Perceptual and acoustic evaluation of individuals with laryngopharyngeal reflux pre- and post-treatment

Outcomes of Vocal Hygiene Program in Facilitating Vocal Health in Female School Teachers With Voice Problems

BACKGROUND

Teachers suffer greater impacts of voice problems due inappropriate voice use and other contributing factors such as physiological, environmental, and individual & work related issues. Structured vocal hygiene programs (VHP) prevent/reduce the risk of vocal trauma and promote vocal health in teachers. This study aimed to estimate the outcome of instituting a sociocultural relevant vocal hygiene program in facilitating vocal health among female school teachers using a comprehensive voice assessment protocol.

METHOD

VHP was developed emphasizing adequate hydration, healthy vocal diet, posture and alignment, vocal practices while teaching, and ideal speaking environment. This was administered via a face to face session to seventeen female teachers with voice concerns. All underwent a comprehensive voice assessment (subjective, objective, and self-perceptual vocal measures) before and four weeks after the VHP. Inter-rater reliability for perceptual and visual examination was estimated using Intra-Class Coefficient. Wilcoxon signed ranks test was used to compare the pre- and post-treatment measures of continuous variables (acoustic, Maximum phonation time, s/z ratio, Vocal Fatigue Index [VFI] & Voice Disorder Outcome Profile [V-DOP]), and McNemar test was used for categorical variables (vocal health questionnaire, visual examination of larynx and perceptual evaluation of voice).

RESULTS

Teachers reported reduction of unhealthy vocal & nonvocal practices after VHP. Improvements in vocal and related symptoms such as sensation of heart burn (P = 0.031), discomfort around the throat (P = 0.008), inadequate breath control while speaking (P = 0.016) were noticed. Perceptually, minimal improvement was seen in voice quality (overall grade). However, MPT & s/z ratio showed no significant difference. Improvement was observed in frequency range (P = 0.004), low I₀ (P = 0.044), shimmer (P = 0.017), and DSI (P = 0.013). Changes were evident in all parameters of stroboscopic evaluation (except nonvibratory portion & ventricular fold hyper-adduction). V-DOP scores indicated positive change in the overall severity (P = 0.002), physical (P = 0.003) and functional domain (P = 0.034). VFI indicated improvement in teachers voice after a period of voice rest (P = 0.048).

CONCLUSION

Though VHP facilitated in improving the teachers' awareness of at risk phono-traumatic behaviors and vocal health, its efficiency was limited in producing physiological improvement in teachers' voice. The comparison of vocal metrics before & after the treatment provides information on changes that can be expected in teachers after guiding them through a systematic VHP.

To Compare and Evaluate Laryngeal Changes in Patients with Dysphonia in Laryngopharyngeal Reflux (LPR) before and after Treatment with Proton Pump Inhibitors (PPI) and Prokinetic Drugs

To evaluate and compare pre and post treatment results using the following parameters by (a) Dual probe pH monitoring. (b) Laryngeal mucosal changes as assessed by direct video laryngoscopy/stroboscopy using Belafsky scores. (c) Voice changes by using GRBAS and Dr Speech software for speech analysis. In our study we have evaluated and compared voice and laryngeal changes in patients with dysphonia and RSI > 10 (which is suggestive of LPR) before treatment and after 6 months of treatment with Tab. Pantoprazole and Tab. Mosapride. This prospective study was carried out on 50 patients attending the ENT OPD of a tertiary care referral centre over a period of 18 months i.e. from Nov 2008 to Apr 2010. The study showed that prolonged therapy (> 6 months) is required to treat LPR effectively and 24 h ambulatory dual probe pH metry and videolaryngoscopy to assess RFS are the most preferred diagnostic tools in LPR. Dr Speech software for voice analysis can give an objective assessment of voice changes in LPR before and after treatment. The treatment consisting of PPI and prokinetic drugs proved to be effective in laryngopharyngeal reflux disease as improvement was seen in all the parameters including reflux findings score, subjective and objective voice assessment. According to results of our study, 24 h ambulatory dual probe pH metry, Reflux Finding Score (RFS), subjective and objective acoustic parameters can be used as indicators of efficacy of treatment.

Responsiveness of Persian Version of Consensus Auditory Perceptual Evaluation of Voice (CAPE-V), Persian Version of Voice Handicap Index (VHI), and Praat in Vocal Mass Lesions with Muscle Tension Dysphonia

OBJECTIVES

This study was aimed at determining the internal and external responsiveness of the Persian version of the Consensus Auditory-Perceptual Evaluation of Voice (called ATSHA), Persian version of the Voice Handicap Index (VHI), and Praat scales among patients with vocal mass lesions and secondary muscle tension dysphonia.

