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Ghasemzadeh H, Hillman RE, Mehta DD. Consistency of the Signature of Phonotraumatic Vocal Hyperfunction Across Different Ambulatory Voice Measures. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024:1-24. [PMID: 38861454 DOI: 10.1044/2024_jslhr-23-00515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
PURPOSE Although different factors and voice measures have been associated with phonotraumatic vocal hyperfunction (PVH), it is unclear what percentage of individuals with PVH exhibit such differences during their daily lives. This study used a machine learning approach to quantify the consistency with which PVH manifests according to ambulatory voice measures. Analyses included acoustic parameters of phonation as well as temporal aspects of phonation and rest, with the goal of determining optimally consistent signatures of PVH. METHOD Ambulatory neck-surface acceleration signals were recorded over 1 week from 116 female participants diagnosed with PVH and age-, sex-, and occupation-matched vocally healthy controls. The consistency of the manifestation of PVH was defined as the percentage of participants in each group that exhibited an atypical signature based on a target voice measure. Evaluation of each machine learning model used nested 10-fold cross-validation to improve the generalizability of findings. In Experiment 1, we trained separate logistic regression models based on the distributional characteristics of 14 voice measures and durations of voicing and resting segments. In Experiments 2 and 3, features of voicing and resting duration augmented the existing distributional characteristics to examine whether more consistent signatures would result. RESULTS Experiment 1 showed that the difference in the magnitude of the first two harmonics (H1-H2) exhibited the most consistent signature (69.4% of participants with PVH and 20.4% of controls had an atypical H1-H2 signature), followed by spectral tilt over eight harmonics (73.6% participants with PVH and 32.1% of controls had an atypical spectral tilt signature) and estimated sound pressure level (SPL; 66.9% participants with PVH and 27.6% of controls had an atypical SPL signature). Additionally, 77.6% of participants with PVH had atypical resting duration, with 68.9% exhibiting atypical voicing duration. Experiments 2 and 3 showed that augmenting the best-performing voice measures with univariate features of voicing or resting durations yielded only incremental improvement in the classifier's performance. CONCLUSIONS Females with PVH were more likely to use more abrupt vocal fold closure (lower H1-H2), phonate louder (higher SPL), and take shorter vocal rests. They were also less likely to use higher fundamental frequency during their daily activities. The difference in the voicing duration signature between participants with PVH and controls had a large effect size, providing strong empirical evidence regarding the role of voice use in the development of PVH.
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Affiliation(s)
- Hamzeh Ghasemzadeh
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
- Department of Communicative Sciences and Disorders, Michigan State University, East Lansing
| | - Robert E Hillman
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
| | - Daryush D Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
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Ferguson SH, Morgan SD, Hunter EJ. Within-talker and within-session stability of acoustic characteristics of conversational and clear speaking stylesa). THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2024; 155:44-55. [PMID: 38174965 PMCID: PMC10990565 DOI: 10.1121/10.0024241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/01/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024]
Abstract
In speech production research, talkers often perform a speech task several times per recording session with different speaking styles or in different environments. For example, Lombard speech studies typically have talkers speak in several different noise conditions. However, it is unknown to what degree simple repetition of a speech task affects speech acoustic characteristics or whether repetition effects might offset or exaggerate effects of speaking style or environment. The present study assessed speech acoustic changes over four within-session repetitions of a speech production taskset performed with two speaking styles recorded in separate sessions: conversational and clear speech. In each style, ten talkers performed a set of three speech tasks four times. Speaking rate, median fundamental frequency, fundamental frequency range, and mid-frequency spectral energy for read sentences were measured and compared across test blocks both within-session and between the two styles. Results indicate that statistically significant changes can occur from one repetition of a speech task to the next, even with a brief practice set and especially in the conversational style. While these changes were smaller than speaking style differences, these findings support using a complete speech set for training while talkers acclimate to the task and to the laboratory environment.
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Affiliation(s)
- Sarah Hargus Ferguson
- Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, Utah 84112, USA
| | - Shae D Morgan
- Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, Utah 84112, USA
| | - Eric J Hunter
- Department of Communicative Sciences and Disorders, Michigan State University, East Lansing, Michigan 48824, USA
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Schloneger M, Hunter EJ, Maxfield L. Quantifying Vocal Repertoire Tessituras Through Real-Time Measures. J Voice 2024; 38:247.e11-247.e25. [PMID: 34315650 PMCID: PMC8786980 DOI: 10.1016/j.jvoice.2021.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/10/2021] [Accepted: 06/15/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Voice teachers use anecdotal evidence and experience in determining the appropriateness of repertoire for each student's development. Tessitura is important in that determination, but until recently a straightforward, repeatable, and quantifiable method for determining tessitura has not existed. However, technology exists to provide the means to estimate the tessituras of standard vocal repertoire by measuring sung pitch (fundamental frequency) and vocal dose (amount of phonation) in real-time performance. PURPOSE The purpose of this study was to examine the combined use of tessituragrams, Voice Range Profiles (VRPs), a singer's self-perception of a performance, and expert listeners perception of a performance towards the goal of a more systematic way of selecting appropriate voice repertoire for singers. The following research questions guided this investigation: 1) How do Performance Range Profiles (PRPs, performance-based tessituragrams computed from neck skin surface vibration during singing), compare to score-based tessituragrams of the same selection in the same key? 2) How do PRPs of the same vocal score compare when performed in three different keys? 3) How do singer VRPs compare with PRPs of three performances of a score, each sung in a different key? and 4) How do singer and expert panel perceptions of the selection's "fit" in three different keys compare with the alignment of each singer's VRP to their PRPs? Four female singers and five expert voice pedagogues were enlisted to address these questions. RESULTS The distribution (histogram) of the score-based tessituragram closely matched the distribution of performance-based tessituragrams (PRP), suggesting that score-based tessituragrams have promise in accurately reflecting the performance-based tessitura of a musical vocal work. Acquired data revealed relationships of practical importance between score-derived tessituragrams, PRPs, acquired VRPs, and singer perceptions of ease in singing. These data suggest that score-based tessituragrams aligned with singer VRPs show promise in repertoire selection. However, there was only a minor relationship between expert panel perceptions of ease in singing and the acquired PRPs or singer perceptions of ease. Creation of a score-based tessituragram database could be combined with singer VRPs to assist in appropriate repertoire selection.
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Affiliation(s)
- Matthew Schloneger
- Division of Fine Arts, Friends University, 2100 W. University Avenue, Wichita, Kansas 67213.
| | - Eric J Hunter
- Dept of Communicative Sciences and Disorders, Michigan State University, 404 Wilson Rd, Room 291, Communication Arts and Sciences Building, East Lansing, MI 48824
| | - Lynn Maxfield
- Utah Center for Vocology, University of Utah, 240 S. 1500 E., Room 206, Salt Lake City, UT 84112
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Eastman SE, Ghasemzadeh H, Van Stan J, Hillman RE, Mehta DD. Quantifying the Occupational Voice Use of Teachers. PERSPECTIVES OF THE ASHA SPECIAL INTEREST GROUPS 2023; 8:1363-1379. [PMID: 38312372 PMCID: PMC10836712 DOI: 10.1044/2023_persp-23-00084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Purpose The teaching profession is a high-voice use occupation at elevated risk for developing voice disorders. Continued research on teachers' vocal demands is necessary to advocate for and establish vocal health programs. This study quantified ambulatory vocal dose measures for teachers during both on- and off-work periods, comparing their occupational voice use to that in other studies that have reported percent phonation ranging from 17% to 30%. Method Participants included 26 full-time, female school teachers between 23 and 55 years of age across multiple grades and subjects, including individuals with and without a voice disorder. Ambulatory voice data were collected from weeklong voice monitoring that recorded phonatory activity through anterior neck-surface vibration. Three vocal dose measures-time, cycle, and distance doses-were computed for each participant for three time periods: on-work weekdays, off-work weekdays, and off-work weekend days. Results The teachers' average percent phonation was 16.2% on-work weekdays, 8.4% off-work weekdays, and 8.0% off-work weekend days. No statistically significant differences for vocal dose measures were found between off-work weekdays and weekend days. Overall, all vocal dose measures were approximately 2 times higher during work relative to off-work time periods. Conclusions This study provides values for vocal dose measures for school teachers using ambulatory voice-monitoring technology. The vocal demands of this particular teacher sample and voice activity detection algorithm are potential factors contributing to percent phonation values on the lower end of the range reported in the literature. Future work is needed to continue to understand occupational voice use and its associated risks related to voice health, with the ultimate goal of preventing and managing voice disorders in individuals engaged in high-risk occupations.
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Affiliation(s)
- Sarah E. Eastman
- Rehabilitation Sciences Program, MGH Institute of Health Professions, Boston, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - Hamzeh Ghasemzadeh
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Jarrad Van Stan
- Rehabilitation Sciences Program, MGH Institute of Health Professions, Boston, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Robert E. Hillman
- Rehabilitation Sciences Program, MGH Institute of Health Professions, Boston, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology Program, Division of Medical Sciences, Harvard University, Boston, MA
| | - Daryush D. Mehta
- Rehabilitation Sciences Program, MGH Institute of Health Professions, Boston, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology Program, Division of Medical Sciences, Harvard University, Boston, MA
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Van Stan JH, Burns J, Hron T, Zeitels S, Panuganti BA, Purnell PR, Mehta DD, Hillman RE, Ghasemzadeh H. Detecting Mild Phonotrauma in Daily Life. Laryngoscope 2023; 133:3094-3099. [PMID: 37194664 PMCID: PMC10592567 DOI: 10.1002/lary.30750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/24/2023] [Accepted: 05/03/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE The aim of this study was to gain quantitative insights into the role of daily voice use associated with mild phonotrauma via the Daily Phonotrauma Index (DPI), a measure derived from neck-surface acceleration magnitude (NSAM) and difference between the first two harmonic magnitudes (H1 - H2). METHODS An ambulatory voice monitor recorded weeklong voice use for 151 female patients with phonotraumatic vocal hyperfunction (PVH) and 181 female vocally healthy controls. Three laryngologists rated phonotrauma severity from each patient's laryngoscopy. Mixed generalized linear models evaluated the accuracy, sensitivity, and specificity of the original DPI trained on all patients versus a mild DPI version trained on only patients rated with mild phonotrauma. Individual contribution of NSAM and H1 - H2 to each DPI model was also evaluated. RESULTS Reliability across the laryngologists' phonotrauma ratings was moderate (Fleiss κ = 0.41). There were 70, 69, and 12 patients with mild, moderate, and severe phonotrauma, respectively. The mild DPI, compared to the original DPI, correctly classified more patients with mild phonotrauma (Cohen's d = 0.9) and less controls (d = -0.9) and did not change in overall accuracy. H1 - H2 contributed less to mild phonotrauma classification than NSAM for mild DPI. CONCLUSIONS Compared with the original DPI, the mild DPI exhibited higher sensitivity to mild phonotrauma and lower specificity to controls, but the same overall classification accuracy. These results support the mild DPI as a promising detector of early phonotrauma and that NSAM may be associated with early phonotrauma, and H1 - H2 may be a biomarker associated with vocal fold vibration in the presence of lesions. LEVEL OF EVIDENCE Level 4, case-control study Laryngoscope, 133:3094-3099, 2023.
