The aging voice: a review, treatment data and familial and genetic perspectives

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION

238274.

Systematic Review: Singing-Based Interventions to Improve Physical Functions Related to Aging Voice in Older Adults

PURPOSE

This systematic review aimed to evaluate the effects of singing as an intervention for aging voice.

METHOD

Quantitative studies of interventions for older adults with any medical condition that involves singing as training were reviewed, measured by respiration, phonation, and posture, which are the physical functions related to the aging voice. English and Chinese studies published until April 2024 were searched using 31 electronic databases, and seven studies were included. The included articles were assessed according to the Grading of Recommendations, Assessment, Development, and Evaluations rubric.

RESULTS

Seven studies were included. These studies reported outcome measures that were related to respiratory functions only. For the intervention effect, statistically significant improvements were observed in five of the included studies, among which three studies had large effect sizes. The overall level of evidence of the included studies was not high, with three studies having moderate levels and the rest having lower levels. The intervention activities included trainings other than singing. These non-singing training items may have caused co-intervention bias in the study results.

CONCLUSIONS

This systematic review suggests that singing as an intervention for older adults with respiratory and cognitive problems could improve respiration and respiratory-phonatory control. However, none of the included studies covers the other two of the physical functions related to aging voice (phonatory and postural functions). The overall level of evidence of the included studies was not high either. There is a need for more research evidence in singing-based intervention specifically for patient with aging voice.

Age and Gender Differences in Belgian Dutch Intonation

PURPOSE

This study investigated whether intonation is influenced by age and gender and obtained normative data for the intonation of Flemish (Belgian Dutch) speaking cis women and cis men in Flanders, Belgium, per age group.

METHOD

A total of 105 cis women and 102 cis men were included and equally spread in five age groups by gender. Semi-structured speech samples were elicited using a prosody protocol. An objective acoustic analysis was performed to determine four intonation parameters (general intonation shift, general fundamental frequency range, final intonation shift, and fundamental frequency variation index).

RESULTS

Cis women used a higher percentage of general upward and downward intonation shifts than cis men. Cis men generally used more flat intonation shifts than cis women. A larger mean value was observed in cis women as compared to cis men for each of the continuous intonation parameters per sentence type. In terms of age, differences in continuous intonation parameters were found between younger and older age groups, mostly with the 46-55-year-old age group, in which the younger age groups showed smaller mean values for all parameters.

CONCLUSIONS

Cis women use a more expressive intonation than cis men. In terms of age, older persons showed a more expressive intonation in a number of sentences compared to younger persons. The prosody protocol and the normative data from this study can be used to determine speech therapy goals.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Effect of Oxidative Stress on the Human Voice

The vocal fold vibrates in high frequency to create voice sound. The vocal fold has a sophisticated histological "layered structure" that enables such vibration. As the vibration causes fricative damage to the mucosa, excessive voicing can cause inflammation or injury to the mucosa. Chronic inflammation or repeated injury to the vocal fold occasionally induces scar formation in the mucosa, which can result in severe dysphonia, which is difficult to treat. Oxidative stress has been proven to be an important factor in aggravating the injury, which can lead to scarring. It is important to avoid excessive oxidative stress during the wound healing period. Excessive accumulation of reactive oxygen species (ROS) has been found in the injured vocal folds of rats during the early phase of wound healing. Antioxidants proved to be useful in preventing the accumulation of ROS during the period with less scar formation in the long-term results. Oxidative stress is also revealed to contribute to aging of the vocal fold, in which the mucosa becomes thin and stiff with a reduction in vibratory capacity. The aged voice can be characterized as weak and breathy. It has been confirmed that ROS gradually increases in rat vocal fold mucosa with age, which may cause further damage to the vocal fold. Antioxidants have also proved effective in avoiding aging of the vocal fold in rat models. Recently, human trials have shown significant effects of the antioxidant Twendee X for maintaining the voice of professional opera singers. In conclusion, it is suggested that oxidative stress has a great impact on the damage or deterioration of the vocal folds, and the use of antioxidants is effective for preventing damage of the vocal fold and maintaining the voice.

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

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

How older adults relate to their own voices: a qualitative study of subjective experiences of the aging voice

AIM

The aim of this study was to investigate how otherwise healthy older adults with self-assessed voice problems relate to their voice and voice changes.

METHOD

Focus groups were conducted at an activity center to identify how older adults reflect on their own voice and the aging voice in general. The interviews were audio recorded and transcribed. The analysis was done using thematic content analysis.

RESULTS

The analysis resulted in three main themes: "communicational aspects of the aging voice," "consequences of deteriorating vocal and communicative capacity," and "attitudes, strategies, and ideas". The participants considered voice to be an important communication tool and presented what could be interpreted as awareness regarding their voice. Voice changes were considered a natural part of aging. This attitude was also an important reason why the participants had not sought medical care for their voice problems. The participants discussed ideas concerning extended voice use to maintain a functioning voice when aging. Simultaneously, voice changes due to aging were considered to have a negative effect on communication and social participation.

CONCLUSIONS

The voice is important for older adults, and an insufficient voice can affect communication and social participation. Information about aging voice and voice exercises, for example from speech language pathologists, could be of interest among older adults. Further studies on the voice of older adults are needed regarding how they experience their voice and the general aspects of a healthy aging voice.

A Cross-sectional Study of Perceptual and Acoustic Voice Characteristics in Healthy Aging

PURPOSE

The human voice qualitatively changes across the lifespan. Although some of these vocal changes may be pathologic, other changes likely reflect natural physiological aging. Normative data for voice characteristics in healthy aging is limited and disparate studies have used a range of different acoustic features, some of which are implicated in pathologic voice changes. We examined the perceptual and acoustic features that predict healthy aging.