STUDY DESIGN

Prospective, within-participant repeated measures.

METHOD

Thirty patients with vocal fold nodules, polyps, and cysts related to secondary muscle tension dysphonia participated in the study. The measures of interest and videostroboscopy examination were used before and after treatment. The Global Perceived Effect questionnaire was used to separate those improved (moderately or greatly improved) and stable (slightly improved) patients.

RESULTS

The mean standardized response, standardized effect size, and Guyatt analyses indicated high internal responsiveness for the all target parameters of the ATSHA, total score of the VHI, and two parameters of the Praat (0.8<). There was poor correlation between the videostroboscopy and the other target scales (r _Pearson = -0.1-0.1). The receiver operating characteristic analysis indicated that all the target scales did not significantly separate those improved and stable subjects (area under the curve = 0), except for the overall severity and roughness parameters of the ATSHA scale (area under the curve = 1).

CONCLUSION

This study recommends both the Consensus Auditory-Perceptual Evaluation of Voice and the VHI scales to show voice therapy changes. The target voice scale changes were not able to predict the videostroboscopy changes as external standard. Furthermore, we recommend that the overall severity and roughness may properly classify those improved and stable patients.

The relationship between acoustical and perceptual measures of vocal effort

Excessive vocal effort is a common clinical voice symptom, yet the acoustical manifestation of vocal effort and how that is perceived by speakers and listeners has not been fully elucidated. Here, 26 vocally healthy adults increased vocal effort during the production of the utterance /ifi/, followed by self-ratings of effort on a 100 mm visual analog scale. Twenty inexperienced listeners assessed the speakers' vocal effort using the visual sort-and-rate method. Previously proposed acoustical correlates of vocal effort were calculated, including: mean sound pressure level (SPL), mean fundamental frequency (f o), relative fundamental frequency (RFF) offset cycle 10 and onset cycle 1, harmonics-to-noise ratio (HNR), cepstral peak prominence and its standard deviation (SD), and low-to-high (L/H) spectral ratio and its SD. Two separate mixed-effects regression models yielded mean SPL, L/H ratio, and HNR as significant predictors of both speaker and listener ratings of vocal effort. RFF offset cycle 10 and mean f o were significant predictors of listener ratings only. Therefore, speakers and listeners attended to similar acoustical cues when making judgments of vocal effort, but listeners also used additional time-based information. Further work is needed to determine how vocal effort manifests in the speech signal in speakers with voice disorders.

Does CPAP Affect Patient-Reported Voice Outcomes?

Upper aerodigestive tract symptoms are common in patients with obstructive sleep apnea (OSA). It remains unclear whether continuous positive airway pressure (CPAP) improves or worsens these otolaryngology symptoms. As therapy-related side effects limit CPAP adherence, this study aimed to determine if CPAP negatively affects voice, sinonasal, and reflux symptoms of the upper airway. Case series with planned data collection was performed at an academic otolaryngology sleep center. Newly diagnosed patients with OSA were evaluated before and 6 months after initiating CPAP therapy. Data collected included CPAP data download, Reflux Symptom Index (RSI), Epworth Sleepiness Scale (ESS), Voice Handicap Index 10 (VHI-10), Sino-Nasal Questionnaire (SNQ), and oral dryness visual analog scale (VAS). For the 11 CPAP-adherent participants, the RSI significantly improved with CPAP (mean RSI, 22.0-9.5; P = .002); however, the VAS, VHI-10, and SNQ did not change after 6 months of CPAP therapy. In a small sample size, patient-reported voice outcomes (VHI-10) and other upper aerodigestive tract symptoms did not worsen with CPAP; rather, CPAP therapy was associated with a reduction in reflux symptoms.

Objective Voice Analysis of Pediatric Cochlear Implant Recipients and Comparison With Hearing Aids Users and Hearing Controls

OBJECTIVES

Phonation is influenced by hearing as a feedback mechanism. The purpose of the present study was to compare selected acoustic parameters in children using cochlear implants (CIs), those using hearing aids (HA), and their normal-hearing (NH) peers.

METHODS

The participants were 15 children using CI (mean age: 72 months), 15 children using HA (mean age: 74 months), and 15 NH children (mean age: 77 months). The vowel /a/ was produced to measure perturbation and mean fundamental frequency. The six Persian vowels in /C_bVC_d/ were obtained to extract vowel duration. Data were analyzed by one-way analysis of variance.