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Affiliation(s)
- Jarrad H Van Stan
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- MGH Institute of Health Professions, Charlestown, Massachusetts, USA
| | - James Burns
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tiffiny Hron
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Steven Zeitels
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Daryush D Mehta
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- MGH Institute of Health Professions, Charlestown, Massachusetts, USA
| | - Robert E Hillman
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- MGH Institute of Health Professions, Charlestown, Massachusetts, USA
| | - Hamzeh Ghasemzadeh
- Massachusetts General Hospital, Boston, Massachusetts, USA
- MGH Institute of Health Professions, Charlestown, Massachusetts, USA
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Deng JJ, Peterson SD. Examining the influence of epithelium layer modeling approaches on vocal fold kinematics and kinetics. Biomech Model Mechanobiol 2023; 22:479-493. [PMID: 36536195 PMCID: PMC10787511 DOI: 10.1007/s10237-022-01658-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 11/19/2022] [Indexed: 12/23/2022]
Abstract
Grouping the thin epithelium and thicker superficial lamina propria layers into a single cover layer has been widely adopted in finite element vocal fold models. Recent silicone vocal fold studies have suggested, however, that inclusion of a distinct epithelial layer leads to more physiologically representative motion. This study systematically explores the ramifications of incorporating an epithelial layer into a cover grouping for finite element vocal fold modeling. A membrane model for the epithelium is introduced to facilitate parametric investigation by reducing the mesh density requirement of the epithelium into a single infinitesimally thin layer. Excluding the epithelium entirely leads to increased energy in higher order modes and larger inferior-superior excursion of the folds. Integrating the epithelium into a cover layer with volume-weighted average stiffness results in similar kinematics to that of a model treating the epithelium as a distinct layer. However, the internal stress/strain and contact pressure during collision are higher, and viscous dissipation is lower, when the epithelium is integrated into the cover. Thus, careful treatment of the epithelium is recommended for finite element studies, particularly when employing the models for estimating measures dependent upon internal stress/strain and/or collision pressure, such as vocal dose.
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Affiliation(s)
- Jonathan J Deng
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Sean D Peterson
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, N2L 3G1, Canada.
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Jeong H, Yoo JY, Ouyang W, Greane ALJX, Wiebe AJ, Huang I, Lee YJ, Lee JY, Kim J, Ni X, Kim S, Huynh HLT, Zhong I, Chin YX, Gu J, Johnson AM, Brancaccio T, Rogers JA. Closed-loop network of skin-interfaced wireless devices for quantifying vocal fatigue and providing user feedback. Proc Natl Acad Sci U S A 2023; 120:e2219394120. [PMID: 36802437 PMCID: PMC9992836 DOI: 10.1073/pnas.2219394120] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/12/2023] [Indexed: 02/23/2023] Open
Abstract
Vocal fatigue is a measurable form of performance fatigue resulting from overuse of the voice and is characterized by negative vocal adaptation. Vocal dose refers to cumulative exposure of the vocal fold tissue to vibration. Professionals with high vocal demands, such as singers and teachers, are especially prone to vocal fatigue. Failure to adjust habits can lead to compensatory lapses in vocal technique and an increased risk of vocal fold injury. Quantifying and recording vocal dose to inform individuals about potential overuse is an important step toward mitigating vocal fatigue. Previous work establishes vocal dosimetry methods, that is, processes to quantify vocal fold vibration dose but with bulky, wired devices that are not amenable to continuous use during natural daily activities; these previously reported systems also provide limited mechanisms for real-time user feedback. This study introduces a soft, wireless, skin-conformal technology that gently mounts on the upper chest to capture vibratory responses associated with vocalization in a manner that is immune to ambient noises. Pairing with a separate, wirelessly linked device supports haptic feedback to the user based on quantitative thresholds in vocal usage. A machine learning-based approach enables precise vocal dosimetry from the recorded data, to support personalized, real-time quantitation and feedback. These systems have strong potential to guide healthy behaviors in vocal use.
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Affiliation(s)
- Hyoyoung Jeong
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
- Department of Electrical and Computer Engineering, University of California, Davis, CA95616
| | - Jae-Young Yoo
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
| | - Wei Ouyang
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
| | - Aurora Lee Jean Xue Greane
- Bienen School of Music, Northwestern University, Evanston, IL60208
- Department of Biomedical Engineering, Northwestern University, Evanston, IL60208
| | | | - Ivy Huang
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
- Department of Materials Science Engineering, Northwestern University, Evanston, IL60208
| | - Young Joong Lee
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
- Department of Mechanical Engineering, Northwestern University, Evanston, IL60208
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA02142
| | - Jong Yoon Lee
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
- Sibel Health, Niles, IL60714
| | - Joohee Kim
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
- Center for Bionics, Biomedical Research Institute, Korea Institute of Science and Technology, Seoul02792, South Korea
| | - Xinchen Ni
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
| | - Suyeon Kim
- Department of Biomedical Engineering, Northwestern University, Evanston, IL60208
| | - Huong Le-Thien Huynh
- Department of Biomedical Engineering, Northwestern University, Evanston, IL60208
| | - Isabel Zhong
- Department of Biomedical Engineering, Northwestern University, Evanston, IL60208
| | - Yu Xuan Chin
- Department of Biomedical Engineering, Northwestern University, Evanston, IL60208
| | - Jianyu Gu
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
| | - Aaron M. Johnson
- Department of Otolaryngology-Head and Neck Surgery, Grossman School of Medicine, New York University, New York, NY10016
- Department of Rehabilitation Medicine, Grossman School of Medicine, New York University, New York, NY10016
| | | | - John A. Rogers
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL60208
- Department of Biomedical Engineering, Northwestern University, Evanston, IL60208
- Department of Materials Science Engineering, Northwestern University, Evanston, IL60208
- Department of Mechanical Engineering, Northwestern University, Evanston, IL60208
- Department of Electrical and Computer Engineering, Northwestern University, Evanston, IL60208
- Department of Chemistry, Northwestern University, Evanston, IL60208
- Department of Neurological Surgery, Northwestern University, Evanston, IL60208
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Immediate Effects of Straw Phonation in Water Exercises on Parameters of Vocal Loading in Carnatic Classical Singers. J Voice 2023; 37:142.e13-142.e22. [PMID: 33288381 DOI: 10.1016/j.jvoice.2020.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The present study aimed to investigate the effect of vocal loading and the immediate effects of straw phonation in water exercises on parameters of vocal loading in Carnatic classical singers. STUDY DESIGN A within-subject pretest-posttest design. METHODS Twelve healthy Carnatic classical singers participated in the vocal loading experiment for 2 days, referred to as no-treatment and treatment conditions. The vocal loading task consisted of 1 hour of continuous singing in the presence of background noise. For the treatment condition, the participants followed a 10-minute straw phonation in water exercises before the vocal loading task. Acoustic, electroglottographic, and self-rated perceptual voice measures were recorded before and after the vocal loading task on both days. RESULTS Pretest and posttest comparison of various outcome measures during no-treatment day suggested a significant increase in shimmer percent, decrease in maximum phonation duration of vowel /a/, and increase in perceived phonatory effort, perceived vocal effort, and Evaluation of Ability to Sing Easily scores. Pretest and posttest comparisons during treatment day showed a significant increase in Mean F0, Highest F0, and Lowest F0, perceived phonatory effort, and perceived vocal effort scores. However, changes in Mean F0, Highest F0, and Lowest F0 measures were small in the posttest condition compared to pretest. CONCLUSION The present results suggest that vocal loading did induce changes in Carnatic classical singers' voices. However, there is no substantial evidence that straw phonation is effective in reducing the vocal loading in Carnatic classical singers. Further studies are required to corroborate the current findings.
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Cortés JP, Lin JZ, Marks KL, Espinoza VM, Ibarra EJ, Zañartu M, Hillman RE, Mehta DD. Ambulatory Monitoring of Subglottal Pressure Estimated from Neck-Surface Vibration in Individuals with and without Voice Disorders. APPLIED SCIENCES (BASEL, SWITZERLAND) 2022; 12:10692. [PMID: 36777332 PMCID: PMC9910342 DOI: 10.3390/app122110692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The aerodynamic voice assessment of subglottal air pressure can discriminate between speakers with typical voices from patients with voice disorders, with further evidence validating subglottal pressure as a clinical outcome measure. Although estimating subglottal pressure during phonation is an important component of a standard voice assessment, current methods for estimating subglottal pressure rely on non-natural speech tasks in a clinical or laboratory setting. This study reports on the validation of a method for subglottal pressure estimation in individuals with and without voice disorders that can be translated to connected speech to enable the monitoring of vocal function and behavior in real-world settings. During a laboratory calibration session, a participant-specific multiple regression model was derived to estimate subglottal pressure from a neck-surface vibration signal that can be recorded during natural speech production. The model was derived for vocally typical individuals and patients diagnosed with phonotraumatic vocal fold lesions, primary muscle tension dysphonia, and unilateral vocal fold paralysis. Estimates of subglottal pressure using the developed method exhibited significantly lower error than alternative methods in the literature, with average errors ranging from 1.13 to 2.08 cm H2O for the participant groups. The model was then applied during activities of daily living, thus yielding ambulatory estimates of subglottal pressure for the first time in these populations. Results point to the feasibility and potential of real-time monitoring of subglottal pressure during an individual's daily life for the prevention, assessment, and treatment of voice disorders.
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Affiliation(s)
- Juan P. Cortés
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso 2390123, Chile
| | - Jon Z. Lin
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Katherine L. Marks
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA 02129, USA
- Speech, Language & Hearing Sciences Department, College of Health & Rehabilitation: Sargent College, Boston University, Boston, MA 02215, USA
| | | | - Emiro J. Ibarra
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso 2390123, Chile
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso 2390123, Chile
| | - Robert E. Hillman
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA 02129, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA 02114, USA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA 02115, USA
| | - Daryush D. Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA 02129, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA 02114, USA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA 02115, USA
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Buckley KL, O’Halloran PD, Oates JM, Carey LB, Ruddock ML. Vocal ergonomics with sports coaches: Co-devised approaches to occupational voice. Work 2022; 73:S109-S126. [DOI: 10.3233/wor-211215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND: Work-system participation and factors are associated with occupational vocal health for vocally reliant workers, such as sports coaches. However, there is limited use of systems approaches and worker collaboration to address occupational voice. OBJECTIVE: The current research aimed to cooperatively consider coaches’ vocally reliant systems participation, including addressing vocal ergonomic factors that can create barriers for occupational vocal health and voice use. METHODS: Collaborative action inquiries explored vocal ergonomics with coaches (n = 24) from nine professional basketball teams. Across three basketball seasons, coaches and a subject matter expert identified what influenced coaches’ voices and trialed approaches to optimize vocally reliant coaching participation. Nine action inquiry methods were used, including search conferences, ergonomic approaches to enhance systems participation, and focus groups. Multi-level analyses were also undertaken. RESULTS: Participants cooperatively generated, implemented, and evaluated different strategies. A cumulative total of 57 strategies were explored within teams (team mean = 6.33, SD = 3, range = 4–14). Cross-case analysis identified 25 different strategy types. Overall, participants appraised 31.58% (18/57) strategies as supportive (i.e., enhanced facilitators for voice), 61.40% (35/57) strategies as somewhat supportive (i.e., some enhanced facilitators and some ongoing barriers), and 7.02% (4/57) strategies as unsupportive (i.e., pervasive ongoing barriers not mitigated by strategies). Further, factors across coaches’ work-systems continued to influence coaches’ voices in dynamic and complex ways. CONCLUSIONS: Collaboration with coaches enriched vocal ergonomic approaches by providing novel, context-anchored insights. Collaboration should form ‘part’ of broader mechanisms to support coaches’ voice use and vocal health at work.