METHOD

Participants (N = 150) aged between 50 and 92 years performed a sustained vowel task. Acoustic features were measured using the Multi-Dimensional Voice Program and the Analysis of Dysphonia in Speech and Voice. We used forward and backward variable elimination techniques based on the Bayesian information criterion and linear regression to assess which of these acoustic features predict age and perceptual features. Hearing thresholds were determined using pure-tone audiometry tests at frequencies 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. We further explored potential relationships between these acoustic features and clinical assessments of voice quality using the Consensus Auditory-Perceptual Evaluation of Voice.

RESULTS

Chronological age was significantly predicted by greater voice turbulence, variability of cepstral fundamental frequency, low relative to high spectral energy, and cepstral intensity. When controlling for hearing loss, age was significantly predicted by amplitude perturbations and cepstral intensity. Clinical assessments of voice indicated perceptual characteristics of speech were predicted by different acoustic features. For example, breathiness was predicted by the soft phonation index, mean cepstral peak prominence, mean low-high spectral ratio, and mean cepstral intensity.

CONCLUSIONS

Findings suggest that acoustic features that predict healthy aging are different than those previously reported for the pathologic voice. We propose a model of healthy and pathologic voice development in which voice characteristics are mediated by the inability to monitor vocal productions associated with age-related hearing loss. This normative data of healthy vocal aging may assist in separating voice pathologies from healthy aging.

Premotor cortex is hypoactive during sustained vowel production in individuals with Parkinson's disease and hypophonia

Introduction

Hypophonia is a common feature of Parkinson's disease (PD); however, the contribution of motor cortical activity to reduced phonatory scaling in PD is still not clear.

Methods

In this study, we employed a sustained vowel production task during functional magnetic resonance imaging to compare brain activity between individuals with PD and hypophonia and an older healthy control (OHC) group.

Results

When comparing vowel production versus rest, the PD group showed fewer regions with significant BOLD activity compared to OHCs. Within the motor cortices, both OHC and PD groups showed bilateral activation of the laryngeal/phonatory area (LPA) of the primary motor cortex as well as activation of the supplementary motor area. The OHC group also recruited additional activity in the bilateral trunk motor area and right dorsal premotor cortex (PMd). A voxel-wise comparison of PD and HC groups showed that activity in right PMd was significantly lower in the PD group compared to OHC (p < 0.001, uncorrected). Right PMd activity was positively correlated with maximum phonation time in the PD group and negatively correlated with perceptual severity ratings of loudness and pitch.

Discussion

Our findings suggest that hypoactivation of PMd may be associated with abnormal phonatory control in PD.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Long-Term Voice Change in Presbylarynges Patients With and Without Intervention

PURPOSE

To explore long-term patient experience of treated and untreated presbylarynges patients two or more years after their previous clinic visit by their responses to a probe about the changes in voice (better, stable, or worse) and standardized rating scales either by phone or from clinic records. Congruences of rating differences between visits and probe responses were assessed.

METHODS

Thirty-seven participated prospectively and seven retrospectively. Better, stable, or worse probe responses and treatment follow-through were obtained. Self-rating scales, completed verbally or obtained from charts, were compared to the previous visit so differences between visits could be converted to be congruent with probe responses.

RESULTS

After a mean of 4.6 years, 44% (63% untreated) reported stable, 36% (38% untreated) worse, and 20% (89% untreated) better. Significantly greater proportions of untreated reported better/stable probe responses while treated reported worse (χ2; P = 0.038). Significantly better means for all ratings were found at follow-up for those with better probe responses, but mean ratings were not significantly worse for those with worse probe response. No significant congruences of rating differences between visits and probe responses were found. In untreated reporting stable probe response, a significantly greater proportion of those with previous clinic ratings within normal limits (WNL) maintained ratings WNL at follow-up (z-statistic; P = 0.0007).

CONCLUSIONS

Ratings WNL at the initial evaluation, especially voice-related quality of life and effort, were found to still be WNL after several years. Little congruence was found between rating differences and probe responses, especially for worse, suggesting need for developing more sensitive rating scales.

A Tutorial Review on Clinical Acoustic Markers in Speech Science

PURPOSE

The human voice changes with the progression of neurological disease and the onset of diseases that affect articulators, often decreasing the effectiveness of communication. These changes can be objectively measured using signal processing techniques that extract acoustic features. When measuring acoustic features, there are often several steps and assumptions that might be known to experts in acoustics and phonetics, but are less transparent for other disciplines (e.g., clinical medicine, speech pathology, engineering, and data science). This tutorial describes these signal processing techniques, explicitly outlines the underlying steps for accurate measurement, and discusses the implications of clinical acoustic markers.

CONCLUSIONS

We establish a vocabulary using straightforward terms, provide visualizations to achieve common ground, and guide understanding for those outside the domains of acoustics and auditory signal processing. Where possible, we highlight the best practices for measuring clinical acoustic markers and suggest resources for obtaining and further understanding these measures.

Perceptual Classification of Motor Speech Disorders: The Role of Severity, Speech Task, and Listener's Expertise

PURPOSE

The clinical diagnosis of motor speech disorders (MSDs) is mainly based on perceptual approaches. However, studies on perceptual classification of MSDs often indicate low classification accuracy. The aim of this study was to determine in a forced-choice dichotomous decision-making task (a) how accuracy of speech-language pathologists (SLPs) in perceptually classifying apraxia of speech (AoS) and dysarthria is impacted by speech task, severity of MSD, and listener's expertise and (b) which perceptual features they use to classify.

METHOD

Speech samples from 29 neurotypical speakers, 14 with hypokinetic dysarthria associated with Parkinson's disease (HD), 10 with poststroke AoS, and six with mixed dysarthria associated with amyotrophic lateral sclerosis (MD-FlSp [combining flaccid and spastic dysarthria]), were classified by 20 expert SLPs and 20 student SLPs. Speech samples were elicited in spontaneous speech, text reading, oral diadochokinetic (DDK) tasks, and a sample concatenating text reading and DDK. For each recorded speech sample, SLPs answered three dichotomic questions following a diagnostic approach, (a) neurotypical versus pathological speaker, (b) AoS versus dysarthria, and (c) MD-FlSp versus HD, and a multiple-choice question on the features their decision was based on.

