approaches combined.

Relationship between laryngoscopic and pathological characteristics of vocal cords leukoplakia

BACKGROUND

To explore the relationship between the morphological characteristics and pathological diagnosis of vocal cords leukoplakia.

METHODS

A total of 1635 vocal cords were collected. The morphology were classified into three types (Type I, II, III): flat and smooth; bulge and smooth; bulge and rough. The pathological reports were classified into five groups: no dysplasia, mild dysplasia, moderate dysplasia, severe dysplasia and cancerization. The number of the patients or vocal cords in each type and group was counted and their ratio was compared.

RESULTS

In Type I, the number of vocal cord in Group A group was 2.2 and 2.6 times of the one in Type II and Type III respectively. In Type II, the mild, moderate dysplasia ratio was higher than those in Type I. In Type III group the ratio of severe dysplasia was 2.6 and 5.5 times of the one in Type II and Type I respectively. The ratio of Group E in Type III was 2.7 and 7.9 times of the one of Type II and Type I. The result was significant (pearson Chi-square value was 517.6, p = .00).

CONCLUSIONS

The pathological results of vocal cord leukoplakia can be evaluated by morphology in most cases.

[The modern possibilities for the treatment of the patients presenting with benign and tumour-like diseases of the larynx]

Rehabilitation of the patients presenting with benign and tumour-like diseases of the larynx (BLT) is currently a serious challenge for modern otorhinolaryngology in view of the high prevalence of this pathology. Dysphonia is a leading clinical symptom of the diseases that considerably deteriorates the quality of life of the patients. Certain benign conditions of the larynx exhibit a tendency toward malignization. The treatment of the patients presenting with benign and tumour-like diseases of the larynx requires a combined approach including the surgical, therapeutic, and phonopedic modalities for the rehabilitation of the vocal function. This article presents a review of the literature on the modern high-energy techniques for the treatment of the patients presenting with benign and tumour-like diseases of the larynx, The advantages and disadvantages of each method are discussed.

Hoarseness-causes and treatments

BACKGROUND

Hoarseness (dysphonia) is the reason for about 1% of all consultations in primary care. It has many causes, ranging from self-limited laryngitis to malignant tumors of the vocal cords.

METHODS

This review is based on literature retrieved by a selective search in PubMed employing the terms "hoarseness," "hoarse voice," and "dysphonia," on the relevant guideline of the American Academy of Otolaryngology -Head and Neck Surgery, and on Cochrane reviews.

RESULTS

Hoarseness can be caused by acute (42.1%) and chronic laryngitis (9.7%), functional vocal disturbances (30%), and benign (10.7-31%) and malignant tumors (2.2-3%), as well as by neurogenic disturbances such as vocal cord paresis (2.8-8%), physiologic aging of the voice (2%), and psychogenic factors (2-2.2 %). Hoarseness is very rarely a manifestation of internal medical illness. The treatment of hoarseness has been studied in only a few randomized controlled trials, all of which were on a small scale. Voice therapy is often successful in the treatment of functional and organic vocal disturbances (level 1a evidence). Surgery on the vocal cords is indicated to treat tumors and inadequate vocal cord closure. The only entity causing hoarseness that can be treated pharmacologically is chronic laryngitis associated with gastro-esophageal reflux, which responds to treatment of the reflux disorder. The empirical treatment of hoarseness with antibiotics or corticosteroids is not recommended.

CONCLUSION

Voice therapy, vocal cord surgery, and drug therapy for appropriate groups of patients with hoarseness are well documented as effective by the available evidence. In patients with risk factors, especially smokers, hoarseness should be immediately evaluated by laryngos - copy.

Intra- and Inter-database Study for Arabic, English, and German Databases: Do Conventional Speech Features Detect Voice Pathology?

A large population around the world has voice complications. Various approaches for subjective and objective evaluations have been suggested in the literature. The subjective approach strongly depends on the experience and area of expertise of a clinician, and human error cannot be neglected. On the other hand, the objective or automatic approach is noninvasive. Automatic developed systems can provide complementary information that may be helpful for a clinician in the early screening of a voice disorder. At the same time, automatic systems can be deployed in remote areas where a general practitioner can use them and may refer the patient to a specialist to avoid complications that may be life threatening. Many automatic systems for disorder detection have been developed by applying different types of conventional speech features such as the linear prediction coefficients, linear prediction cepstral coefficients, and Mel-frequency cepstral coefficients (MFCCs). This study aims to ascertain whether conventional speech features detect voice pathology reliably, and whether they can be correlated with voice quality. To investigate this, an automatic detection system based on MFCC was developed, and three different voice disorder databases were used in this study. The experimental results suggest that the accuracy of the MFCC-based system varies from database to database. The detection rate for the intra-database ranges from 72% to 95%, and that for the inter-database is from 47% to 82%. The results conclude that conventional speech features are not correlated with voice, and hence are not reliable in pathology detection.