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Affiliation(s)
- Katie L. Buckley
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
- Human Factors/Ergonomics (HF/E) - Health and Technical Services, WorkSafe New Zealand, Wellington, Aotearoa New Zealand
| | - Paul D. O’Halloran
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Jennifer M. Oates
- Department of Speech Pathology, Orthoptics and Audiology, La Trobe University, Melbourne, VIC, Australia
| | - Lindsay B. Carey
- Palliative Care Unit, Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Mandy L. Ruddock
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
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Banks RE, Cantor-Cutiva LC, Hunter E. Factors Influencing Teachers' Experience of Vocal Fatigue and Classroom Voice Amplification. J Voice 2022:S0892-1997(22)00192-8. [PMID: 35999093 PMCID: PMC9939560 DOI: 10.1016/j.jvoice.2022.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Voice disorders among teachers are widespread. Teachers' voice problems have been shown to influence the teaching-learning process, thereby impeding students' academic performance. Voice amplification has been used as a preventative strategy to avoid voice problems and as a means of augmenting student reception of a teacher's voice. However, the relationship between perceived vocal fatigue and amplification use has not been established, nor have factors been identified which may be associated with the use of voice amplification in the classroom. PURPOSE This research has two aims: (1) determine the relationship between self-reported vocal fatigue and self-reported teachers' use of sound field amplification in the classroom; and (2) identify which factors are related with the use of amplification systems among the participating teachers. METHODS Paper and online surveys were provided to teachers throughout the United States. These surveys contained the 19-question Vocal Fatigue Index (VFI), in addition to other questions regarding health-related conditions and lifestyle habits of respondents. Access to and use of amplification systems, as well as other work-related factors that might influence the use of such systems were detailed by the respondents. RESULTS Regardless of grades levels or measured factors, teachers who reported using amplification systems were more likely to report higher levels of vocal fatigue. Teachers who taught in lower grade levels or in larger capacity classrooms not only reported a greater likelihood of using the systems more frequently, but also reported a greater access to amplification systems. Overall, less than 40% of teachers had access to an amplification system. Teachers of lower grades reported having the least access. CONCLUSIONS Our results suggest an association between teachers' use of voice amplification systems and vocal fatigue. In addition, some work-related factors (eg, grade level, classroom capacity) were associated with the use of amplification systems. The results can be beneficial to teachers, school administrators, lawmakers and health professionals to more efficiently use diminishing educational resources in a targeted fashion to better train and potentially reduce the occurrence of voice problems among teachers.
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Affiliation(s)
- Russell E Banks
- Linus Health, Inc, Boston MA; Department of Communicative Sciences and Disorders, Michigan State University, East Lansing, MI.
| | - Lady C Cantor-Cutiva
- Department of Communicative Sciences and Disorders, Michigan State University, East Lansing, MI
| | - Eric Hunter
- Department of Communicative Sciences and Disorders, Michigan State University, East Lansing, MI
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12
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Motie-Shirazi M, Zañartu M, Peterson SD, Mehta DD, Hillman RE, Erath BD. Collision Pressure and Dissipated Power Dose in a Self-Oscillating Silicone Vocal Fold Model With a Posterior Glottal Opening. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2022; 65:2829-2845. [PMID: 35914018 PMCID: PMC9911124 DOI: 10.1044/2022_jslhr-21-00471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/24/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The goal of this study was to experimentally evaluate how compensating for the adverse acoustic effects of a posterior glottal opening (PGO) by increasing subglottal pressure and changing supraglottal compression, as have been associated with vocal hyperfunction, influences the risk of vocal fold (VF) trauma. METHOD A self-oscillating synthetic silicone model of the VFs with an airflow bypass that modeled a PGO was investigated in a hemilaryngeal flow facility. The influence of compensatory mechanisms on collision pressure and dissipated collision power was investigated for different PGO areas and supraglottal compression. Compensatory behaviors were mimicked by increasing the subglottal pressure to achieve a target sound pressure level (SPL). RESULTS Increasing the subglottal pressure to compensate for decreased SPL due to a PGO produced higher values for both collision pressure and dissipated collision power. Whereas a 10-mm2 PGO area produced a 12% increase in the peak collision pressure, the dissipated collision power increased by 122%, mainly due to an increase in the magnitude of the collision velocity. This suggests that the value of peak collision pressure may not fully capture the mechanisms by which phonotrauma occurs. It was also found that an optimal value of supraglottal compression exists that maximizes the radiated SPL, indicating the potential utility of supraglottal compression as a compensatory mechanism. CONCLUSIONS Larger PGO areas are expected to increase the risk of phonotrauma due to the concomitant increase in dissipated collision power associated with maintaining SPL. Furthermore, the risk of VF damage may not be fully characterized by only the peak collision pressure.
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Affiliation(s)
- Mohsen Motie-Shirazi
- Department of Mechanical and Aeronautical Engineering, Clarkson University, Potsdam, NY
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
| | - Sean D. Peterson
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Ontario, Canada
| | - Daryush D. Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - Robert E. Hillman
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - Byron D. Erath
- Department of Mechanical and Aeronautical Engineering, Clarkson University, Potsdam, NY
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13
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Toles LE, Ortiz AJ, Marks KL, Mehta DD, Van Stan JH, Hillman RE. Amount and Characteristics of Speaking and Singing Voice Use in Vocally Healthy Female College Student Singers During a Typical Week. J Voice 2022; 36:203-211. [PMID: 32451254 PMCID: PMC7680342 DOI: 10.1016/j.jvoice.2020.04.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Singers, college students, and females are groups known to be at an elevated risk of developing functional/hyperfunctional voice disorders; therefore, female college students majoring in vocal performance may be at an even higher risk. To mitigate this risk, it would be helpful to know the "safe limits" for voice use that would help maintain vocal health in this vulnerable group, but there is a paucity of high-quality objective information upon which to base such limits. This study employed weeklong ambulatory voice monitoring in a large group of vocally healthy female college student singers to begin providing the types of objective data that could be used to help develop improved vocal health guidelines. METHODS Participants included 64 vocally healthy females currently enrolled in a vocal performance or similar program at a college or university. An ambulatory voice monitor recorded neck-surface acceleration throughout a typical week. A singing classifier was applied to the data to separate singing from speech. Weeklong vocal dose measures and distributional characteristics for standard voice measures were computed separately for singing and speech, and for both types of phonation combined. RESULTS Participants spent 6.2% of the total monitoring time speaking and 2.1% singing (with total phonation time being 8.4%). Singing had a higher fo mode, more pitch variability, higher average sound pressure level (SPL), negatively skewed SPL distributions, lower average CPP, and higher H1-H2 values than speaking. CONCLUSIONS These results provide a basis for beginning to establish vocal health guidelines for female students enrolled in college-level vocal performance programs and for future studies of the types of voice disorders that are common in this group. Results also demonstrate the potential value that ambulatory voice monitoring may have in helping to objectively identify vocal behaviors that could contribute to voice problems in this population.
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Affiliation(s)
- Laura E. Toles
- Massachusetts General Hospital, Center for Laryngeal Surgery and Voice Rehabilitation, 1 Bowdoin Square, 11 Floor, Boston, MA 02114,MGH Institute of Health Professions, Rehabilitation Science, 36 1 Ave, Charlestown, MA 02129
| | - Andrew J. Ortiz
- Massachusetts General Hospital, Center for Laryngeal Surgery and Voice Rehabilitation, 1 Bowdoin Square, 11 Floor, Boston, MA 02114
| | - Katherine L. Marks
- Massachusetts General Hospital, Center for Laryngeal Surgery and Voice Rehabilitation, 1 Bowdoin Square, 11 Floor, Boston, MA 02114,MGH Institute of Health Professions, Rehabilitation Science, 36 1 Ave, Charlestown, MA 02129
| | - Daryush D. Mehta
- Massachusetts General Hospital, Center for Laryngeal Surgery and Voice Rehabilitation, 1 Bowdoin Square, 11 Floor, Boston, MA 02114,MGH Institute of Health Professions, Rehabilitation Science, 36 1 Ave, Charlestown, MA 02129,Harvard Medical School, Department of Surgery, 25 Shattuck St., Boston, MA 02115
| | - Jarrad H. Van Stan
- Massachusetts General Hospital, Center for Laryngeal Surgery and Voice Rehabilitation, 1 Bowdoin Square, 11 Floor, Boston, MA 02114,MGH Institute of Health Professions, Rehabilitation Science, 36 1 Ave, Charlestown, MA 02129,Harvard Medical School, Department of Surgery, 25 Shattuck St., Boston, MA 02115
| | - Robert E. Hillman
- Massachusetts General Hospital, Center for Laryngeal Surgery and Voice Rehabilitation, 1 Bowdoin Square, 11 Floor, Boston, MA 02114,MGH Institute of Health Professions, Rehabilitation Science, 36 1 Ave, Charlestown, MA 02129,Harvard Medical School, Department of Surgery, 25 Shattuck St., Boston, MA 02115
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14
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Hunter EJ, Berardi ML, Whitling S. A Semiautomated Protocol Towards Quantifying Vocal Effort in Relation to Vocal Performance During a Vocal Loading Task. J Voice 2022:S0892-1997(22)00004-2. [PMID: 35168867 PMCID: PMC9372227 DOI: 10.1016/j.jvoice.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 11/19/2022]
Abstract
To increase the reliability and comparability of vocal loading studies, this paper proposes the use of a standardized approach with experiments that are [1] grounded on consistent definitions of terms related to vocal fatigue (vocal effort, vocal demand, and vocal demand response), and [2] designed to reduce uncertainty and increase repeatability. In the approach, a semi-automated vocal loading task that also increases efficiencies in collecting and preparing vocal samples for analysis was used to answer the following research question: To what extent is vocal effort and vocal demand response sensitive to changes in vocal demands (ie, noise only, noise plus duration)? Results indicate that the proposed protocol design consistently induced change in both vocal effort and vocal demand response, indicating vocal fatigue. The efficacy of future vocal loading studies would be improved by adopting a more consistent methodology for quantifying vocal fatigue, thus increasing interstudy comparability of results and conclusions.
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Affiliation(s)
- Eric J Hunter
- Department of Communicative Sciences and Disorders, Michigan State University, East Lansing, Michigan.
| | | | - Susanna Whitling
- Department of Logopedics, Phoniatrics and Audiology, Lund University, Lund, Sweden
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15
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Van Stan JH, Ortiz AJ, Sternad D, Mehta DD, Huo C, Hillman RE. Ambulatory Voice Biofeedback: Acquisition and Retention of Modified Daily Voice Use in Patients With Phonotraumatic Vocal Hyperfunction. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:409-418. [PMID: 34843372 PMCID: PMC9135013 DOI: 10.1044/2021_ajslp-21-00141] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/02/2021] [Accepted: 09/01/2021] [Indexed: 06/03/2023]
Abstract
PURPOSE Voice ambulatory biofeedback (VAB) has potential to improve carryover of therapeutic voice use into daily life. Previous work in vocally healthy participants demonstrated that motor learning inspired variations to VAB produced expected differences in acquisition and retention of modified daily voice use. This proof-of-concept study was designed to evaluate whether these VAB variations have the same desired effects on acquisition and retention in patients with phonotraumatic vocal hyperfunction (PVH). METHOD Seventeen female patients with PVH wore an ambulatory voice monitor for 6 days: three baseline days, one biofeedback day, one short-term retention day, and one long-term retention day. Short- and long-term retention were 1- and 7-days postbiofeedback, respectively. Patients were block-randomized to receive one of three types of VAB: 100%, 25%, and Summary. Performance was measured in terms of adherence time below a subject-specific vocal intensity threshold. RESULTS All three types of VAB produced a biofeedback effect with 13 out of 17 patients displaying an increase in adherence time compared to baseline days. Additionally, multiple patients from each VAB group increased their adherence time during short- and/or long-term retention monitoring compared to baseline. CONCLUSIONS These findings show that VAB can be associated with acquisition and retention of desired voice use in patients with PVH. Specifically, all three feedback types improved multiple patients' performance and retention for up to 1 week after biofeedback removal. Future work can investigate the impact of incorporating VAB into voice therapy.