RESULTS

Overall classification accuracy was 72% with good interrater reliability, varying with SLP expertise, speech task, and MSD severity. Correct classification of speech samples was higher for speakers with dysarthria than for AoS and higher for HD than for MD-FlSp. Samples elicited with continuous speech reached the best classification rates. An average number of three perceptual features were used for correct classifications, and their type and combination differed between the three MSDs.

CONCLUSIONS

The auditory-perceptual classification of MSDs in a diagnostic approach reaches substantial performance only in expert SLPs with continuous speech samples, albeit with lower accuracy for AoS. Specific training associated with objective classification tools seems necessary to improve recognition of neurotypical speech and distinction between AoS and dysarthria.

The Acoustic Voice Quality Index (AVQI) in People with Parkinson's Disease Before and After Intensive Voice and Articulation Therapies: Secondary Outcome of a Randomized Controlled Trial

OBJECTIVES

The majority of individuals with Parkinson's disease (PD) experience voice and speech problems during the course of the disease. Despite the importance of voice quality in communication and the documented disordered voice quality in PD, few studies have explored the effects of speech treatment on this variable.

STUDY DESIGN/METHODS

A parallel arm, unblinded randomized controlled trial (RCT) was conducted with two active comparators, LSVT LOUD (n = 23) and LSVT ARTIC (n = 20), and an inactive comparator group of untreated individuals with PD (n = 22). A group of 20 healthy adults was also included for pre-treatment analysis. Voice recordings were obtained pre-treatment, immediately post-treatment and at 6-month follow-up. The acoustic voice quality index (AVQI) is reported here as a secondary outcome measure of the RCT. Linear mixed-effects regression analysis was performed with AVQI and sound pressure level (SPL) as dependent variables. Pearson correlation coefficient analysis was also conducted to explore the relationship between voice quality and SPL.

RESULTS

Statistically significant improvements in AVQI and SPL from pre-treatment to post-treatment and follow-up were only observed in the LSVT LOUD group. Voice quality significantly improved only from pre-treatment to follow-up in the LSVT ARTIC group, whilst significant improvements in SPL were observed during maximum phonation only immediately post-treatment. No significant changes were observed in the untreated group.

DISCUSSION

This study investigated the effects of intensive speech treatment targeting voice or targeting articulation on voice quality, as measured by the AVQI, in individuals with PD. Findings indicate that voice-focused treatment leads to greater improvements in voice quality in this population.

Oral diadochokinetic rates across languages: Multilingual speakers comparison

BACKGROUND

It is unclear whether oral diadochokinetic rate (oral-DDK) performance is affected by different languages within a multilingual country.

AIMS

This study investigated the effects of age, sex, and stimulus type (real word in L1, L2 vs. non-word) on oral-DDK rates among healthy Malaysian-Malay speakers in order to establish language- and age-sensitive norms. The second aim was to compared the nonword 'pataka' oral-DDK rates produced by Malaysian-Malay speakers on currently available normative data for Hebrew speakers and Malaysian-Mandarin speakers.

METHODS & PROCEDURES

Oral-DDK performance of 90 participants (aged 20-77 years) using nonword ('pataka'), Malay real word ('patahkan'), and English real word ('buttercake') was audio recorded. The number of syllables produced in 8 seconds was calculated. Mixed analysis of variance (ANOVA) was conducted to examine the effects of stimulus type (nonword, Malay, and English real word), sex (male, female), age (younger, 20-40 years; middle, 41-60 years; older, ≥61 years), and their interactions on the oral-DDK rate. Data obtained were also compared with the raw data of Malaysian-Mandarin and Hebrew speakers from the previous studies.

OUTCOMES & RESULTS

A normative oral-DDK rate has been established for healthy Malaysian-Malay speakers. The oral-DDK rate was significantly affected by stimuli (p < 0.001). Malay real word showed the slowest rate, whereas there was no significant difference between English real word and nonword. The oral-DDK rate for Malay speakers was significantly higher than Mandarin and Hebrew speakers across stimuli (all p < 0.01). Interestingly, oral-DDK rates were not affected by age group for Malay speakers.

CONCLUSIONS & IMPLICATIONS

Stimuli type and language affect the oral-DDK rate, indicating that speech-language therapists should consider using language-specific norms when assessing multilingual speakers.

WHAT THIS PAPER ADDS

What is already known on the subject Age, sex, and language are factors that need to be considered when developing oral-DDK normative protocol. It is unclear whether oral-DDK performance is affected by different languages within a multilingual country. What this paper adds to existing knowledge No ageing effect across real word versus nonword on oral-DDK performance was observed among Malaysian-Malay speakers, contrasting with current available literature that speech movements slow down as we age. Additionally, Malaysian-Malay speakers have faster oral-DDK rates than Malaysian-Mandarin and Hebrew speakers across all stimuli. What are the potential or actual clinical implications of this work? Establishing normative data of different languages will enable speech-language therapists to select the appropriate reference dataset based on the language mastery of these multilingual speakers.

Oral-diadochokinetic rates among healthy Malaysian-Mandarin speakers: A cross linguistic comparison

PURPOSE

This study examined the effects of non-word versus real word, age, and gender on oral-DDK rates among healthy Malaysian-Mandarin speakers. Comparison between non-word of Malaysian-Mandarin and Hebrew speakers was examined.

METHOD

One-hundred and seventeen speakers (18-83 years old, 46% men) were audio-recorded while performing non-word (repetition of "pataka") and real-word oral-DDK tasks ("butter cake" and " ([p^ha4t^ha1k^han4])"). The number of syllables produced in 8 seconds was counted from the audio recording to derive the oral-DDK rates. A MANOVA was conducted to compare the rates between age groups (young = 18-40 years, n = 56; middle = 41-60 years, n = 39; older = 61-83 years, n = 22) and gender. In a second analysis, "pataka" results were compared between this study and previous findings with Hebrew speakers.