RESULTS

Results revealed a statistically significant difference between the NH group and the HA group regarding fundamental frequency (F_2,51 = 3.443, P < 0.05), jitter local (F_2,51 = 1.629, P < 0.05), jitter local absolute (F_2,51 = 6.519, P < 0.001), jitter rap (F_2,51 = 7.151, P < 0.001), jitter ppq5 (F_2,51 = 5.894, P < 0.001), shimmer local (%) (F_2,51 = 8.070, P < 0.001), shimmer local (dB) (F_2,51 = 3.884, P < 0.05), shimmer apq3 (F_2,51 = 4.926, P < 0.05), shimmer apq5 (F_2,51 = 8.442, P < 0.001), and harmonic-to-noise ratio (F_2,51 = 4.117, P < 0.001). The mean values of the duration of all six vowels were significantly greater in children with CI and HA than in NH children (P < 0.001).

CONCLUSION

It seems that after 8 months of using CI, auditory control of voice production would be enabled. Furthermore, children with hearing impairment potentially regard vowel sound duration as a distinguishing feature, whereas in NH speakers, the duration has the least effect in vowel identification.

Impact of laryngopharyngeal reflux on subjective and objective voice assessments: a prospective study

Background

Laryngopharyngeal reflux is a prevalent, not well-understood disease affecting a high proportion of patients who seek laryngology consultation. The objective of this prospective case series is to explore the subjective and objective voice modifications in Laryngopharyngeal reflux (LPR), especially the usefulness of acoustic parameters as treatment outcomes, and to better understand the pathophysiological mechanisms underlying the development of voice disorder.

Methods

Forty-one patients with a reflux finding score (RFS) > 7 and a reflux symptom index (RSI) > 13 were enrolled and treated with pantoprazole 20 mg twice daily for three months. RSI, RFS, Voice Handicap Index (VHI), and Grade, Roughness, Breathiness, Asthenia, Strain and Instability (GRBASI) were assessed at baseline and after three months post-therapy. Acoustic parameters were measured by selecting the most stable interval of the vowel /a/. A study of correlations between acoustic measurements and laryngoscopic signs was conducted in patients with roughness. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS).

Results

Significant improvement in RSI, RFS, VHI, jitter, percent jitter, relative average perturbation (RAP), shimmer, percent shimmer, and amplitude perturbation quotient (APQ) was found at 3 months of treatment (p < .05). A correlation analysis revealed significant correlations between the grade of dysphonia, breathiness, asthenia, instability and jitter, percent jitter, RAP, shimmer, percent shimmer and APQ. In dividing our cohort into two groups of patients according to the presence of roughness, shimmer, percent shimmer and APQ significantly improved in patients with roughness, but no positive correlation was found between acoustic parameters and laryngoscopic signs.

Conclusion

Acoustic parameters can help to better understand voice disorders in LPR and can be used as treatment outcomes in patients with roughness.

Prevalence of voice & swallowing complaints in Pre-operative thyroidectomy patients: a prospective cohort study

Background

Compressive symptoms are common in patients with thyroid disease and are an accepted indication for thyroidectomy. The objective of this study was to evaluate the prevalence and severity of voice and swallowing complaints in pre-operative thyroidectomy patients and to compare these with thyroid volume, thyroid pathology and laryngopharyngeal reflux.

Methods

A consecutive case series design was performed. All patients undergoing a thyroidectomy (partial or total) at a tertiary care centre during a 2 year period were invited to participate. Fifty nine (10 male, 49 female) aged 19–73 were enrolled (59.3% total thyroidectomy, 40.7% partial thyroidectomy). Voice and swallowing complaints were subjectively evaluated using the Voice Handicap Index (VHI) and the Modified Swallowing Impairment Score (MSIS), respectively. All patients completed the Reflux Symptom Index (RSI) and underwent videostroboscopy. Vocal function was objectively evaluated using perceptual ratings (GRBAS) and acoustic voice analysis (jitter, shimmer, maximum phonation time, maximum fundamental frequency range). The relationship between voice and swallowing symptoms was compared with thyroid volume and surgical pathology.

Results and discussion

The average VHI score was 8.39, representing normal voice scores. Of the objective voice measures, only jitter and a subset of GRBAS measures were slightly elevated. Swallowing complaints were reported at least “some of the time” by 25 patients (41.7%), and “often or always” by 16 patients (26.7%). Of the patients with voice and swallowing complaints, 68.4% and 56%, respectively, had elevated RSI scores consistent with laryngopharyngeal reflux. No correlation was found with thyroid volume or thyroid pathology.

Conclusions

Swallowing complaints appear to be common in pre-operative thyroidectomy patients. A large percentage, however, have associated laryngopharyngeal reflux which may in part account for these symptoms. Patients presenting with compressive thyroid symptoms should be evaluated for laryngopharyngeal reflux, and treated where appropriate.