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Affiliation(s)
- Jarrad H. Van Stan
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
| | | | | | - Daryush D. Mehta
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
| | - Chuanbing Huo
- Massachusetts General Hospital, Boston
- MGH Institute of Health Professions, Boston, MA
| | - Robert E. Hillman
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
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16
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Kadiri SR, Alku P. Glottal features for classification of phonation type from speech and neck surface accelerometer signals. COMPUT SPEECH LANG 2021. [DOI: 10.1016/j.csl.2021.101232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Rapp M, Cabrera D, Yadav M. Effect of voice support level and spectrum on conversational speech. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2021; 150:2635. [PMID: 34717507 DOI: 10.1121/10.0006570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 09/16/2021] [Indexed: 06/13/2023]
Abstract
One's own voice (autophony) is transmitted to the ears as direct airborne sound, bone conduction, and indirect airborne sound from reflections characterized by overall gain and spectro-temporal features. This study investigates how the spectral profile and gain of simulated indirect airborne sound, quantified as voice support (STV), affect the speaking voice of talkers. Pairs of participants performed a conversation elicitation task in anechoic conditions. The indirect airborne sound was provided in real-time via open headphones that maintain the direct airborne transmission path. Experimental conditions included high-pass, low-pass, and all-pass versions of STV, each presented at three overall gains, and a Baseline condition with no electroacoustic contribution to STV. The results show an overall speech level reduction of 0.22 dB for every additional dB of speech-weighted STV, i.e., a -0.22 dB/dB slope. There was some effect of STV spectrum on speech: slope for the high-pass condition was steeper (statistically significant) and significantly different from the all-pass slope; spectral balance (2-4 kHz vs 0-2 kHz) of speech showed an interaction effect between gender and experimental conditions. This paper's findings may inform acoustic treatments in environments where overall sound reduction is of interest for favorable ergonomics and occupational health for voice professionals.
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Affiliation(s)
- Mary Rapp
- Sydney School of Architecture, Design and Planning, University of Sydney, Sydney, New South Wales 2006, Australia
| | - Densil Cabrera
- Sydney School of Architecture, Design and Planning, University of Sydney, Sydney, New South Wales 2006, Australia
| | - Manuj Yadav
- Sydney School of Architecture, Design and Planning, University of Sydney, Sydney, New South Wales 2006, Australia
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18
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Ibarra EJ, Parra JA, Alzamendi GA, Cortés JP, Espinoza VM, Mehta DD, Hillman RE, Zañartu M. Estimation of Subglottal Pressure, Vocal Fold Collision Pressure, and Intrinsic Laryngeal Muscle Activation From Neck-Surface Vibration Using a Neural Network Framework and a Voice Production Model. Front Physiol 2021; 12:732244. [PMID: 34539451 PMCID: PMC8440844 DOI: 10.3389/fphys.2021.732244] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022] Open
Abstract
The ambulatory assessment of vocal function can be significantly enhanced by having access to physiologically based features that describe underlying pathophysiological mechanisms in individuals with voice disorders. This type of enhancement can improve methods for the prevention, diagnosis, and treatment of behaviorally based voice disorders. Unfortunately, the direct measurement of important vocal features such as subglottal pressure, vocal fold collision pressure, and laryngeal muscle activation is impractical in laboratory and ambulatory settings. In this study, we introduce a method to estimate these features during phonation from a neck-surface vibration signal through a framework that integrates a physiologically relevant model of voice production and machine learning tools. The signal from a neck-surface accelerometer is first processed using subglottal impedance-based inverse filtering to yield an estimate of the unsteady glottal airflow. Seven aerodynamic and acoustic features are extracted from the neck surface accelerometer and an optional microphone signal. A neural network architecture is selected to provide a mapping between the seven input features and subglottal pressure, vocal fold collision pressure, and cricothyroid and thyroarytenoid muscle activation. This non-linear mapping is trained solely with 13,000 Monte Carlo simulations of a voice production model that utilizes a symmetric triangular body-cover model of the vocal folds. The performance of the method was compared against laboratory data from synchronous recordings of oral airflow, intraoral pressure, microphone, and neck-surface vibration in 79 vocally healthy female participants uttering consecutive /pæ/ syllable strings at comfortable, loud, and soft levels. The mean absolute error and root-mean-square error for estimating the mean subglottal pressure were 191 Pa (1.95 cm H2O) and 243 Pa (2.48 cm H2O), respectively, which are comparable with previous studies but with the key advantage of not requiring subject-specific training and yielding more output measures. The validation of vocal fold collision pressure and laryngeal muscle activation was performed with synthetic values as reference. These initial results provide valuable insight for further vocal fold model refinement and constitute a proof of concept that the proposed machine learning method is a feasible option for providing physiologically relevant measures for laboratory and ambulatory assessment of vocal function.
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Affiliation(s)
- Emiro J. Ibarra
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
- School of Electrical Engineering, University of the Andes, Mérida, Venezuela
| | - Jesús A. Parra
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
| | - Gabriel A. Alzamendi
- Institute for Research and Development on Bioengineering and Bioinformatics, Consejo Nacional de Investigaciones Científicas y Técnicas - Universidad Nacional de Entre Ríos, Oro Verde, Argentina
| | - Juan P. Cortés
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
- Center for Laryngeal Surgery and Voice Rehabilitation Laboratory, Massachusetts General Hospital–Harvard Medical School, Boston, MA, United States
| | - Víctor M. Espinoza
- Department of Sound, Faculty of Arts, University of Chile, Santiago, Chile
| | - Daryush D. Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation Laboratory, Massachusetts General Hospital–Harvard Medical School, Boston, MA, United States
| | - Robert E. Hillman
- Center for Laryngeal Surgery and Voice Rehabilitation Laboratory, Massachusetts General Hospital–Harvard Medical School, Boston, MA, United States
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
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19
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Mehta DD, Kobler JB, Zeitels SM, Zañartu M, Ibarra EJ, Alzamendi GA, Manriquez R, Erath BD, Peterson SD, Petrillo RH, Hillman RE. Direct measurement and modeling of intraglottal, subglottal, and vocal fold collision pressures during phonation in an individual with a hemilaryngectomy. APPLIED SCIENCES (BASEL, SWITZERLAND) 2021; 11:7256. [PMID: 36210866 PMCID: PMC9541559 DOI: 10.3390/app11167256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The purpose of this paper is to report on the first in vivo application of a recently developed transoral, dual-sensor pressure probe that directly measures intraglottal, subglottal, and vocal fold collision pressures during phonation. Synchronous measurement of intraglottal and subglottal pressures was accomplished using two miniature pressure sensors mounted on the end of the probe and inserted transorally in a 78-year-old male who had previously undergone surgical removal of his right vocal fold for treatment of laryngeal cancer. The endoscopist used one hand to position the custom probe against the surgically medialized scar band that replaced the right vocal fold and used the other hand to position a transoral endoscope to record laryngeal high-speed videoendoscopy of the vibrating left vocal fold contacting the pressure probe. Visualization of the larynx during sustained phonation allowed the endoscopist to place the dual-sensor pressure probe such that the proximal sensor was positioned intraglottally and the distal sensor subglottally. The proximal pressure sensor was verified to be in the strike zone of vocal fold collision during phonation when the intraglottal pressure signal exhibited three characteristics: an impulsive peak at the start of the closed phase, rounded peak during the open phase, and minimum value around zero immediately preceding the impulsive peak of the subsequent phonatory cycle. Numerical voice production modeling was applied to validate model-based predictions of vocal fold collision pressure using kinematic vocal fold measures. The results successfully demonstrated feasibility of in vivo measurement of vocal fold collision pressure in an individual with a hemilaryngectomy, motivating ongoing data collection that is designed to aid in the development of vocal dose measures that incorporate vocal fold impact collision and stresses.
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Affiliation(s)
- Daryush D. Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA, USA
- MGH Institute of Health Professions, Boston, MA, USA
| | - James B. Kobler
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA, USA
| | - Steven M. Zeitels
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA, USA
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
| | - Emiro J. Ibarra
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
| | - Gabriel A. Alzamendi
- Institute for Research and Development on Bioengineering and Bioinformatics, National University of Entre Rios–CONICET, Entre Ríos, Argentina
| | - Rodrigo Manriquez
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
| | - Byron D. Erath
- Department of Mechanical & Aeronautical Engineering, Clarkson University, Potsdam, NY, USA
| | - Sean D. Peterson
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Ontario, Canada
| | - Robert H. Petrillo
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA, USA
| | - Robert E. Hillman
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA, USA
- MGH Institute of Health Professions, Boston, MA, USA
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20
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Motie-Shirazi M, Zañartu M, Peterson SD, Erath BD. Vocal fold dynamics in a synthetic self-oscillating model: Intraglottal aerodynamic pressure and energy. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2021; 150:1332. [PMID: 34470335 PMCID: PMC8387087 DOI: 10.1121/10.0005882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 06/13/2023]
Abstract
Self-sustained oscillations of the vocal folds (VFs) during phonation are the result of the energy exchange between the airflow and VF tissue. Understanding this mechanism requires accurate investigation of the aerodynamic pressures acting on the VF surface during oscillation. A self-oscillating silicone VF model was used in a hemilaryngeal flow facility to measure the time-varying pressure distribution along the inferior-superior thickness of the VF and at four discrete locations in the anterior-posterior direction. It was found that the intraglottal pressures during the opening and closing phases of the glottis are highly dependent on three-dimensional and unsteady flow behaviors. The measured aerodynamic pressures and estimates of the medial surface velocity were used to compute the intraglottal energy transfer from the airflow to the VFs. The energy was greatest at the anterior-posterior midline and decreased significantly toward the anterior/posterior endpoints. The findings provide insight into the dynamics of the VF oscillation and potential causes of some VF disorders.
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Affiliation(s)
- Mohsen Motie-Shirazi
- Department of Mechanical and Aeronautical Engineering, Clarkson University, Potsdam, New York, USA
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
| | - Sean D Peterson
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Byron D Erath
- Department of Mechanical and Aeronautical Engineering, Clarkson University, Potsdam, New York, USA
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21
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Motie-Shirazi M, Zañartu M, Peterson SD, Erath BD. Vocal fold dynamics in a synthetic self-oscillating model: Contact pressure and dissipated-energy dose. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2021; 150:478. [PMID: 34340498 PMCID: PMC8298101 DOI: 10.1121/10.0005596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 06/13/2023]
Abstract
The energy dissipated during vocal fold (VF) contact is a predictor of phonotrauma. Difficulty measuring contact pressure has forced prior energy dissipation estimates to rely upon generalized approximations of the contact dynamics. To address this shortcoming, contact pressure was measured in a self-oscillating synthetic VF model with high spatiotemporal resolution using a hemilaryngeal configuration. The approach yields a temporal resolution of less than 0.26 ms and a spatial resolution of 0.254 mm in the inferior-superior direction. The average contact pressure was found to be 32% of the peak contact pressure, 60% higher than the ratio estimated in prior studies. It was found that 52% of the total power was dissipated due to collision. The power dissipated during contact was an order of magnitude higher than the power dissipated due to internal friction during the non-contact phase of oscillation. Both the contact pressure magnitude and dissipated power were found to be maximums at the mid anterior-posterior position, supporting the idea that collision is responsible for the formation of benign lesions, which normally appear at the middle third of the VF.
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Affiliation(s)
- Mohsen Motie-Shirazi
- Department of Mechanical and Aeronautical Engineering, Clarkson University, Potsdam, New York 13699, USA
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, Chile
| | - Sean D Peterson
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Byron D Erath
- Department of Mechanical and Aeronautical Engineering, Clarkson University, Potsdam, New York 13699, USA
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22
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Mora LA, Ramirez H, Yuz JI, Le Gorec Y, Zañartu M. Energy-based fluid-structure model of the vocal folds. IMA JOURNAL OF MATHEMATICAL CONTROL AND INFORMATION 2021; 38:466-492. [PMID: 34149312 PMCID: PMC8210679 DOI: 10.1093/imamci/dnaa031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/29/2020] [Accepted: 09/30/2020] [Indexed: 06/12/2023]
Abstract
Lumped elements models of vocal folds are relevant research tools that can enhance the understanding of the pathophysiology of many voice disorders. In this paper, we use the port-Hamiltonian framework to obtain an energy-based model for the fluid-structure interactions between the vocal folds and the airflow in the glottis. The vocal fold behavior is represented by a three-mass model and the airflow is described as a fluid with irrotational flow. The proposed approach allows to go beyond the usual quasi-steady one-dimensional flow assumption in lumped mass models. The simulation results show that the proposed energy-based model successfully reproduces the oscillations of the vocal folds, including the collision phenomena, and it is useful to analyze the energy exchange between the airflow and the vocal folds.