RESULT

No gender effects were found. However, rates significantly decreased with age (p < 0.001). Repetition of real words was faster than that of non-words - English words (5.55 ± 1.19 syllables/s) > non-words (5.29 ± 1.23) > Mandarin words (4.91 ± 1.13). Malaysian-Mandarin speakers performed slower than Hebrew speakers on "pataka" task.

CONCLUSION

Aging has a large impact on oromotor functions, indicating that speech-language pathologists should consider using age-adjusted norms.

Does Voice Therapy Improve Vocal Outcomes in Vocal Fold Atrophy?

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term voice quality outcome after thyroidectomy without laryngeal nerve injury: a prospective 10 year follow up study

PURPOSE

This study investigates the long-term voice outcome of thyroidectomy up to 10 years after the surgery using a longitudinal prospective study design.

METHODS

Eighteen participants (6 men and 12 women, mean age: 54 years) who underwent a thyroidectomy between September 2006 and May 2007 were included in this study. A voice assessment protocol consisting of subjective (videolaryngostroboscopic evaluation, auditory- perceptual evaluation, patients' self-report) and objective voice assessments (maximum performance task, acoustic analysis, voice range profile and Dysphonia Severity Index) was used to evaluate the participants' pre- and postoperative voice. Voice measurements were compared before and one week, six weeks, three months and 10 years after the surgery.

RESULTS

No significant differences over time in auditory-perceptual and objective voice parameters were found, except for shimmer. Only in the first postoperative condition, significantly more patients reported vocal complaints. A progressive amelioration of the vocal folds' movement patterns was observed in the postoperative conditions.

CONCLUSION

The findings of this small longitudinal prospective study suggest that thyroidectomy without laryngeal nerve injury does not cause a permanent deterioration of the laryngeal aspect or function, vocal fold behavior and the self-perceived, perceptual and objective vocal quality. The increase of the shimmer 10 years post-thyroidectomy may be related to vocal aging.

Regenerative efficacy of fibroblast growth factor for the treatment of aged vocal fold: From animal model to clinical application

OBJECTIVES

We assessed fibroblast growth factor (FGF) regenerative efficacy in an aged vocal fold rat model and confirmed it in a prospective clinical trial.

DESIGN, SETTING, AND PARTICIPANTS

For animal experiments, 48 Sprague-Dawley rats were divided into two groups: 24 six-month-olds (young group) and 24 twenty-four-month-olds (old group). FGF was injected once a week thrice into the left vocal fold of the old group, dividing them into two sub-groups (injected [left] and uninjected [right]). Additionally, we conducted a prospective clinical trial for 38 patients with aged atrophic vocal fold.

MAIN OUTCOME MEASURES

A month post-injection, excised larynx from the three groups was subjected to comparative histopathological (ratio of relative lamina propria to total vocal fold) and mRNA expression analysis (of procollagen I, hyaluronic acid synthase (HAS)-2 and matrix metalloproteinase (MMP)-2) by real-time PCR. We performed perceptual, stroboscopic, acoustic aerodynamic test and Voice Handicap Index survey prior to and 1, 6 and 12 months after FGF injection.

RESULTS

In rats, the relative lamina propria ratio increased after FGF injection. Procollagen I mRNA level decreased, whereas that of HAS-2 and MMP-2 increased significantly in the injected compared to the uninjected old group. Enrolled patients showed improved subjective and objective voice parameters after FGF injection, and these were maintained for a year. Potential side effects were not observed.

CONCLUSIONS

Animal experiments and prospective clinical trial suggest that FGF injection to vocal fold can significantly improve voice quality until one year, without complications, and is effective for aged atrophic vocal fold treatment.

Influence of vocal and aerodynamics aspects on the voice-related quality of life of older adults

The pursuit for quality of life urged a better understanding of aspects involved in ageing to minimize its consequences. Although many studies investigated older adults’ voice, aspects affecting this population voice-related quality of life have not yet been explored.

Perceptual Characterization of Voice Quality in Nonadvanced Stages of Parkinson's Disease

INTRODUCTION

Parkinson's disease (PD) is a neurodegenerative disorder that impacts motor and nonmotor systems, and consequently influences voice. In later stages of the disease, people with PD develop salient hypokinetic dysarthria. However, it is unclear how extensive the voice impairment is in the nonadvanced stages of PD. Therefore, the aim of the current research was to investigate the auditory-perceptual characteristics of voice in people with Parkinson's disease (PWPD) in nonadvanced stages.

METHODS

29 PWPD and 32 healthy older controls were recruited. For each participant, a recording of the sentence "We were away a year ago" was acquired. These recordings were evaluated by 2 licensed and experienced speech-language pathologists, who provided perceptual ratings of overall dysphonia severity, breathiness, roughness, and perceived age.

RESULTS

MANCOVA analysis showed that, when controlling for age and intensity, there was a significant effect of group (P = 0.001) on perceptual voice quality. PWPD were perceived to be significantly older, more breathy and more severely dysphonic than the older healthy controls. No differences were found for the perceived roughness.

CONCLUSIONS

The results suggest that perceptual features of hypokinetic dysarthria in voice, specifically breathiness, are present in nonadvanced stages of PWPD and may contribute to listener perceptions of speaker age. Moreover, the perceptual voice profiles in PWPD showed great variability, possibly reflecting the heterogeneity of disease impact on individuals. The results of this study may inform how research targets rehabilitation and maintenance of voice and laryngeal function in PWPD at nonadvanced stages.

Management of presbyphonia: A systematic review of the efficacy of surgical intervention

OBJECTIVE

The aging larynx undergoes structural changes that have functional consequences for voice production known as presbyphonia. Treatment of presbyphonia includes voice therapy and surgery. This review seeks to examine voice outcomes after surgery for presbyphonia.

DATA SOURCES

Three electronic databases (PreMed, ScienceDirect, Embase) were reviewed for articles published between 1 January 1900 and 1 June 2019.