Voice problems among laryngopharyngeal reflux patients diagnosed with oropharyngeal pH monitoring

BACKGROUND AND OBJECTIVES

There is a lack of consensus regarding the clinical presentation and diagnosis of laryngopharyngeal reflux (LPR). The aim of this study was to explore voice-related abnormalities in a group of LPR patients, diagnosed with a 24-hour oropharyngeal pH monitoring.

PATIENTS AND METHODS

Eighty-two patients with voice-related problems participated in the study. Diagnosis of LPR was made using a 24-hour oropharyngeal pH monitoring. Patients were divided accordingly into positive and negative pH groups. Comparisons between the two groups were done, including results of clinical presentation, Voice Handicap Index-10 (VHI-10), reflux symptom index (RSI), reflux finding score (RFS), and acoustic measurements. The correlation was conducted between Ryan scores and other variables including VHI-10, RSI, and RFS.

RESULTS

Significant differences were found between the two groups for RSI and VHI-10. No significant differences were found between the two groups regarding clinical presentation, RFS or acoustic measures. Significant positive correlations were found between the Ryan composite measurements and both severity ratings (VHI-10, RSI).

CONCLUSION

LPR clinical presentation appears to be non-specific in terms of symptoms and laryngeal findings. LPR appears to have an effect on the patients' self-perception of voice problems. Further studies are needed to clarify the effect of LPR on acoustic measurements.

Laryngeal and voice disorders in patients with gastroesophageal symptoms. Correlation with pH-monitoring

PURPOSE

To investigate laryngeal and voice disorders in patients with gastroesophageal symptoms and their correlation with pH-monitoring.

METHODS

A prospective study was carried out in patients attended at the Voice Disorder Outpatient Clinics of Botucatu Medical School in a five-year period and had vocal and gastroesophagic symptoms. Patients underwent videolaryngoscopy, auditory-perceptual vocal analyses, computerized acoustic vocal analysis and dual probe pH-monitoring for 24 hours.

RESULTS

Fifty-seven patients were included (aged between 21 and 65 years; 45 women and 12 men), 18 had normal (31.6%) and 39 had abnormal pH-monitoring results (68.4%). Videolaryngoscopy recorded several laryngeal lesions for both patients with normal and abnormal pH-monitoring, but mostly for the latter group, highlighting posterior pachyderma. Auditory-perceptual vocal assessments identified vocal changes of several intensities for both groups but especially for patients with abnormal pH-monitoring results. All acoustic parameters, except f0, were abnormal for both groups, compared to the control population.

CONCLUSION

Acoustic and perceptual vocal changes and laryngeal lesions were recorded for both patients with normal pH-monitoring results and patients with abnormal pH-monitoring results, evidencing the importance of clinical history and videolaryngoscopic findings for diagnosing acid laryngitis.

The effect of anti-reflux treatment on subjective voice measurements of patients with laryngopharyngeal reflux

OBJECTIVE

To assess the impact of anti-reflux treatment and speech therapy on subjective voice measurements of patients with laryngopharyngeal reflux.

METHODS

This paper reports a prospective study of patients seen in a voice clinic over a three-year period who were being treated for laryngopharyngeal reflux. Patients were assessed at presentation using the reflux symptom index and voice symptom scale, and were reassessed at three months and six months post-treatment. Treatment entailed twice daily proton pump inhibitor therapy and speech therapy.

RESULTS

The study comprised 74 patients. The reflux symptom index and voice symptom scale scores significantly improved following treatment at both three and six months. There was a correlation between improved reflux symptom index scores and improved voice symptom scale scores.

CONCLUSION

Treatment of laryngopharyngeal reflux with twice daily proton pump inhibitors and speech therapy resulted in improved subjective voice measurements for patients.

Effects of omeprazole over voice quality in muscle tension dysphonia patients with laryngopharyngeal reflux

Backround

Laryngopharyngeal reflux (LPR) is the backflow of stomach contents above upper esophageal sphincter, into the pharynx, larynx, and upper aerodigestive system.

Objectives

In this study, effects of omeprazole over voice quality in muscle tension dysphonia with laryngopharyngeal reflux was ınvestigated.

Patients and Methods

Nine patients, 7 males and 2 females, aged between 27-43 (mean age:31) were included to this study. The diagnosis of muscle tension dysphonia with LPR was established by video laryngoscopy, rigid scope 70º. The laryngeal changes related with LPR were evaluated according to Reflux Finding Score. The patients received omeprazole 20 mg twice a day for a period of 6 months. None of the patients received voice therapy. Vocal hygiene guidelines were also explained to the patients. Objective and subjective voice parameters (Jitter, shimmer, NHR, Voice Handicap Index, and Auditive analysis; Roughness, breathiness, and hoarseness) were evaluated in this study.