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Affiliation(s)
- Luis A Mora
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, 2390123 Valparaiso, Chile
- Département AS2M, FEMTO-ST/ENSMM, Université de Bourgogne Franche-Comté, 25000 Besançon, France
| | - Hector Ramirez
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, 2390123 Valparaiso, Chile
| | - Juan I Yuz
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, 2390123 Valparaiso, Chile
| | - Yann Le Gorec
- Département AS2M, FEMTO-ST/ENSMM, Université de Bourgogne Franche-Comté, 25000 Besançon, France
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, 2390123 Valparaiso, Chile
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Jakobsen L, Christensen-Dalsgaard J, Juhl PM, Elemans CPH. How Loud Can you go? Physical and Physiological Constraints to Producing High Sound Pressures in Animal Vocalizations. Front Ecol Evol 2021. [DOI: 10.3389/fevo.2021.657254] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Sound is vital for communication and navigation across the animal kingdom and sound communication is unrivaled in accuracy and information richness over long distances both in air and water. The source level (SL) of the sound is a key factor in determining the range at which animals can communicate and the range at which echolocators can operate their biosonar. Here we compile, standardize and compare measurements of the loudest animals both in air and water. In air we find a remarkable similarity in the highest SLs produced across the different taxa. Within all taxa we find species that produce sound above 100 dBpeak re 20 μPa at 1 m, and a few bird and mammal species have SLs as high as 125 dBpeak re 20 μPa at 1 m. We next used pulsating sphere and piston models to estimate the maximum sound pressures generated in the radiated sound field. These data suggest that the loudest species within all taxa converge upon maximum pressures of 140–150 dBpeak re 20 μPa in air. In water, the toothed whales produce by far the loudest SLs up to 240 dBpeak re 1 μPa at 1 m. We discuss possible physical limitations to the production, radiation and propagation of high sound pressures. Furthermore, we discuss physiological limitations to the wide variety of sound generating mechanisms that have evolved in air and water of which many are still not well-understood or even unknown. We propose that in air, non-linear sound propagation forms a limit to producing louder sounds. While non-linear sound propagation may play a role in water as well, both sperm whale and pistol shrimp reach another physical limit of sound production, the cavitation limit in water. Taken together, our data suggests that both in air and water, animals evolved that produce sound so loud that they are pushing against physical rather than physiological limits of sound production, radiation and propagation.
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Khoramshahi H, Dehqan A, Scherer RC, Sharifi Z, Ahmadi S. Comparison of vocal fatigue and vocal tract discomfort between teachers of normal pupils and teachers of mentally disabled pupils. Eur Arch Otorhinolaryngol 2021; 278:2429-2436. [PMID: 33978817 DOI: 10.1007/s00405-021-06863-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aims to study the comparison of vocal fatigue and vocal tract discomfort between teachers of normal pupils and teachers of mentally disabled pupils. STUDY DESIGN Cross-sectional study METHODS: Participants were 179 teachers (50 male, 129 female) and 30 non-teachers (14 male, 16 female) who participated in the current study. The teachers work in elementary schools. Furthermore, 87 of the teachers work for mentally disabled pupils at special elementary schools. Non-teachers were Ahvaz Jundishapur University of Medical Sciences employees who consider as the control group. They completed the Persian VFI and VTDp questionnaires three times, at the beginning, middle, and end of their office hours for 1 workday. RESULTS The current study's findings indicate that the Persian VFI and VTD scores of non-teachers were significantly lower than teachers' scores. Furthermore, teachers of mentally disabled pupils demonstrated higher values from teachers of normal pupils based on the Persian VFI and VTDp scores CONCLUSION: The study results showed that teachers experienced more vocal fatigue and vocal tract discomfort than non-teachers. Furthermore, teachers of mentally disabled pupils indicated more vocal fatigue, the larynx's physical discomfort, and vocal tract discomfort, but this difference was practically small.
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Affiliation(s)
- Hassan Khoramshahi
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Ali Dehqan
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Ronald Callaway Scherer
- Department of Communication Sciences and Disorders, Bowling Green State University, Bowling Green, Ohio, USA
| | - Zahra Sharifi
- MSc Student of Speech Therapy, Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Shayan Ahmadi
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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25
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Syringeal vocal folds do not have a voice in zebra finch vocal development. Sci Rep 2021; 11:6469. [PMID: 33742101 PMCID: PMC7979720 DOI: 10.1038/s41598-021-85929-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/03/2021] [Indexed: 01/31/2023] Open
Abstract
Vocal behavior can be dramatically changed by both neural circuit development and postnatal maturation of the body. During song learning in songbirds, both the song system and syringeal muscles are functionally changing, but it is unknown if maturation of sound generators within the syrinx contributes to vocal development. Here we densely sample the respiratory pressure control space of the zebra finch syrinx in vitro. We show that the syrinx produces sound very efficiently and that key acoustic parameters, minimal fundamental frequency, entropy and source level, do not change over development in both sexes. Thus, our data suggest that the observed acoustic changes in vocal development must be attributed to changes in the motor control pathway, from song system circuitry to muscle force, and not by material property changes in the avian analog of the vocal folds. We propose that in songbirds, muscle use and training driven by the sexually dimorphic song system are the crucial drivers that lead to sexual dimorphism of the syringeal skeleton and musculature. The size and properties of the instrument are thus not changing, while its player is.
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Remacle A, Lefèvre N. Which teachers are most at risk for voice disorders? Individual factors predicting vocal acoustic parameters monitored in situ during a workweek. Int Arch Occup Environ Health 2021; 94:1271-1285. [PMID: 33686473 DOI: 10.1007/s00420-021-01681-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 01/08/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To identify the factors affecting teachers' vocal acoustic parameters, with the aim of detecting individuals at risk of phonotrauma. METHOD The voicing time, voice sound pressure level [SPL] and fundamental frequency [fo] of 87 teachers were measured during one workweek using a voice dosimeter. We retrospectively investigated the impact of 10 factors (gender, age, teaching experience, teaching level, tobacco, gastro-esophageal problems, nonoccupational voice activity, voice education, past voice problems, and biopsychosocial impact of voice problems measured using the Voice Handicap Index [VHI]) on each voice parameter. RESULTS None of the above factors affected voicing time or SPL. fo depended significantly on gender, teaching level, nonoccupational voice activity and VHI score. Specifically, fo was higher in women (Δ = 69 Hz), in individuals without nonoccupational voice activities (Δ = 11 Hz), and in individuals with a lower VHI score (increase of 0.7 Hz for each additional point). For females, post hoc comparisons revealed a substantial impact of teaching level on fo: university instructors had deeper voices than kindergarten (Δ = 66 Hz), elementary (Δ = 52 Hz), or secondary teachers (Δ = 41 Hz). CONCLUSIONS Since higher fo increases the mechanical stress related to vocal fold vibration, the screening and prevention of phonotrauma should focus primarily on women, particularly those who teach at lower levels, and teachers with more self-rated voice problems. The lower fo of teachers who engage in nonprofessional voice activities may suggest acute inflammation or muscle fatigue due to voice overload.
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Affiliation(s)
- Angélique Remacle
- Département de Logopédie, Faculté de Psychologie, Logopédie et Sciences de l'Education, Université de Liège, Rue de l'Aunaie, 30 (B38), 4000, Liège, Belgium. .,Faculté des Sciences Psychologiques et de l'Éducation, Université Libre de Bruxelles, Brussels, Belgium.
| | - Nathalie Lefèvre
- Psychological Sciences Research Institute, Université Catholique de Louvain, Louvain-la-Neuve, Belgium.,Louvain Institute of Data Analysis and Modeling in Economics and Statistics, Statistical Methodology and Computing Service, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
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Knickerbocker K, Bryan C, Ziegler A. Phonogenic Voice Problems among Speech-Language Pathologists in Synchronous Telepractice: An Overview and Recommendations. Semin Speech Lang 2021; 42:73-84. [PMID: 33596606 DOI: 10.1055/s-0040-1722754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Many speech-language pathologists (SLPs) recently adopted a live, synchronous online distribution of clinical services due to physical distancing measures aimed at bringing the coronavirus disease 2019 (COVID-19) outbreak under control. Few SLPs had received training in telepractice to prepare them for changes from an in-person service delivery model to synchronous telepractice. The new telepractice environment may alter vocal behaviors and communication interactions in such a way that negatively impacts voice production. Thus, delivering synchronous online clinical services may require that SLPs adopt novel prevention strategies for avoiding phonogenic voice problems. Guided by two complementary injury frameworks, the Haddon Matrix and the Haddon Countermeasures, this article provides an overview of potential factors associated with phonogenic voice problems among SLPs in telepractice and proposes possible prevention strategies to maintain optimal vocal health and function with synchronous modes of online clinical practice.
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Affiliation(s)
| | | | - Aaron Ziegler
- The Wellness Group for Voice, Speech, and Swallowing, LLC
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28
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Atará-Piraquive ÁP, Cantor-Cutiva LC. Gender differences in vocal doses among occupational voice users: a systematic review of literature and meta-analysis. LOGOP PHONIATR VOCO 2021; 47:63-72. [DOI: 10.1080/14015439.2021.1873415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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29
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Van Stan JH, Mehta DD, Ortiz AJ, Burns JA, Marks KL, Toles LE, Stadelman-Cohen T, Krusemark C, Muise J, Hron T, Zeitels SM, Fox AB, Hillman RE. Changes in a Daily Phonotrauma Index After Laryngeal Surgery and Voice Therapy: Implications for the Role of Daily Voice Use in the Etiology and Pathophysiology of Phonotraumatic Vocal Hyperfunction. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2020; 63:3934-3944. [PMID: 33197360 PMCID: PMC8608140 DOI: 10.1044/2020_jslhr-20-00168] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Purpose This study attempts to gain insights into the role of daily voice use in the etiology and pathophysiology of phonotraumatic vocal hyperfunction (PVH) by applying a logistic regression-based daily phonotrauma index (DPI) to predict group-based improvements in patients with PVH after laryngeal surgery and/or postsurgical voice therapy. Method A custom-designed ambulatory voice monitor was used to collect 1 week of pre- and postsurgery data from 27 female patients with PVH; 13 of these patients were also monitored after postsurgical voice therapy. Normative weeklong data were obtained from 27 matched controls. Each week was represented by the DPI, standard deviation of the difference between the first and second harmonic amplitudes (H1-H2). Results Compared to pretreatment, the DPI significantly decreased in the patient group after surgery (Cohen's d effect size = -0.86) and voice therapy (d = -1.06). The patient group DPI only normalized after voice therapy. Conclusions The DPI produced the expected pattern of improved ambulatory voice use across laryngeal surgery and postsurgical voice therapy in a group of patients with PVH. The results were interpreted as providing new objective information about the role of daily voice use in the etiology and pathophysiology of PVH. The DPI is viewed as an estimate of potential vocal fold trauma that relies on combining the long-term distributional characteristics of two parameters representing the magnitude of phonatory forces (neck-surface acceleration magnitude) and vocal fold closure dynamics (H1-H2). Further validation of the DPI is needed to better understand its potential clinical use.