REVIEW METHODS

Original English-language studies examining surgical treatment of presbyphonia in elderly patients (≥65 years) were included according to PRISMA. Two researchers independently analyzed articles. Outcome measures were extracted from and qualitatively compared across studies.

RESULTS

Of the 118 articles identified, five satisfied eligibility criteria. In all studies, diagnosis of presbyphonia was based on videostroboscopy. 85 patients (61M, 21F) were evaluated. 37.6% underwent implantation thyroplasty (IT), 48.2% underwent injection augmentation (IA), 7.1% underwent both, and 7.1% underwent basic-fibroblastic growth factor (b-FGF) injection. Average patient age was 71.3 years. Average follow-up time was 5.4 months. Three months post-intervention, IT patients self-reported greater improvement in quality of life (QoL) metrics compared to IA patients. Aerodynamic measures, like mean phonation time, were significantly improved in IT and IA, but not b-FGF-injected patients. All patients experienced improvements in the auditory perception of voice three months post-intervention.

CONCLUSION

Surgical modalities currently utilized for presbyphonia include IT and IA, with bFGF-injection being trialed abroad. IT patients reported enhanced QoL relative to IA and bFGF-injected patients. Overall there is a paucity of high-power, prospective studies that explore the efficacy of these modalities. Moreover, wide variability exists in reported outcomes among published studies.

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

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

Age-Related Changes in Speech and Voice: Spectral and Cepstral Measures

Purpose This study examined differences in selected acoustic measures of speech and voice according to age and sex and across families. Method Participants included 169 individuals, 79 men and 90 women, from 18 families, ranging in age from 17 to 87 years. Participants reported no history of articulation disorders, stroke or active neurologic disease, or severe-to-profound hearing loss. They read aloud two passages to facilitate examination of the following speech and voice acoustic parameters: fricative spectral moments (center of gravity, standard deviation, skewness, and kurtosis), the proportion of time spent speaking, mean speaking fundamental frequency, semitone standard deviation (STSD), and cepstral peak prominence smoothed. Results The results indicated a significant age effect for fricative spectral center of gravity, spectral skewness, and speaking STSD. There was a significant sex effect for spectral center of gravity, spectral kurtosis, and mean fundamental frequency. Familial relationship was significant for spectral skewness, STSD, and cepstral peak prominence smoothed. Conclusions These findings revealed that certain speech and voice features change with age and some change differently for men and women. Additionally, speakers from the same family units may demonstrate similar patterns for prosody, voicing, and articulatory behavior. The results also demonstrated normal differences in speech and voice variation across age, sex, and family unit. Understanding patterns and differences across these demographic variables in healthy speakers is important to distinguishing more confidently between normal and disordered speech and voice patterns clinically.

How Does Our Voice Change as We Age? A Systematic Review and Meta-Analysis of Acoustic and Perceptual Voice Data From Healthy Adults Over 50 Years of Age

Purpose Approximately 30% of adults over the age of 50 years present with altered vocal function. Our understanding of how these changes manifest acoustically and perceptually is derived from relatively modest-sized studies using a diversity of tools. Voice changes can arise from the onset of disease or disorder, but also age-related physiological changes, which may not reflect pathology as such. Here, we bring together data on acoustic, perceptual, and instrumental assessments (electroglottography), with the aim of gaining a better understanding of the changes occurring across these measurement domains. We consider these changes in the context of different acoustic features, software programs, and perceptual protocols. Method Studies of voice function in healthy older adults over the age of 50 years were sought. Literature was systematically searched with 746 abstracts reviewed. Forty-seven studies were included in the review. A meta-analysis of included studies compared voice acoustic parameters between sex and age. Sixteen acoustic parameters collected from 1,475 participants were analyzed in the meta-analysis. These included some previously unpublished analyses using data provided by authors of included studies. Results Data from the systematic review suggest that older individuals are perceived to present with higher overall scores of dysphonia and roughness, breathiness, strain, and instability. Acoustically, males have significantly higher scores on measures of perturbation, including noise-to-harmonic ratio and absolute jitter. The meta-analysis outcomes suggest that participants aged 80-89 years produce significantly higher fundamental frequency, jitter percent, shimmer percent, and shimmer in decibels compared to participants aged 60-69 years and a significant increase in relative average perturbation, jitter percent, and shimmer in decibels compared to participants aged 70-79 years. Limited data were available comparing acoustic measures using the same acoustic software. Conclusions Variations in fundamental frequency and frequency and amplitude perturbation increase as healthy adults age. It was difficult to draw definitive conclusions based on existing literature due to variability in hardware used, limited descriptions of study cohorts, or missing data from statistical analysis. Supplemental Material https://doi.org/10.23641/asha.11868663.

Comparison of the immediate effect of voiced oral high-frequency oscillation and flow phonation with resonance tube in vocally-healthy elderly women

PURPOSE

To verify and compare the immediate effects of the voiced oral high-frequency oscillation (VOHFO) technique and the phonation into a silicone resonance tube in the elderly self-perception of vocal and laryngeal symptoms and in their voice quality.

METHODS

14 elderly women, over 60 years old, performed the VOHFO and phonation into a resonance tube technique (35cm in length and 9mm in diameter) with one-week interval between both to avoid carry-over effect. Initially, all participants answered questions regarding the frequency and intensity of their vocal/laryngeal symptoms. Recordings of the sustained vowel /a/ and counting numbers were performed for posterior perceptual and acoustic analyses of the voice quality. The maximum phonation time (MPT) for /a/, /s/, /z/ and counting numbers were also obtained. After that, a draw lot established which technique (VOHFO or resonance tube) would be initially applied for three minutes. After the exercise performance the same procedures were carried out and the elderly women answered a self-assessment questionnaire about the effect of the techniques in her voice, larynx, breathing and articulation. Comparison pre and post each technique were analyzed using ANOVA, Wilcoxon and Mann-Whitney tests. The sensations after the techniques were assessed using the Chi-square test (p<0.05).