Results

After treatment with omeprazol, all the parameters showed an improvement in voice quality, but only VHI (P = 0) and shimmer (P = 0,018) are statistically significant.

Conclusions

For FD patients with LPR condition, we highly recommend that LPR treatment should be part of the treatment plan.

Índice de sintomas do refluxo Faringo-Laríngeo: relação com os principais sintomas de refluxo gastresofágico, nível de uso de voz e triagem vocal

OBJETIVO: relacionar o Índice de Sintomas do Refluxo Faringo-Laríngeo - ISRFL com os principais sintomas do refluxo gastresofágico - RGE (azia/queimação e dor retroesternal), com o nível de uso da voz e com uma triagem vocal. MÉTODO: participaram deste estudo 179 voluntários maiores de 18 anos, 107 mulheres e 72 homens, classificados em dois grupos de acordo com o escore total do ISRFL, grupo positivo (escore total igual ou maior a 13 pontos) e negativo (abaixo deste). Os participantes foram questionados sobre a presença dos sinais característicos do refluxo gastresofágico (azia/queimação e/ou dor retroesternal), sobre a demanda de uso da voz (baixa/alta demanda) e submetidos à triagem vocal durante a entrevista. RESULTADOS: quanto ao ISRFL, 35 (19,6%) indivíduos compuseram o grupo positivo (escore médio de 20) e 144 (80,4%) o grupo negativo (média de 4,34 pontos). Os sintomas característicos do RGE foram maiores no grupo positivo: azia/queimação em 54,2% (19) verso 30,5% (44), dor retroesternal em 51,4% (18) verso 20,1% (29), sendo que 74,3% dos indivíduos do grupo positivo e apenas 43,1% do negativo apresentaram algum dos sintomas. Quanto à triagem vocal, 37,1% do grupo positivo e 13% do negativo falharam. Não houve diferença de demanda vocal auto-relatada entre os grupos. Foi encontrada associação estatística entre IRFL positivo, os sintomas de refluxo gastresofágico e fracasso na triagem vocal (p< 0,001). Não houve associação quanto ao uso da voz. CONCLUSÃO: o ISRFL positivo pode estar relacionado com os sinais do RGE e com a alteração na qualidade vocal percebida em triagem.

The effects of cigarette smoking on the female voice

To investigate voice changes as they develop over time due to cigarette smoking, women who never smoked (NS), women who smoked less than 10 years (S1), and women who smoked 10 or more years (S2) were compared. Acoustic (fundamental frequency, jitter, shimmer, signal-to-noise ratio), electroglottographic (open, closing, and speed quotients), aerodynamic (subglottal pressure, airflow, laryngeal airway resistance), and perceptual measures were obtained. Fundamental frequency and open quotient significantly decreased and speed quotient significantly increased in S1 and S2; jitter and shimmer significantly increased in S2 only. NS were perceived as non-smokers more reliably than S1 and S2 as smokers. Fundamental frequency, open quotient, and speed quotient were the most sensitive indicators of smoking effects on the female voice.

Gender differences affecting vocal health of women in vocally demanding careers

Studies suggest that occupational voice users have a greater incidence of vocal issues than the general population. Women have been found to experience vocal health problems more frequently than men, regardless of their occupation. Traditionally, it has been assumed that differences in the laryngeal system are the cause of this disproportion. Nevertheless, it is valuable to identify other potential gender distinctions which may make women more vulnerable to voice disorders. A search of the literature was conducted for gender-specific characteristics which might impact the vocal health of women. This search can be used by health care practitioners to help female patients avoid serious vocal health injuries, as well as to treat better those women who already suffer from such vocal health issues.

The effect of esomeprazole 20 mg twice daily on acoustic and perception parameters of the voice in laryngopharyngeal reflux

BACKGROUND

Randomized, placebo-controlled studies have failed to demonstrate a significant treatment effect for laryngopharyngeal reflux (LPR) using traditional clinical endpoints. We compared the effect of esomeprazole 20 mg twice daily (b.i.d.) vs placebo on voice and acoustic-related measures in patients with LPR.

METHODS

Patients with LPR underwent endoscopy and pH testing. Subsequently, patients underwent videostroboscopic recordings of the larynx, acoustic voice and speech analysis. A voice use and quality diary and oesophageal symptom diary were completed at baseline. Thereafter, patients were randomized to esomeprazole 20 mg twice daily vs placebo for 3 months. The voice use and quality diary and oesophageal symptom dairy were repeated during the last week of treatment. Videostroboscopy and acoustic voice and speech analysis were also performed at the end of treatment.