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Affiliation(s)
- Jarrad H. Van Stan
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
| | - Daryush D. Mehta
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
| | | | - James A. Burns
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Katherine L. Marks
- Massachusetts General Hospital, Boston
- MGH Institute of Health Professions, Boston, MA
| | - Laura E. Toles
- Massachusetts General Hospital, Boston
- MGH Institute of Health Professions, Boston, MA
| | - Tara Stadelman-Cohen
- Massachusetts General Hospital, Boston
- MGH Institute of Health Professions, Boston, MA
| | - Carol Krusemark
- Massachusetts General Hospital, Boston
- MGH Institute of Health Professions, Boston, MA
| | - Jason Muise
- Massachusetts General Hospital, Boston
- MGH Institute of Health Professions, Boston, MA
| | - Tiffiny Hron
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Steven M. Zeitels
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | | | - Robert E. Hillman
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
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30
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Vocal Function Differences Before and After Sorority Recruitment. J Voice 2020; 36:212-218. [DOI: 10.1016/j.jvoice.2020.04.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022]
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Abstract
Vocal loading tasks are often used to investigate the relationship between voice use and vocal fatigue in laboratory settings. The present study investigated the concept of a novel quantitative dose-based vocal loading task for vocal fatigue evaluation. Ten female subjects participated in the study. Voice use was monitored and quantified using an online vocal distance dose calculator during six consecutive 30-min long sessions. Voice quality was evaluated subjectively using the CAPE-V and SAVRa before, between, and after each vocal loading task session. Fatigue-indicative symptoms, such as cough, swallowing, and voice clearance, were recorded. Statistical analysis of the results showed that the overall severity, the roughness, and the strain ratings obtained from CAPE-V obeyed similar trends as the three ratings from the SAVRa. These metrics increased over the first two thirds of the sessions to reach a maximum, and then decreased slightly near the session end. Quantitative metrics obtained from surface neck accelerometer signals were found to obey similar trends. The results consistently showed that an initial adjustment of voice quality was followed by vocal saturation, supporting the effectiveness of the proposed loading task.
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Van Stan JH, Mehta DD, Ortiz AJ, Burns JA, Toles LE, Marks KL, Vangel M, Hron T, Zeitels S, Hillman RE. Differences in Weeklong Ambulatory Vocal Behavior Between Female Patients With Phonotraumatic Lesions and Matched Controls. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2020; 63:372-384. [PMID: 31995428 PMCID: PMC7210443 DOI: 10.1044/2019_jslhr-19-00065] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Purpose Previous work using ambulatory voice recordings has shown no differences in average vocal behavior between patients with phonotraumatic vocal hyperfunction and matched controls. This study used larger groups to replicate these results and expanded the analysis to include distributional characteristics of ambulatory voice use and measures indicative of glottal closure. Method Subjects included 180 adult women: 90 diagnosed with vocal fold nodules or polyps and 90 age-, sex-, and occupation-matched controls with no history of voice disorders. Weeklong summary statistics (average, variability, skewness, kurtosis) of voice use were computed from neck-surface acceleration recorded using an ambulatory voice monitor. Voice measures included estimates of sound pressure level (SPL), fundamental frequency (f o), cepstral peak prominence, and the difference between the first and second harmonic magnitudes (H1-H2). Results Statistical comparisons resulted in medium-large differences (Cohen's d ≥ 0.5) between groups for SPL skewness, f o variability, and H1-H2 variability. Two logistic regressions (theory-based and stepwise) found SPL skewness and H1-H2 variability to classify patients and controls based on their weekly voice data, with an area under the receiver operating characteristic curve of 0.85 and 0.82 on training and test sets, respectively. Conclusion Compared to controls, the weekly voice use of patients with phonotraumatic vocal hyperfunction reflected higher SPL tendencies (negatively skewed SPL) with more abrupt glottal closure (reduced H1-H2 variability, especially toward higher values). Further work could examine posttreatment data (e.g., after surgery and/or therapy) to determine the extent to which these differences are associated with the etiology and pathophysiology of phonotraumatic vocal fold lesions.
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Affiliation(s)
- Jarrad H. Van Stan
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
| | - Daryush D. Mehta
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
| | | | - James A. Burns
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Laura E. Toles
- Massachusetts General Hospital, Boston
- MGH Institute of Health Professions, Boston, MA
| | - Katherine L. Marks
- Massachusetts General Hospital, Boston
- MGH Institute of Health Professions, Boston, MA
| | - Mark Vangel
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Tiffiny Hron
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Steven Zeitels
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Robert E. Hillman
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
- MGH Institute of Health Professions, Boston, MA
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Hunter EJ, Cantor-Cutiva LC, van Leer E, van Mersbergen M, Nanjundeswaran CD, Bottalico P, Sandage MJ, Whitling S. Toward a Consensus Description of Vocal Effort, Vocal Load, Vocal Loading, and Vocal Fatigue. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2020; 63:509-532. [PMID: 32078404 PMCID: PMC7210446 DOI: 10.1044/2019_jslhr-19-00057] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Purpose The purpose of this document is threefold: (a) review the uses of the terms "vocal fatigue," "vocal effort," "vocal load," and "vocal loading" (as found in the literature) in order to track the occurrence and the related evolution of research; (b) present a "linguistically modeled" definition of the same from the review of literature on the terms; and (c) propose conceptualized definitions of the concepts. Method A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scientific Electronic Library Online. Four terms ("vocal fatigue," "vocal effort," "vocal load," and "vocal loading"), as well as possible variants, were included in the search, and their usages were compiled into conceptual definitions. Finally, a focus group of eight experts in the field (current authors) worked together to make conceptual connections and proposed consensus definitions. Results The occurrence and frequency of "vocal load," "vocal loading," "vocal effort," and "vocal fatigue" in the literature are presented, and summary definitions are developed. The results indicate that these terms appear to be often interchanged with blurred distinctions. Therefore, the focus group proposes the use of two new terms, "vocal demand" and "vocal demand response," in place of the terms "vocal load" and "vocal loading." We also propose standardized definitions for all four concepts. Conclusion Through a comprehensive literature search, the terms "vocal fatigue," "vocal effort," "vocal load," and "vocal loading" were explored, new terms were proposed, and standardized definitions were presented. Future work should refine these proposed definitions as research continues to address vocal health concerns.
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Affiliation(s)
- Eric J. Hunter
- Department of Communicative Sciences and Disorders, Michigan State University, East Lansing
| | - Lady Catherine Cantor-Cutiva
- Department of Collective Health, Universidad Nacional de Colombia, Bogotá
- Department of Speech and Language Pathology, Universidad Manuela Beltrán, Bogotá, Colombia
| | - Eva van Leer
- Department of Communication Sciences and Disorders, Georgia State University, Atlanta
| | | | - Chaya Devie Nanjundeswaran
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN
| | - Pasquale Bottalico
- Department of Speech and Hearing Science, University of Illinois at Urbana–Champaign
| | - Mary J. Sandage
- Department of Communication Disorders, Auburn University, AL
| | - Susanna Whitling
- Department of Logopedics, Phoniatrics and Audiology, Lund University, Sweden
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Lin JZ, Espinoza VM, Marks KL, Zañartu M, Mehta DD. Improved subglottal pressure estimation from neck-surface vibration in healthy speakers producing non-modal phonation. IEEE JOURNAL OF SELECTED TOPICS IN SIGNAL PROCESSING 2020; 14:449-460. [PMID: 34079612 PMCID: PMC8168553 DOI: 10.1109/jstsp.2019.2959267] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Subglottal air pressure plays a major role in voice production and is a primary factor in controlling voice onset, offset, sound pressure level, glottal airflow, vocal fold collision pressures, and variations in fundamental frequency. Previous work has shown promise for the estimation of subglottal pressure from an unobtrusive miniature accelerometer sensor attached to the anterior base of the neck during typical modal voice production across multiple pitch and vowel contexts. This study expands on that work to incorporate additional accelerometer-based measures of vocal function to compensate for non-modal phonation characteristics and achieve an improved estimation of subglottal pressure. Subjects with normal voices repeated /p/-vowel syllable strings from loud-to-soft levels in multiple vowel contexts (/ɑ/, /i/, and /u/), pitch conditions (comfortable, lower than comfortable, higher than comfortable), and voice quality types (modal, breathy, strained, and rough). Subject-specific, stepwise regression models were constructed using root-mean-square (RMS) values of the accelerometer signal alone (baseline condition) and in combination with cepstral peak prominence, fundamental frequency, and glottal airflow measures derived using subglottal impedance-based inverse filtering. Five-fold cross-validation assessed the robustness of model performance using the root-mean-square error metric for each regression model. Each cross-validation fold exhibited up to a 25% decrease in prediction error when the model incorporated multidimensional aspects of the accelerometer signal compared with RMS-only models. Improved estimation of subglottal pressure for non-modal phonation was thus achievable, lending to future studies of subglottal pressure estimation in patients with voice disorders and in ambulatory voice recordings.
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Affiliation(s)
- Jon Z Lin
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114 USA
| | | | - Katherine L Marks
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114 USA
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa Maria, Valparaíso, Chile
| | - Daryush D Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital-Harvard Medical School, Boston, MA 02114 USA
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Chan RW. Ovine Vocal Fold Tissue Fatigue Response to Accumulated, Large-Amplitude Vibration Exposure at Phonatory Frequencies. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2019; 62:4291-4299. [PMID: 31770065 PMCID: PMC7201329 DOI: 10.1044/2019_jslhr-s-19-0181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/20/2019] [Accepted: 08/23/2019] [Indexed: 06/10/2023]
Abstract
Purpose The contribution of tissue mechanical response to vocal fatigue is poorly understood. This study investigated the fatigue response of vocal fold tissues to large-amplitude vibration exposure at phonatory frequencies, using an ex vivo ovine model. Method Twelve sheep vocal fold mucosal specimens were subjected to sinusoidal, simple-shear deformation for prolonged cycles, under a large but physiological shear strain (46%) in a frequency range of 100-230 Hz. The duration of shear varied from a critical vibration exposure limit of 1,040 s to 4 times the limit (4,160 s). Tissue viscoelastic response was quantified by the elastic shear modulus (G'), viscous shear modulus (G″), and damping ratio (G″/G'). Results Distinct response patterns were observed at different frequencies. G' and G″ generally decreased with vibration exposure at 100 Hz, whereas they generally increased with vibration exposure at 200 and 230 Hz. Statistically significant differences were found for G″ increasing with vibration exposure at 200 Hz and damping ratio decreasing with vibration exposure at 200 Hz. Significant increases with frequency were also found for all viscoelastic functions. Results suggested that the contribution of tissue viscoelastic response to vocal fatigue could be highly frequency dependent. In particular, increases in G″ with vibration exposure could lead to high phonation threshold pressures and difficulty sustaining phonation at higher frequencies following prolonged vocalization. Conclusion These preliminary findings may help us better understand vocal fatigue and recovery and should be corroborated by studies with human vocal fold tissues.