RESULTS

The comparison of both techniques showed decrease in roughness and improvement in resonance for counting numbers after the resonance tube and same outcomes post VOHFO. There were no significant differences for the other analyzed variables between groups.

CONCLUSION

The phonation into a resonance tube exercise improves the vocal quality of elderly women. In addition, both exercises are similar regarding self-perception of vocal / laryngeal symptoms and sensations post three minutes of the technique, suggesting that VOHFO can be safely applied in voice therapy for this population.

Self-Perceived Voice Problems in a Nontreatment Seeking Older Population in Hong Kong

OBJECTIVE

To evaluate the prevalence of self-perceived voice problems and voice-related quality of life in a nontreatment seeking older population in Hong Kong.

STUDY DESIGN

Prospective, cross-sectional survey.

METHODS

One hundred and one older individuals aged 65 years or above were recruited from senior citizen community centers in Hong Kong. Each participant received a face-to-face interview with the researcher. The participants were asked to report the presence of voice problems and the voice symptoms that they experienced. They were also asked to complete the Cantonese version of the Voice Handicap Index to ascertain their voice-related quality of life.

RESULTS

Over one-fourth (27.7%) of participants reported having current voice problems. Perceived voice problems were found to pose significant negative impacts on the older individuals' voice-related quality of life. The prevalence of voice problems and extent of impacts of voice-related quality of life were similar across the young-old, old-old, and the oldest-old groups of participants.

CONCLUSION

The results suggest that voice problems are common in the older population and should not be underestimated. The study urges the need to allocate more resources to provide voice-related services from the young-old group for promoting positive aging.

Functional Electrical Stimulation for Presbyphonia: A Prospective Randomized Trial

Objectives

The aim of this prospective study was to examine the effects of transcutaneous functional electrical stimulation (FES) in a group of elderly women with presbyphonia.

Study Design

Prospective randomized study.

Methods

Fourteen participants were enrolled prospectively and attributed randomly to two different treatment groups, where one group (n = 7) received 8 weeks of training (5 days a week), whereas the other group (n = 7) received 4 weeks of ineffective stimulation, followed by 4 weeks of effective training. Stimulation protocols were established during baseline examination and confirmed with endoscopy to ensure a glottal reaction. Numerous acoustical, vocal, patient‐centered, and respiratory parameters were obtained at several time points.

Results

Neither 4 weeks nor 8 weeks of functional electrical transcutaneous stimulation led to changes of vocal, acoustical, or respiratory parameters, apart from patient‐centered items (Voice Handicap Index 12, Voice‐Related Quality of Life), which improved over time. However, there were no differences between the two arms for both items.

Conclusions

Transcutaneous FES over 4 weeks and 8 weeks did not lead to significantly improved objective voice and acoustical parameters, which could be caused by the fact that the muscles of interest cannot be targeted specifically enough. However, we found a significant improvement of subjective voice perception and voice‐related quality of life in both groups. We explain this finding with an observer‐expectancy effect secondary to the very time‐consuming and elaborate study procedures.

Level of Evidence

1b Laryngoscope, 130:E662–E666, 2020

Autologous fibroblasts for vocal scars and age-related atrophy: A randomized clinical trial

OBJECTIVES/HYPOTHESIS

To assess the safety and efficacy of autologous cultured fibroblasts (ACFs) to treat dysphonia related to vocal fold scar and age-related vocal atrophy (ARVA).

STUDY DESIGN

Randomized, double-blinded, placebo-controlled, multi-institutional, phase II trial.

METHODS

ACFs were expanded from punch biopsies of the postauricular skin in each subject; randomization was 2:1 (treatment vs. placebo). Three injections of 1-2 × 10⁷ cells or placebo saline was performed at 4-week intervals for each vocal fold. Follow-up was performed at 4, 8, and 12 months. The primary outcome was improved mucosal waves. Secondary outcomes included Voice Handicap Index (VHI)-30, patient reported voice quality outcomes, and perceptual analysis of voice.

RESULTS

Fifteen subjects received ACF and six received saline injections. At 4, 8, and 12 months after ACF treatments, a significant improvement in mucosal wave grade relative to baseline was observed in both vocal scar and ARVA groups. Relative to control group, mucosal waves were significantly improved in the ARVA group at 4 and 8 months. Perceptual analysis significantly improved in the vocal scar group 12 months after ACF treatments compared to controls. Vocal scar group reported significantly improved vocal quality from baseline. VHI and expert rater voice grade improved in both groups, but did not achieve significance. No adverse events related to fibroblast injections were observed.

CONCLUSIONS

In this cohort, injection of ACFs into the vocal fold lamina propria (LP) was safe and significantly improved mucosal waves in patients with vocal scar and ARVA. ACF may hold promise to reconstruct the LP.

LEVEL OF EVIDENCE

1 Laryngoscope, 130:2650-2658, 2020.

The Jena Speaker Set (JESS)-A database of voice stimuli from unfamiliar young and old adult speakers

Here we describe the Jena Speaker Set (JESS), a free database for unfamiliar adult voice stimuli, comprising voices from 61 young (18-25 years) and 59 old (60-81 years) female and male speakers uttering various sentences, syllables, read text, semi-spontaneous speech, and vowels. Listeners rated two voice samples (short sentences) per speaker for attractiveness, likeability, two measures of distinctiveness ("deviation"-based [DEV] and "voice in the crowd"-based [VITC]), regional accent, and age. Interrater reliability was high, with Cronbach's α between .82 and .99. Young voices were generally rated as more attractive than old voices, but particularly so when male listeners judged female voices. Moreover, young female voices were rated as more likeable than both young male and old female voices. Young voices were judged to be less distinctive than old voices according to the DEV measure, with no differences in the VITC measure. In age ratings, listeners almost perfectly discriminated young from old voices; additionally, young female voices were perceived as being younger than young male voices. Correlations between the rating dimensions above demonstrated (among other things) that DEV-based distinctiveness was strongly negatively correlated with rated attractiveness and likeability. By contrast, VITC-based distinctiveness was uncorrelated with rated attractiveness and likeability in young voices, although a moderate negative correlation was observed for old voices. Overall, the present results demonstrate systematic effects of vocal age and gender on impressions based on the voice and inform as to the selection of suitable voice stimuli for further research into voice perception, learning, and memory.