Recognizing Whispered Speech Produced by an Individual with Surgically Reconstructed Larynx Using Articulatory Movement Data

Individuals with larynx (vocal folds) impaired have problems in controlling their glottal vibration, producing whispered speech with extreme hoarseness. Standard automatic speech recognition using only acoustic cues is typically ineffective for whispered speech because the corresponding spectral characteristics are distorted. Articulatory cues such as the tongue and lip motion may help in recognizing whispered speech since articulatory motion patterns are generally not affected. In this paper, we investigated whispered speech recognition for patients with reconstructed larynx using articulatory movement data. A data set with both acoustic and articulatory motion data was collected from a patient with surgically reconstructed larynx using an electromagnetic articulograph. Two speech recognition systems, Gaussian mixture model-hidden Markov model (GMM-HMM) and deep neural network-HMM (DNN-HMM), were used in the experiments. Experimental results showed adding either tongue or lip motion data to acoustic features such as mel-frequency cepstral coefficient (MFCC) significantly reduced the phone error rates on both speech recognition systems. Adding both tongue and lip data achieved the best performance.

The improvement of internal consistency of the Acoustic Voice Quality Index

PURPOSE

This investigation aims to explore the improvement of the relatively new hoarseness severity quantification method, called Acoustic Voice Quality Index (AVQI), which measures the concatenation of continuous speech (CS) and sustained phonation (SP) segments. Earlier investigations indicated that the proportion of the SP is more dominant in the final AVQI result than the CS.

METHOD

Sixty voice samples were selected with different voice pathologies and equal distribution of hoarseness severity ranged from normal to severe. Every voice sample varied in three different durations: voice duration-one (VD-1) with seventeen syllables text plus three seconds of SP, voice duration-two (VD-2) with customized length of CS plus three seconds of SP, and voice duration-three (VD-3) with a whole text plus three seconds SP. All voice samples were perceptually judged on overall voice quality by five experienced voice clinicians. AVQI's precision and concurrent validity were assessed in all three VDs. Finally, the internal consistency across all three VDs was analyzed.

RESULTS

No significant differences were found in the perceptual evaluation of overall voice quality across all three VDs by acceptable rater reliability. The concurrent validity distinguished in all three VDs as a marked degree of correlation (i.e., ranged from rs=0.891 to rs=0.929) with no significant differences across all three VDs. The best precision was found in VD-2. Finally, the internal consistency showed in VD-2 a balanced out impact of the final AVQI score with no significant differences from both speech tasks.

CONCLUSION

Although AVQI currently uses the speech material of VD-1, the present study demonstrated the best results in VD-2 (i.e., precision and internal consistency). These features of VD-2 facilitate higher representativity and improve the validity of this objective diagnostic instrument.

Vocal cord paralysis and its etiologies: a prospective study

Introduction: Vocal cord paralysis is a common symptom of numerous diseases and it may be due to neurogenic or mechanical fixation of the cords. Paralysis of the vocal cords is just a symptom of underlying disease in some cases; so, clinical diagnosis of the underlying cause leading to paralysis of the vocal cords is important. This study evaluates the causes of vocal cord paralysis.

Methods: In a prospective study, 45 patients with paralyzed vocal cord diagnosis were examined by tests such as examination of the pharynx, larynx, esophagus, thyroid, cervical, lung, and mediastinum, brain and heart by diagnostic imaging to investigate the cause vocal cord paralysis. The study was ended by diagnosing the reason of vocal cord paralysis at each stage of the examination and the clinical studies.

Results: The mean duration of symptoms was 18.95±6.50 months. The reason for referral was phonation changes (97.8%) and aspiration (37.8%) in the subjects. There was bilateral paralysis in 6.82%, left paralysis in 56.82% and right in 63.36% of subjects. The type of vocal cord placement was midline in 52.8%, paramedian in 44.4% and lateral in 2.8% of the subjects. The causes of vocal cords paralysis were idiopathic paralysis (31.11%), tumors (31.11%), surgery (28.89%), trauma, brain problems, systemic disease and other causes (2.2%).

Conclusion: An integrated diagnostic and treatment program is necessary for patients with vocal cord paralysis. Possibility of malignancy should be excluded before marking idiopathic reason to vocal cord paralysis.

Laryngeal problems

Laryngeal complaints are common reasons for patients to seek care. There is considerable overlap between patient symptoms and final diagnosis. This article begins with a general approach to laryngeal symptoms followed by individual consideration of both the common and serious conditions of the larynx. Early diagnosis and treatment are important for improving outcomes in patients with laryngeal complaints.

Diagnostic and therapeutic pitfalls in benign vocal fold diseases

More than half of patients presenting with hoarseness show benign vocal fold changes. The clinician should be familiar with the anatomy, physiology and functional aspects of voice disorders and also the modern diagnostic and therapeutic possibilities in order to ensure an optimal and patient specific management. This review article focuses on the diagnostic and therapeutic limitations and difficulties of treatment of benign vocal fold tumors, the management and prevention of scarred vocal folds and the issue of unilateral vocal fold paresis.

An unusual cause of hoarseness

A 55-year-old man had a 3 month history of hoarseness and choking when he drinks liquids. Physical examination revealed evidence of left sided palsy of 9th, 10th, 11th and 12th cranial nerves. A brain MRI revealed a skull base lytic lesion. The authors diagnosed Collet-Sicard syndrome. The patient was found to have colon cancer. He received palliative skull radiotherapy and died few weeks later in hospice care.