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Affiliation(s)
- Roger W. Chan
- Department of Speech Language Pathology and Audiology, National Taipei University of Nursing and Health Sciences, Taiwan
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Mehta DD, Kobler JB, Zeitels SM, Zañartu M, Erath BD, Motie-Shirazi M, Peterson SD, Petrillo RH, Hillman RE. Toward Development of a Vocal Fold Contact Pressure Probe: Bench-Top Validation of a Dual-Sensor Probe Using Excised Human Larynx Models. APPLIED SCIENCES (BASEL, SWITZERLAND) 2019; 9:4360. [PMID: 34084559 PMCID: PMC8171492 DOI: 10.3390/app9204360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A critical element in understanding voice production mechanisms is the characterization of vocal fold collision, which is widely considered a primary etiological factor in the development of common phonotraumatic lesions such as nodules and polyps. This paper describes the development of a transoral, dual-sensor intraglottal/subglottal pressure probe for the simultaneous measurement of vocal fold collision and subglottal pressures during phonation using two miniature sensors positioned 7.6 mm apart at the distal end of a rigid cannula. Proof-of-concept testing was performed using excised whole-mount and hemilarynx human tissue aerodynamically driven into self-sustained oscillation, with systematic variation of the superior-inferior positioning of the vocal fold collision sensor. In the hemilarynx experiment, signals from the pressure sensors were synchronized with an acoustic microphone, a tracheal-surface accelerometer, and two high-speed video cameras recording at 4000 frames per second for top-down and en face imaging of the superior and medial vocal fold surfaces, respectively. As expected, the intraglottal pressure signal exhibited an impulse-like peak when vocal fold contact occurred, followed by a broader peak associated with intraglottal pressure build-up during the de-contacting phase. As subglottal pressure was increased, the peak amplitude of the collision pressure increased and typically reached a value below that of the average subglottal pressure. Results provide important baseline vocal fold collision pressure data with which computational models of voice production can be developed and in vivo measurements can be referenced.
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Affiliation(s)
- Daryush D. Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA 02114, USA
- MGH Institute of Health Professions, Boston, MA 02129, USA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA 02115, USA
| | - James B. Kobler
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA 02114, USA
- MGH Institute of Health Professions, Boston, MA 02129, USA
| | - Steven M. Zeitels
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA 02114, USA
- MGH Institute of Health Professions, Boston, MA 02129, USA
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso 2390123, Chile
| | - Byron D. Erath
- Department of Mechanical & Aeronautical Engineering, Clarkson University, Potsdam, NY 13699, USA
| | - Mohsen Motie-Shirazi
- Department of Mechanical & Aeronautical Engineering, Clarkson University, Potsdam, NY 13699, USA
| | - Sean D. Peterson
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Robert H. Petrillo
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA 02114, USA
| | - Robert E. Hillman
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Surgery, Massachusetts General Hospital–Harvard Medical School, Boston, MA 02114, USA
- MGH Institute of Health Professions, Boston, MA 02129, USA
- Speech and Hearing Bioscience and Technology, Division of Medical Sciences, Harvard Medical School, Boston, MA 02115, USA
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Marks KL, Lin JZ, Fox AB, Toles LE, Mehta DD. Impact of Nonmodal Phonation on Estimates of Subglottal Pressure From Neck-Surface Acceleration in Healthy Speakers. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2019; 62:3339-3358. [PMID: 31518510 PMCID: PMC6808343 DOI: 10.1044/2019_jslhr-s-19-0067] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Purpose The purpose of this study was to evaluate the effects of nonmodal phonation on estimates of subglottal pressure (Ps) derived from the magnitude of a neck-surface accelerometer (ACC) signal and to confirm previous findings regarding the impact of vowel contexts and pitch levels in a larger cohort of participants. Method Twenty-six vocally healthy participants (18 women, 8 men) were asked to produce a series of p-vowel syllables with descending loudness in 3 vowel contexts (/a/, /i/, and /u/), 3 pitch levels (comfortable, high, and low), and 4 elicited phonatory conditions (modal, breathy, strained, and rough). Estimates of Ps for each vowel segment were obtained by averaging the intraoral air pressure plateau before and after each segment. The root-mean-square magnitude of the neck-surface ACC signal was computed for each vowel segment. Three linear mixed-effects models were used to statistically assess the effects of vowel, pitch, and phonatory condition on the linear relationship (slope and intercept) between Ps and ACC signal magnitude. Results Results demonstrated statistically significant linear relationships between ACC signal magnitude and Ps within participants but with increased intercepts for the nonmodal phonatory conditions; slopes were affected to a lesser extent. Vowel and pitch contexts did not significantly affect the linear relationship between ACC signal magnitude and Ps. Conclusion The classic linear relationship between ACC signal magnitude and Ps is significantly affected when nonmodal phonation is produced by a speaker. Future work is warranted to further characterize nonmodal phonatory characteristics to improve the ACC-based prediction of Ps during naturalistic speech production.
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Affiliation(s)
- Katherine L. Marks
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- PhD Program in Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA
| | - Jonathan Z. Lin
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - Annie B. Fox
- Center for Interprofessional Studies and Innovation, MGH Institute of Health Professions, Boston, MA
| | - Laura E. Toles
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- PhD Program in Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA
| | - Daryush D. Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- PhD Program in Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
- Speech and Hearing Bioscience and Technology Program, Division of Medical Sciences, Harvard Medical School, Boston, MA
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Dynamically Monitoring Vocal Fatigue and Recovery Using Aerodynamic, Acoustic, and Subjective Self-Rating Measurements. J Voice 2019; 33:809.e11-809.e18. [DOI: 10.1016/j.jvoice.2018.03.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/19/2018] [Indexed: 11/23/2022]
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Huttunen K, Rantala L. Effects of Humidification of the Vocal Tract and Respiratory Muscle Training in Women With Voice Symptoms-A Pilot Study. J Voice 2019; 35:158.e21-158.e33. [PMID: 31416750 DOI: 10.1016/j.jvoice.2019.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/20/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the efficacy of a 4-week breathing exercise intervention in participants with voice symptoms. METHODS Six nonsmoking women (mean age 49) experiencing voice symptoms used a novel device WellO2 for respiratory exercises that provides counter pressure during both inspiration and expiration and warms and humidifies the breathing air. Speech samples were acoustically (Acoustic Voice Quality Index) and perceptually (grade, roughness, breathiness, asthenia, and strain scale) analyzed, and perceived voice symptoms and self-reported effort in breathing and phonation were obtained. Respiratory measurements included breathing frequency and pattern, peak expiratory flow, forced vital capacity, and forced expiratory volume in 1 minute. RESULTS The total scores of Acoustic Voice Quality Index and some of its subcomponents (shimmer and harmonic-to-noise ratio), and the grade, roughness, and strain of the GRBAS scale indicated significantly improved voice quality. However, neither the nature or frequency of the experienced voice symptoms nor the perceived phonatory effort changed as the function of intervention. According to the participants, their breathing was significantly less effortful after the intervention, although no significant changes were observed in the objective respiratory measurements with a spirometer. CONCLUSION Training with the WellO2 device has the potential to improve voice quality. The combination of inspiratory and expiratory training and warmed, humidified air is a multifaceted entity influencing several parts in the physiology of voice production. The effects of using WellO2 need to be confirmed by further studies with a larger number of participants.
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Affiliation(s)
- Kerttu Huttunen
- Faculty of Humanities, Research Unit of Logopedics, University of Oulu, Oulu, Finland; PEDEGO Research Unit, University of Oulu, Oulu, Finland; MRC Oulu, Oulu, Finland; Department of Otorhinolaryngology, Head and Neck Surgery, Oulu University Hospital, Oulu, Finland.
| | - Leena Rantala
- Degree Programme in Logopedics, University of Tampere, Tampere, Finland
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Ortiz AJ, Toles LE, Marks KL, Capobianco S, Mehta DD, Hillman RE, Van Stan JH. Automatic speech and singing classification in ambulatory recordings for normal and disordered voices. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2019; 146:EL22. [PMID: 31370647 PMCID: PMC6624122 DOI: 10.1121/1.5115804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Ambulatory voice monitoring is a promising tool for investigating phonotraumatic vocal hyperfunction (PVH), associated with the development of vocal fold lesions. Since many patients with PVH are professional vocalists, a classifier was developed to better understand phonatory mechanisms during speech and singing. Twenty singers with PVH and 20 matched healthy controls were monitored with a neck-surface accelerometer-based ambulatory voice monitor. An expert-labeled ground truth data set was used to train a logistic regression on 15 subject-pairs with fundamental frequency and autocorrelation peak amplitude as input features. Overall classification accuracy of 94.2% was achieved on the held-out test set.
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Affiliation(s)
- Andrew J Ortiz
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, , ,
| | - Laura E Toles
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, , ,
| | - Katherine L Marks
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, , ,
| | - Silvia Capobianco
- Universita di Pavia, Pavia, for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, , ,
| | - Daryush D Mehta
- Universita di Pavia, Pavia, for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, , ,
| | - Robert E Hillman
- Universita di Pavia, Pavia, for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, , ,
| | - Jarrad H Van Stan
- Universita di Pavia, Pavia, for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, , ,
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Mehta DD, Espinoza VM, Van Stan JH, Zañartu M, Hillman RE. The difference between first and second harmonic amplitudes correlates between glottal airflow and neck-surface accelerometer signals during phonation. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2019; 145:EL386. [PMID: 31153299 PMCID: PMC6520097 DOI: 10.1121/1.5100909] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Miniature high-bandwidth accelerometers on the anterior neck surface are used in laboratory and ambulatory settings to obtain vocal function measures. This study compared the widely applied L1-L2 measure (historically, H1-H2)-the difference between the log-magnitude of the first and second harmonics-computed from the glottal airflow waveform with L1-L2 derived from the raw neck-surface acceleration signal in 79 vocally healthy female speakers. Results showed a significant correlation (r = 0.72) between L1-L2 values estimated from both airflow and accelerometer signals, suggesting that raw accelerometer-based estimates of L1-L2 may be interpreted as reflecting glottal physiological parameters and voice quality attributes during phonation.
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Affiliation(s)
- Daryush D Mehta
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - Víctor M Espinoza
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, , , , ,
| | - Jarrad H Van Stan
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - Matías Zañartu
- Department of Electronic Engineering, Universidad Técnica Federico Santa María, Valparaíso, , , , ,
| | - Robert E Hillman
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Kobler JB, Tynan MA, Zeitels SM, Liss AS, Gianatasio MT, Morin AA, Schmidt TA. Lubricin/proteoglycan 4 detected in vocal folds of humans and five other mammals. Laryngoscope 2019; 129:E229-E237. [PMID: 30613972 DOI: 10.1002/lary.27783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES/HYPOTHESIS Lubricin/proteoglycan-4 (PRG4) lubricates connective tissues such as joints and tendon sheaths, enabling them to better withstand shearing and frictional forces during motion. We wondered whether PRG4 might play a role in phonation, as normal vocal folds withstand repetitive, high-velocity deformations remarkably well. As a first step, we tested whether PRG4 is expressed in vocal folds. STUDY DESIGN Laboratory study. METHODS Anatomical and molecular methods were applied to 47 larynges from humans, macaque (Macaca fascicularis), canines, pigs, calves, and rats. Immunohistochemistry (IHC), Western blot, and quantitative real-time polymerase chain reaction (qRT-PCR) methods were used to test for the presence of PRG4. RESULTS In all species, the true vocal fold lamina propria (TVF-LP) was positive for PRG4 by IHC, whereas immunoreactivity of the false vocal fold was weak or absent, depending on the species. Human TVF-LP was strongly stained across all layers. Immunoreactivity was seen variably on the vocal fold surface and within the vocal fold epithelium, in the conus elasticus and thyroglottic ligament, and at the tip of vocal process. Western blots of four humans and six pigs demonstrated immunoreactivity at appropriate molecular weight. qRT-PCR of pig tissues confirmed PRG4 mRNA expression, which was highest in the TVF-LP. CONCLUSIONS PRG4 was found in phonatory tissues of six mammals. We suggest it might act as a lubricant within the lamina propria and possibly on the vocal fold surface, limiting phonation-related damage to vocal fold extracellular matrix and epithelium, and enhancing vocal efficiency by reducing internal friction (viscosity) within the vocal fold. LEVEL OF EVIDENCE NA Laryngoscope, 129:E229-E237, 2019.