The Effect of Supraclavicular Radiotherapy on Acoustic Voice Quality Index (AVQI), Spectral Amplitude and Perturbation Values

OBJECTIVE

The Acoustic Voice Quality Index (AVQI), spectral amplitude, and voice perturbation parameters are objective assessment methods that are used in clinical settings and for research purposes. The aim of this study was to demonstrate the effect of supraclavicular RT on the physiology and function of the vocal fold.

METHODS

A total of 29 female patients were included in the study. The voices of the patients, who were diagnosed with breast cancer and underwent supraclavicular RT, were recorded before and after the treatment (1 and 6 months). AVQI, spectral amplitude (H1-H2, H1-A1, H1-A2, H1-A3) and acoustic analyses of the voice perturbation parameters were performed.

RESULTS

AVQI was significantly higher in the first month (P < 0.05). Of the voice perturbation parameters, shimmer was found to be significantly high in the first month (P < 0.05). However, not all spectral amplitude values showed a significant change (P > 0.05).

CONCLUSION

In this study, AVQI and shimmer values were found to be higher following the application of supraclavicular RT. These results showed that nonlaryngeal RT might cause changes in the acoustic values of the voice in the early stage.

Aging and Sex Influence Cortical Auditory-Motor Integration for Speech Control

It is well known that acoustic change in speech production is subject to age-related declines. How aging alters cortical sensorimotor integration in speech control, however, remains poorly understood. The present event-related potential study examined the behavioral and neural effects of aging and sex on the auditory-motor processing of voice pitch errors. Behaviorally, older adults produced significantly larger vocal compensations for pitch perturbations than young adults across the sexes, while the effects of sex on vocal compensation did not exist for both young and older adults. At the cortical level, there was a significant interaction between aging and sex on the N1-P2 complex. Older males produced significantly smaller P2 amplitudes than young males, while young males produced significantly larger N1 and P2 amplitudes than young females. In addition, females produced faster N1 responses than males regardless of age, while young adults produced faster P2 responses than older adults across the sexes. These findings provide the first neurobehavioral evidence that demonstrates the aging influence on auditory feedback control of speech production, and highlight the importance of sex in understanding the aging of the neuromotor control of speech production.

Vocal Dose in Older Adults with Presbyphonia: An Analytic, Cross-Sectional Study

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.

Clear speech adaptations in spontaneous speech produced by young and older adults

The study investigated the speech adaptations by older adults (OA) with and without age-related hearing loss made to communicate effectively in challenging communicative conditions. Acoustic analyses were carried out on spontaneous speech produced during a problem-solving task (diapix) carried out by talker pairs in different listening conditions. There were 83 talkers of Southern British English. Fifty-seven talkers were OAs aged 65-84, 30 older adults with normal hearing (OANH), and 27 older adults with hearing loss (OAHL) [mean pure tone average (PTA) 0.250-4 kHz: 27.7 dB HL]. Twenty-six talkers were younger adults (YA) aged 18-26 with normal hearing. Participants were recorded while completing the diapix task with a conversational partner (YA of the same sex) when (a) both talkers heard normally (NORM), (b) the partner had a simulated hearing loss, and (c) both talkers heard babble noise. Irrespective of hearing status, there were age-related differences in some acoustic characteristics of YA and OA speech produced in NORM, most likely linked to physiological factors. In challenging conditions, while OANH talkers typically patterned with YA talkers, OAHL talkers made adaptations more consistent with an increase in vocal effort. The study suggests that even mild presbycusis in healthy OAs can affect the speech adaptations made to maintain effective communication.

Treatment Receipt and Outcomes of Self-Reported Voice Problems in the US Population Aged ≥65 Years

Objectives

(1) Characterize the US population aged ≥65 years with self-reported voice problems, (2) describe voice treatment characteristics in this group, and (3) identify factors associated with self-reported voice improvement.

Study Design

Retrospective cohort study.

Setting

Population-based cross-sectional US national survey sample.

Subjects and Methods

We identified a cohort of adults aged ≥65 years from the 2012 National Health Interview Survey, a population-based US national survey. Descriptive and multivariable regression analyses were performed.

Results

The prevalence of self-reported voice problems in this cohort was 10%. Of those, 44% reported voice problems for >1 month. The strongest predictor of reporting voice improvement was receipt of voice treatment (odds ratio, 3.50; 95% confidence interval, 1.36-9.00), after adjusting for sex, age, race, education, and health status. Eleven percent reported voice treatment, which included 20% of those with moderate or worse voice problem severity. Female sex and worse health status were associated with reporting voice treatment. Among those with voice treatment, 38% reported “better,” 33% “same,” and 29% “worse” voice symptoms over the past year, compared to 17%, 67%, and 16%, respectively, among those without treatment. Health status influenced likelihood of reporting voice improvement but not universally.

Conclusions

We observed a significant self-reported burden of voice problems in the US population aged ≥65 years. Most are untreated and thus not well represented in the current literature. Vocal improvement was strongly associated with treatment. Further investigation is needed to clarify patient and treatment characteristics most associated with vocal improvement.

Biomechanical simulation of vocal fold dynamics in adults based on laryngeal high-speed videoendoscopy

MOTIVATION

Human voice is generated in the larynx by the two oscillating vocal folds. Owing to the limited space and accessibility of the larynx, endoscopic investigation of the actual phonatory process in detail is challenging. Hence the biomechanics of the human phonatory process are still not yet fully understood. Therefore, we adapt a mathematical model of the vocal folds towards vocal fold oscillations to quantify gender and age related differences expressed by computed biomechanical model parameters.