KEY RESULTS

Twenty-four patients were randomized to the esomeprazole group and 17 to the placebo group. There was no significant difference in videostroboscopic reflux finding scores from baseline to post-treatment. Acoustic measures also failed to demonstrate significant differences within the same or between groups, even when a sub-group analysis of patients with endoscopically documented oesophageal inflammation at baseline was performed. Additionally, no significant differences were found between groups when using voice use and quality diary.

CONCLUSIONS & INFERENCES

Use of more specific laryngeal functional parameters such as voice-related acoustic measures of pitch range, fundamental frequency and intensity also failed to demonstrate a significant response to proton pump inhibitor treatment as compared to placebo in patients with suspected LPR.

Effectiveness of voice therapy in reflux-related voice disorders

Gastroesophageal reflux (GER) with laryngopharyngeal reflux plays a significant role in voice disorders. A significant proportion of patients attending ear, nose, and throat clinics with voice disorders may have gastroesophageal reflux disease (GERD). There is no controlled study of the effect of voice therapy on GERD. We assessed the effect of voice therapy in patients with dysphonia and GERD. Thirty-two patients with dysphonia and GERD underwent indirect laryngoscopy and voice analysis. Esophageal and laryngeal symptoms were assessed using the reflux symptom index (RSI). At endoscopy, esophagitis was graded according to Los Angeles classification. Patients were randomized to receive either voice therapy and omeprazole (20 mg bid) (n=16, mean [SD] age 36.1 [9.6] y; 5 men; Gp A) or omeprazole alone (n=16, age 31.8 [11.7] y; 9 men; Gp B). During voice analysis, jitter, shimmer, harmonic-to-noise ratio (HNR) and normalized noise energy (NNE) were assessed using the Dr. Speech software (version 4 1998; Tigers DRS, Inc). Hoarseness and breathiness of voice were assessed using a perceptual rating scale of 0-3. Parameters were reassessed after 6 weeks, and analyzed using parametric or nonparametric tests as applicable. In Group A, 9 patients had Grade A, 3 had Grade B, and 1 had Grade C esophagitis; 3 had normal study. In Group B, 8 patients had Grade A, 2 had Grade B esophagitis, and 6 had normal study. Baseline findings: median RSI scores were comparable (Group A 20.0 [range 14-27], Group B 19.0 [15-24]). Median rating was 2.0 for hoarseness and breathiness for both groups. Values in Groups A and B for jitter 0.5 (0.6) versus 0.5 (0.8), shimmer 3.1 (2.5) versus 2.8 (2.0), HNR 23.0 (5.6) versus 23.1 (4.2), and NNE -7.3 (3.2) versus -7.2 (3.4) were similar. Post-therapy values for Groups A and B: RSI scores were 9.0 (5-13; P<0.01 as compared with baseline) and 13.0 (10-17; P<0.01), respectively. Ratings for hoarseness and breathiness were 0.5 (P<0.01) and 1.0 (P<0.01) and 2.0. Values for jitter were 0.2 (0.0; P=0.02) versus 0.4 (0.7), shimmer 1.3 (0.7; P<0.01) versus 2.3 (1.2), HNR 26.7 (2.3; P<0.01) versus 23.7 (3.2), and NNE -12.3 (3.0, P<0.01) versus -9.2 (3.4; P<0.01). Improvement in the voice therapy group was significantly better than in patients who received omeprazole alone. Dysphonia is a significant problem in GER. Treatment for GER improves dysphonia, but in addition, voice therapy enhances the improvement.

Disfonia organofuncional e queixas de distúrbios alérgicos e/ou digestivos

OBJETIVO: verificar a ocorrência de queixas de distúrbios alérgicos e/ou digestivos em pacientes com disfonia organofuncional, atendidos no Setor de Voz de uma clínica-escola de Fonoaudiologia. MÉTODOS: este estudo caracteriza-se como estudo de série, retrospectivo e transversal. Realizou-se uma análise de 113 prontuários de pacientes com disfonia organofuncional que apresentavam queixas de distúrbios alérgicos e/ou digestivos, na faixa etária de cinco a 76 anos, sendo 41 do sexo masculino e 72 do feminino. O procedimento estatístico utilizado foi o Teste de Hipótese para Duas Proporções. RESULTADOS: houve significante frequência de queixas de distúrbios alérgicos e digestivos associados nos pacientes dos disfonia organofuncional; entre as queixas de distúrbios alérgicos, de distúrbios digestivos, e de ambas associadas, as queixas de distúrbios alérgicos foram significantemente mais frequentes nos pacientes com disfonia organofuncional. CONCLUSÃO: existe uma relação entre as queixas de distúrbios alérgicos e/ou digestivos e a disfonia, uma vez que esses são co-fatores para o estabelecimento da disfonia e da lesão laríngea. A alta freqüência de queixas de distúrbios alérgicos nos indivíduos com disfonia organofuncional, no presente estudo, pode ter relação com o clima do sul do Brasil.