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Affiliation(s)
- James B Kobler
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Monica A Tynan
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Steven M Zeitels
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Andrew S Liss
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Maria T Gianatasio
- Cancer Center Histopathology Core, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Alyssa A Morin
- Biomedical Engineering Department, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Tannin A Schmidt
- Biomedical Engineering Department, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
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Ziegler A, Hapner ER. Vocal Dose in Older Adults with Presbyphonia: An Analytic, Cross-Sectional Study. J Voice 2018; 34:221-230. [PMID: 30322822 DOI: 10.1016/j.jvoice.2018.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Older patients with age-related voice changes (presbyphonia) are considered vocal under-doers due to a reportedly low a amount and intensity of voice use (ie, low vocal dose). This low voice use may be consequential to negative effects of presbyphonia like throat discomfort, as well as anxiety and frustration from difficulty communicating. Causally speaking, vocal fold atrophy (presbylaryngis) may indicate inadequate intrinsic laryngeal muscle loading with low voice use, though research is lacking. As a first step, this study examined voice use objectively using vocal dosimetry in older adults with presbyphonia. We hypothesized participants, especially if retired, would exhibit low vocal doses, and lower than reported for other populations. METHOD This research used an analytic, cross-sectional design with subgroup analyses to determine feasibility of vocal dosimetry in older adults with presbyphonia. Thirteen older adults with presbyphonia (7 males) completed vocal dose monitoring using an ambulatory phonation monitor (APM). The APM measured vocal parameters over a day of monitoring, from which time, cycle, and distance doses were calculated. Data also were gathered on demographics, vocal handicap, and vocal effort. RESULTS Descriptively, the group showed a low mean time dose as compared to published vocal dose data from other populations. Females exhibited significantly higher mean values of time dose, cycle dose, and fundamental frequency than males. Time dose for males was negatively correlated with vocal effort. Subgroup analyses failed to detect an effect of age group, but found significantly a higher mean value for time dose in employed, compared to retired, participants. CONCLUSIONS Consistent with self-report, we found older adults with presbyphonia exhibit low time doses, which were in contrast to high vocal doses published on teachers, patients with dysphonia, and even office workers. We found differences in vocal dose as a function of sex and employment status. Though a limited sample, findings suggest patients with presbyphonia may demonstrate low vocal dose, which may be a useful target in treatment.
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Affiliation(s)
- Aaron Ziegler
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon.
| | - Edie R Hapner
- Department of Otolaryngology-Head & Neck Surgery, University of Southern California, Los Angeles, California
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Vocal Behavior in Environmental Noise: Comparisons Between Work and Leisure Conditions in Women With Work-related Voice Disorders and Matched Controls. J Voice 2018; 32:126.e23-126.e38. [DOI: 10.1016/j.jvoice.2017.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/15/2017] [Accepted: 04/17/2017] [Indexed: 11/30/2022]
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45
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Smith AG, Sandage MJ, Pascoe DD, Plexico LW, Lima IR, Cao G. Elementary School Teachers' Vocal Dose: Muscle Bioenergetics and Training Implications. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2017; 60:1831-1842. [PMID: 28614843 DOI: 10.1044/2016_jslhr-s-16-0193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 11/29/2016] [Indexed: 06/07/2023]
Abstract
PURPOSE Translating exercise-science methodology for determination of muscle bioenergetics, we hypothesized that the temporal voice-use patterns for classroom and music teachers would indicate a reliance on the immediate energy system for laryngeal skeletal-muscle metabolism. It was hypothesized that the music-teacher group would produce longer voiced segments than the classroom teachers. METHOD Using a between- and within-group multivariate analysis-of-variance design (5 classroom teachers; 7 music teachers), we analyzed fundamental-frequency data-collected via an ambulatory phonation monitor-for length (seconds) of voiced and nonvoiced intervals. Data were collected for 7.5 hr during the workday, over the course of several workdays for each teacher. RESULTS Descriptive analyses of voiced and nonvoiced intervals indicated that over 99% of voiced segments for both groups were no longer than 3.15 s, supporting the hypothesis of reliance on the immediate energy system for muscle bioenergetics. Significant differences were identified between and within the classroom- and music-teacher groups, with the music-teacher group producing longer voiced segments overall. CONCLUSIONS Knowledge of probable intrinsic laryngeal skeletal-muscle bioenergetics requirements could inform new interdisciplinary considerations for voice habilitation and rehabilitation.
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Assad JP, Magalhães MDC, Santos JN, Gama ACC. Dose Vocal: uma revisão integrativa da literatura. REVISTA CEFAC 2017. [DOI: 10.1590/1982-021620171932617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO O objetivo da pesquisa foi realizar uma revisão da literatura referente aos tipos de dose vocal e aos resultados destas medidas em diferentes situações comunicativas. Houve levantamento da literatura nacional e internacional, publicada nos idiomas Inglês, Espanhol ou Português, utilizando-se as bases de dados MEDLINE, LILACS, IBECS e ISI (Web of Science), dos últimos 21 anos, cujos artigos estavam disponíveis na íntegra. Quinze estudos contemplaram os critérios propostos. A maioria dos artigos estudou professores, visto que são mais vulneráveis para a ocorrência de disfonia. Os tipos de dose encontrados foram porcentagem de fonação, dose temporal, dose cíclica, dose de distância, dose de energia radiada e dose de energia dissipada. O aumento da dose vocal está associado ao uso excessivo e prolongado da voz na atividade docente, principalmente entre os professores da educação infantil e os de canto. As altas doses vocais correlacionam-se também à presença de disfonia, ao maior nível de ruído ambiental, à grande variação prosódica na fala e à autopercepção de fadiga vocal. Pacientes com disfonia comportamental (nódulos e pólipos) apresentam maiores doses vocais que pacientes com outros quadros disfônicos. Fatores como repouso de voz e uso do amplificador vocal indicam a diminuição da dose da voz.
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Novaleski CK, Carter BD, Sivasankar MP, Ridner SH, Dietrich MS, Rousseau B. Apoptosis and Vocal Fold Disease: Clinically Relevant Implications of Epithelial Cell Death. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2017; 60:1264-1272. [PMID: 28492834 PMCID: PMC5755547 DOI: 10.1044/2016_jslhr-s-16-0326] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/22/2016] [Indexed: 05/05/2023]
Abstract
PURPOSE Vocal fold diseases affecting the epithelium have a detrimental impact on vocal function. This review article provides an overview of apoptosis, the most commonly studied type of programmed cell death. Because apoptosis can damage epithelial cells, this article examines the implications of apoptosis on diseases affecting the vocal fold cover. METHOD A review of the extant literature was performed. We summarized the topics of epithelial tissue properties and apoptotic cell death, described what is currently understood about apoptosis in the vocal fold, and proposed several possible explanations for how the role of abnormal apoptosis during wound healing may be involved in vocal pathology. RESULTS AND CONCLUSIONS Apoptosis plays an important role in maintaining normal epithelial tissue function. The biological mechanisms responsible for vocal fold diseases of epithelial origin are only beginning to emerge. This article discusses speculations to explain the potential role of deficient versus excessive rates of apoptosis and how disorganized apoptosis may contribute to the development of common diseases of the vocal folds.
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Affiliation(s)
- Carolyn K. Novaleski
- Department of Hearing and Speech Sciences, School of Medicine, Vanderbilt University, Nashville, TN
| | - Bruce D. Carter
- Department of Biochemistry, School of Medicine, Vanderbilt University, Nashville, TN
| | - M. Preeti Sivasankar
- Department of Speech, Language, and Hearing Sciences, Purdue University, West Lafayette, IN
| | - Sheila H. Ridner
- Department of Nursing Science, School of Nursing, Vanderbilt University, Nashville, TN
| | - Mary S. Dietrich
- Department of Nursing Science, School of Nursing, Vanderbilt University, Nashville, TN
| | - Bernard Rousseau
- Department of Otolaryngology, Hearing and Speech Sciences, and Mechanical Engineering, School of Medicine, Vanderbilt University, Nashville, TN
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Fujiki RB, Sivasankar MP. A Review of Vocal Loading Tasks in the Voice Literature. J Voice 2017; 31:388.e33-388.e39. [DOI: 10.1016/j.jvoice.2016.09.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/15/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
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Van Stan JH, Mehta DD, Hillman RE. Recent Innovations in Voice Assessment Expected to Impact the Clinical Management of Voice Disorders. ACTA ACUST UNITED AC 2017. [DOI: 10.1044/persp2.sig3.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This article provides a summary of some recent innovations in voice assessment expected to have an impact in the next 5–10 years on how patients with voice disorders are clinically managed by speech-language pathologists. Specific innovations discussed are in the areas of laryngeal imaging, ambulatory voice monitoring, and “big data” analysis using machine learning to produce new metrics for vocal health. Also discussed is the potential for using voice analysis to detect and monitor other health conditions.
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Affiliation(s)
- Jarrad H. Van Stan
- Center for Laryngeal Surgery & Voice Rehabilitation, Massachusetts General Hospital Communication Sciences and Disorders, Massachusetts General Hospital
Boston, MA
- Institute of Health Professions
Charlestown, MA
| | - Daryush D. Mehta
- Center for Laryngeal Surgery & Voice Rehabilitation, Massachusetts General Hospital Communication Sciences and Disorders, Massachusetts General Hospital
Boston, MA
- Department of Surgery, Harvard Medical School
Boston, MA
- Communication Sciences and Disorders, MGH Institute of Health Professions
Charlestown, MA
| | - Robert E. Hillman
- Center for Laryngeal Surgery & Voice Rehabilitation, Massachusetts General Hospital Communication Sciences and Disorders, Massachusetts General Hospital
Boston, MA
- Department of Surgery, Harvard Medical School
Boston, MA
- Communication Sciences and Disorders, MGH Institute of Health Professions
Charlestown, MA
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Fryd AS, Van Stan JH, Hillman RE, Mehta DD. Estimating Subglottal Pressure From Neck-Surface Acceleration During Normal Voice Production. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2016; 59:1335-1345. [PMID: 27959974 PMCID: PMC5399761 DOI: 10.1044/2016_jslhr-s-15-0430] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/10/2016] [Accepted: 05/06/2016] [Indexed: 05/10/2023]
Abstract
Purpose The purpose of this study was to evaluate the potential for estimating subglottal air pressure using a neck-surface accelerometer and to compare the accuracy of predicting subglottal air pressure relative to predicting acoustic sound pressure level (SPL). Method Indirect estimates of subglottal pressure (Psg') were obtained from 10 vocally healthy speakers during loud-to-soft repetitions of 3 different /p/-vowel gestures (/pa/, /pi/, /pu/) at 3 pitch levels in the modal register. Intraoral air pressure, neck-surface acceleration, and radiated acoustic pressure were recorded, and the root-mean-square amplitude of the acceleration signal was correlated with Psg' and SPL. Results The coefficient of determination between accelerometer level and Psg' was high when data were pooled from all vowel and pitch contexts for each participant (r2 = .68-.93). These relationships were stronger than corresponding relationships between accelerometer level and SPL (r2 = .46-.81). The average 95% prediction interval for estimating Psg' using accelerometer level was ±2.53 cm H2O, ranging from ±1.70 to ±3.74 cm H2O across participants. Conclusions Accelerometer signal amplitude correlated more strongly with Psg' than with SPL. Future work is warranted to investigate the robustness of the relationship in nonmodal voice qualities, individuals with voice disorders, and accelerometer-based ambulatory monitoring of subglottal pressure.
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Affiliation(s)
- Amanda S. Fryd
- Communication Sciences and Disorders, MGH Institute of Health Professions, Charlestown, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - Jarrad H. Van Stan
- Communication Sciences and Disorders, MGH Institute of Health Professions, Charlestown, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - Robert E. Hillman
- Communication Sciences and Disorders, MGH Institute of Health Professions, Charlestown, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
- Surgery & Health Sciences and Technology, Harvard Medical School, Boston, MA
| | - Daryush D. Mehta
- Communication Sciences and Disorders, MGH Institute of Health Professions, Charlestown, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
- Department of Surgery, Harvard Medical School, Boston, MA
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