METHODS

The vocal fold dynamics are visualized by laryngeal high-speed videoendoscopy (4000 fps). A total of 33 healthy young subjects (16 females, 17 males) and 11 elderly subjects (5 females, 6 males) were recorded. A numerical two-mass model is adapted to the recorded vocal fold oscillations by varying model masses, stiffness and subglottal pressure. For adapting the model towards the recorded vocal fold dynamics, three different optimization algorithms (Nelder-Mead, Particle Swarm Optimization and Simulated Bee Colony) in combination with three cost functions were considered for applicability. Gender differences and age-related kinematic differences reflected by the model parameters were analyzed.

RESULTS AND CONCLUSION

The biomechanical model in combination with numerical optimization techniques allowed phonatory behavior to be simulated and laryngeal parameters involved to be quantified. All three optimization algorithms showed promising results. However, only one cost function seems to be suitable for this optimization task. The gained model parameters reflect the phonatory biomechanics for men and women well and show quantitative age- and gender-specific differences. The model parameters for younger females and males showed lower subglottal pressures, lower stiffness and higher masses than the corresponding elderly groups. Females exhibited higher subglottal pressures, smaller oscillation masses and larger stiffness than the corresponding similar aged male groups. Optimizing numerical models towards vocal fold oscillations is useful to identify underlying laryngeal components controlling the phonatory process.

Laryngeal Aerodynamics in Healthy Older Adults and Adults With Parkinson's Disease

PURPOSE

The present study compared laryngeal aerodynamic function of healthy older adults (HOA) to adults with Parkinson's disease (PD) while speaking at a comfortable and increased vocal intensity.

METHOD

Laryngeal aerodynamic measures (subglottal pressure, peak-to-peak flow, minimum flow, and open quotient [OQ]) were compared between HOAs and individuals with PD who had a diagnosis of hypophonia. Increased vocal intensity was elicited via monaurally presented multitalker background noise.

RESULTS

At a comfortable speaking intensity, HOAs and individuals with PD produced comparable vocal intensity, rates of vocal fold closure, and minimum flow. HOAs used smaller OQs, higher subglottal pressure, and lower peak-to-peak flow than individuals with PD. Both groups increased speaking intensity when speaking in noise to the same degree. However, HOAs produced increased intensity with greater driving pressure, faster vocal fold closure rates, and smaller OQs than individuals with PD.

CONCLUSIONS

Monaural background noise elicited equivalent vocal intensity increases in HOAs and individuals with PD. Although both groups used laryngeal mechanisms as expected to increase sound pressure level, they used these mechanisms to different degrees. The HOAs appeared to have better control of the laryngeal mechanism to make changes to their vocal intensity.

Regeneration of Aged Vocal Folds with Basic Fibroblast Growth Factor in a Rat Model: A Preliminary Report

Aged vocal folds have been reported to have dense collagen deposition and decreased hyaluronic acid (HA) in the lamina propria. These characteristics are thought to contribute to vocal problems that occur with age (presbyphonia). To restore better viscoelasticity to aged vocal folds, an intervention that might increase HA and decrease collagen production from aged vocal fold fibroblasts would appear to be a potentially useful approach. Our previous in vitro study has revealed that basic fibroblast growth factor (bFGF) consistently stimulates HA production and decreases collagen production from aged rat vocal fold fibroblasts. The present in vivo study examined the effects of intracordal injection of bFGF into aged rats' vocal folds in terms of restoration of HA and collagen distribution in the lamina propria. We injected bFGF transorally into the lamina propria of (unilateral) vocal folds. The injection was repeated 4 times weekly, and rats were painlessly sacrificed 1 week, 1 month, and 2 months after the final injection. Histologic examination revealed that bFGF significantly increased the HA content of the lamina propria up to 2 months, but showed no effect on collagen, even after 2 months. Because it might take longer for excessive collagen to be degraded, further studies are necessary to clarify the long-term effect on collagen. A drug delivery system for bFGF also needs to be developed to maximize its effect in the future. The present study suggested at least a positive effect of bFGF in restoring the HA content in the aged vocal fold lamina propria.

Effects of age on the amplitude, frequency and perceived quality of voice

The manner and extent to which voice amplitude and frequency control mechanisms change with age is not well understood. The related question of whether the assessment of one's own voice evolves with age, concomitant with the acoustical changes that the voice undergoes, also remains unanswered. In the present study, we characterized the aging of voice production mechanisms (amplitude, frequency), compared the aging voice in different experimental contexts (vowel utterance, connected speech) and examined the relationship between voice self-assessment and age-related voice acoustical changes. Eighty healthy adults (20 to 75 years old) participated in the study, which involved computation of several acoustical measures of voice (including measures of fundamental frequency, voice amplitude, and stability) as well as self-assessments of voice. Because depression is frequent in older adults, depression and anxiety scores were also measured. As was expected, analyses revealed age effects on most acoustical measures. However, there was no interaction between age and the ability to produce high/low voice amplitude/frequency, suggesting that voice amplitude and frequency control mechanisms are preserved in aging. Multiple mediation analyses demonstrated that the relationship between age and voice self-assessment was moderated by depression and anxiety scores. Taken together, these results reveal that while voice production undergoes important changes throughout aging, the ability to increase/decrease the amplitude and frequency of voice are preserved, at least within the age range studied, and that depression and anxiety scores have a stronger impact on perceived voice quality than acoustical changes themselves.

Voice pedagogy-what do we need?

The final keynote panel of the 10th Pan-European Voice Conference (PEVOC) was concerned with the topic 'Voice pedagogy-what do we need?' In this communication the panel discussion is summarized, and the authors provide a deepening discussion on one of the key questions, addressing the roles and tasks of people working with voice students. In particular, a distinction is made between (1) voice building (derived from the German term 'Stimmbildung'), primarily comprising the functional and physiological aspects of singing; (2) coaching, mostly concerned with performance skills; and (3) singing voice rehabilitation. Both public and private educators are encouraged to apply this distinction to their curricula, in order to arrive at more efficient singing teaching and to reduce the risk of vocal injury to the singers concerned.