[Multidimensional acoustic analysis of pathological voice]

INTRODUCTION

There are subjective and objective ways to examine the effects of vocal therapy in voice disorders. The most precise and objective check-up is the use of computer voice analysis.

OBJECTIVE

The aim of the research was to perform a detailed analysis of acoustic structure of the vowel A before and after voice treatment in patients with vocal fold nodules in order to obtain objective verification of the vocal rehabilitation success.

METHODS

We examined 30 female patients, aged 34.6 +/- 6.69 years, with vocal fold nodules. Acoustic parameters of voice were compared with the control group consisting of 21 subjects without voice pathology. In all persons the vowel A was recorded and analyzed before and after a month of vocal therapy. The success of the vocal therapy was tracked using computer analysis of vocal structure. Signal, noise and tremor parameters were processed.

RESULTS

Of the analyzed vowel A parameters: STD, PER, JITA, JITT, RAP, vFO, ShdB, SHIM, APQ, VTI, SPI, FO, NHR, FTRI, eleven improved (p < 0.05 and p < 0.01). Three parameters (FO, NHR, FTRI) changed showing improvement, but the obtained differences were not statistically significant (p > 0.05).

CONCLUSION

Based on the obtained results it was concluded that vocal therapy gave satisfactory results, but that it should be continually applied until full stabilization of the voice.

Automated speech analysis applied to laryngeal disease categorization

The long-term goal of the work is a decision support system for diagnostics of laryngeal diseases. Colour images of vocal folds, a voice signal, and questionnaire data are the information sources to be used in the analysis. This paper is concerned with automated analysis of a voice signal applied to screening of laryngeal diseases. The effectiveness of 11 different feature sets in classification of voice recordings of the sustained phonation of the vowel sound /a/ into a healthy and two pathological classes, diffuse and nodular, is investigated. A k-NN classifier, SVM, and a committee build using various aggregation options are used for the classification. The study was made using the mixed gender database containing 312 voice recordings. The correct classification rate of 84.6% was achieved when using an SVM committee consisting of four members. The pitch and amplitude perturbation measures, cepstral energy features, autocorrelation features as well as linear prediction cosine transform coefficients were amongst the feature sets providing the best performance. In the case of two class classification, using recordings from 79 subjects representing the pathological and 69 the healthy class, the correct classification rate of 95.5% was obtained from a five member committee. Again the pitch and amplitude perturbation measures provided the best performance.

Change of acoustic parameters before and after treatment in laryngopharyngeal reflux patients

OBJECTIVES

To evaluate the usefulness of acoustic parameters as an indicator of laryngopharyngeal reflux (LPR) treatment efficacy.

STUDY DESIGN

A prospective case series analysis.

MATERIALS AND METHODS

From January to September 2005, we prospectively analyzed 40 patients who were diagnosed with laryngopharyngeal reflux by 24-hour ambulatory double-probe pH monitoring. Laryngopharyngeal reflux patients were treated medically and voice analysis was conducted three times: before treatment, 1 to 2 months after treatment, and 3 to 4 months after treatment. Jitter, shimmer, and harmonic-to-noise ratio (HNR) were analyzed as the acoustic parameters. Pre- and posttreatment reflux symptom index and reflux finding score were documented.

RESULTS

Jitter, shimmer, and HNR had improved significantly at 1 to 2 months after treatment and were maintained at 3 to 4 months after treatment. Jitter was significantly correlated with reflux symptom index.

CONCLUSION

Acoustic parameters can be used as indicators of treatment efficacy for laryngopharyngeal reflux disease.

Acoustic Analysis Findings in Objective Laryngopharyngeal Reflux Patients

OBJECTIVE

The aim of this study was to identify the effects of objective laryngopharyngeal reflux (LPR) on the acoustic parameters of patients by comparing their voice samples with that of control subjects.

STUDY DESIGN

Prospective study in two tertiary reference hospitals.

METHODS

48 consecutive patients with symptoms related to LPR and 64 control subjects were included in the study. Suspected LPR patients underwent a 24-hour ambulatory pH monitoring, and 25 (52%) of them were shown to have objective LPR. Acoustical evaluation results of objective LPR patients were compared with that of symptomatic LPR patients and control subjects.

RESULTS

All frequency perturbation values obtained from objective and symptomatic LPR patients were higher than the control subjects (P<0.01). Mean fundamental frequency, amplitude perturbation measures, and noise-to-harmonics ratio were not significantly different between groups.

CONCLUSION

LPR patients have significantly different frequency perturbation values than control subjects.

Voice disorders and gastroesophageal reflux

Gastroesophageal reflux (GER) can cause serious voice problems and laryngopharyngeal disorders influencing the patient's quality of life. Forty-three patients with suspected laryngopharyngeal reflux (LPR) were included into a prospective study. The diagnosis was made on the basis of the patient's history, the videoendolaryngoscopy, the oesophago-gastroscopy and the biopsy of the oesophageal mucosa. All the LPR patients were treated with esomeprasol for eight weeks. An acoustic analysis of the vowel /a/ samples was performed in the LPR group before and after the treatment. Thirty-six patients with vocal fold polyps served as the control group for a subjective estimation of the voice problems. All the patients from both groups subjectively evaluated their voice problems using the Voice Handicap Index (VHI) questionnaire. The results of VHI showed that the severity of the voice problems of the patients with LPR could be compared to that experienced by the patients with vocal fold polyps. Videoendolaryngoscopy and history proved LPR in all 43 patients. Oesophago-gastroscopy combined with the histopathological examination of the oesophageal biopsy specimens detected signs of possible GER in 38 patients (88%). The results of the videoendolaryngoscopy combined with a subjective and objective voice assessment, performed before and after treatment with a proton-pump inhibitor, showed a significant improvement in most of the studied parameters by the end of the therapy. In the diagnostics of LPR, the patient's history and videoendolaryngoscopy demonstrated to be superior to oesophago-gastroscopy. Videoendolaryngoscopic assessment of the laryngeal mucosa, and oesophago-gastroscopy supplemented with a biopsy of the oesophageal mucosa, showed to be a convenient diagnostic method when GER and LPR were suspected. Esomeprasol proved to be very effective in the treatment of LPR. LPR should not be overlooked in the treatment of dysphonic patients.

Effects of unilateral vocal cord paralysis on objective voice measures obtained by Praat

Unilateral vocal cord paralysis (VCP) affects the objective properties of voice by diminished neurologic control and degenerative changes in laryngeal tissue. The goal of this study was to compare the acoustic parameters of VCP patients with control volunteers using the software Praat. Acoustic analysis results of 18 unilateral VCP patients were compared with age and sex matched 72 normal adult volunteers. Comparison of acoustic analysis results of male and female VCP patients with their age and sex matched control groups revealed statistically significant difference in jitter, shimmer, and noise-to-harmonics ratio values (P < 0.01) in both groups. There were no differences in mean fundamental frequency and intensity values. We conclude that these differences were in accordance with the results obtained by commercially available voice analysis programs. This study reflects the first results obtained with Praat software in VCP patients. Using the software Praat, is free and easy, that supports the clinician to rely on objective scientific data.

Acoustic-perceptual correlates of voice quality in elderly men and women

Common perceptual characteristics of the elderly voice include hoarseness, breathiness, instability, and a change in the pitch of the voice. Although research is available concerning changes in the elderly voice, little research has been completed to examine the relationship between the perception of voice quality and acoustic measures. The purpose of this study was to examine the relationship between perceived breathiness and hoarseness and selected acoustic variables. The results of the study revealed significant age-related differences in fundamental frequency standard deviation, amplitude perturbation quotient, and noise-to-harmonic ratio. No significant difference in perceived hoarseness was found between the young and elderly speakers. However, the young women were perceived as significantly more breathy than the elderly women. Moderate correlations were found between the perceptions of hoarseness and breathiness and the acoustic measures. These findings are discussed relative to age-related laryngeal changes that may contribute to the perception of aging.

LEARNING OUTCOMES

(1) To understand the perceptual attributes of the aging voice in men and women. (2) To understand the relation between the perception of voice quality and acoustic measures of voice production in the aging voice.

Perceptual and Acoustic Characteristics of Voice Changes in Reflux Laryngitis Patients

The aim of the study was to outline the multidimensional perceptual, subjective, and instrumental acoustic voice changes in the group of reflux laryngitis (RL) patients. Data of multidimensional voice assessment of 108 RL patients and 90 healthy persons of the control group were subjected to comparative analysis. A slight hoarseness according to the GRB (G-grade, R- rough, B-breathy) scale was prevailing in the RL patients group. Statistically significant difference (P < 0.001) between RL patients group and the control group was found of all voice parameters measured, with the patients having worse results--increased mean jitter, shimmer, normalized noise energy, voice handicap index (VHI), and decreased parameters of phonetogram. The results of the study demonstrated that multidimensional voice assessment documented deteriorated voice quality and restricted phonation capabilities in the tested group of RL patients.