Acoustic measurement of change in voice quality with treatment for chronic posterior laryngitis

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.

Cross-cultural Adaptation and Validation of the Greek Voice Handicap Index-10 (GVHI-10) With Additional Receiver Operating Characteristic Analysis

OBJECTIVE(S)

The use of subjective evaluation tools are proven useful and of high clinical value in the case of voice disordered population. For that type of evaluation, self-assessment questionnaires about the severity of the voice like Voice Handicap Index-30 (VHI-30) have been developed. The VHI-30 is the most studied tool which includes psychometrically robustness while guiding physician's therapeutic decision making. Additionally, a valid abbreviated version of VHI-30 was developed for the first time in the Greek Language which is named as Greek Voice Handicap Index-10 (GVHI-10). Consequently, the aim of our study was to validate the proposed version of the VHI-10.

METHODS

Ninety nondysphonic individuals and 90 dysphonic patients were classified by Otolaryngologists and Speech Language Pathologists. The study's subjects were evaluated with endoscopy and stroboscopy. Also, they were administrated the GVHI-30 and the translated version of the Voice Evaluation Template (VEF). The GVHI-10 was extracted by the Greek version of VHI-30.

RESULTS

The group with voice disorders exhibited higher statistical significance in all GVHI-10 scores compared to those of the control group. The GVHI-10 showed a high internal consistency (Cronbach's a = 0.915 and split-half reliability coefficient equal to 0.86), good sensitivity compared to Greek VHI-30 (r = 0.764, P = 0.000) and intraclass correlation. A total cut-off point equal to 6.50 (AUC: 0.964; P < 0.001) was also calculated.

CONCLUSIONS

The proposed version of GVHI-10 distinguished the perceived levels of voice between dysphonic and nondysphonic groups and between different voice disordered populations. The GVHI-10 is shown to be clinically valid and sensitive exhibiting high reliability.

WITHDRAWN: Acid reflux treatment for hoarseness

Review withdrawn from Issue 4, 2015 as it is out of date.

The editorial group responsible for this previously published document have withdrawn it from publication.

LPR: how different diagnostic tools shape the outcomes of treatment

OBJECTIVE

To seek a deeper and more comprehensive understanding of two major diagnostic methods for laryngopharyngeal reflux by exploring whether and how differences exist before and after treatment between patients diagnosed by either Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) or 24-hour pH monitoring.

MATERIALS AND METHODS

Two groups of patients who confirmed laryngopharyngeal reflux disease (LPRD) by either a combination of RSI and RFS (Questionnaire group, 35 patients) or 24-hour multichannel intraluminal impedance (MII) pH monitoring (pH Group, 23 patients) were recruited. All patients were prescribed esomeprazole 20 mg twice a day for 1 month. RSI, RFS, and acoustic parameters before and after treatment were compared between the two groups. Intrinsic correlations involving multiple parameters were investigated as well.

RESULTS

Except for excess throat mucus (P = 0.019) and subglottic edema (P = 0.042), most RSI and RFS items before treatment were not significantly different between the Questionnaire and pH Groups, and nearly all such items in both groups exhibited distinct remission after therapy (P < 0.05). Absolute value of remission in RSI after treatment was more prominent in pH Group than in the Questionnaire group (P = 0.007). Jitter (P = 0.252), shimmer (P = 0.815), and harmonics-to-noise ratio (P = 0.117) descended to normal value after treatment. Moderate to high levels of correlation were found between the patient's original status and the absolute value of remission in most items of RSI and RFS as well as voice parameters.

CONCLUSION

The 24-hour MII pH monitoring and a combination of RSI and RFS are quite competitive with each other in selecting LPRD patients. Although treatment worked out on nearly all the symptoms, laryngeal images and voice parameters, 24-hour MII pH seems to be more promising in a greater symptom relief. The extent of relief that can take place in most of the measurements is considerably determined by their initial status.

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.

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.

Voice outcome measures: Correlations with patients' assessment of their condition and the effectiveness of voice therapy

This study investigated correlations between voice outcome measures. Participants' ratings from the Voice Handicap Index (VHI) and a self-rating scale of vocal impairment (SRS) were compared with perceptual assessment (using GRBAS) and acoustic analysis of sustained vowels and connected speech. The measures were taken from ten female participants, pre- and post-therapy. Correlations between pre-therapy measures were generally stronger than between post-therapy measures; and parameters significantly related to participants' assessment of their condition differed from those related to participants' perceptions of improvement. Within the framework of the importance of multidimensional outcome measures, it is recognized that interdimensional relationships need not necessarily exist. For certain parameters, this appeared to be the case.

Voice loudness and gender effects on jitter and shimmer in healthy adults

PURPOSE

The aim of this study was to investigate voice loudness and gender effects on jitter and shimmer in healthy young adults because previous descriptions have been inconsistent.

METHOD

Fifty-seven healthy adults (28 women, 29 men) aged 20-40 years were included in this cross-sectional single-cohort study. Three phonations of /a/ at soft, medium, and loud individual loudness were recorded and analyzed using PRAAT software (P. Boersma & D. Weeninkk, 2006). Voice loudness and gender effects on measured sound pressure level, fundamental frequency, jitter, and shimmer were assessed through the use of descriptive and inferential (analysis of variance) statistics.

RESULTS

Jitter and shimmer significantly increased with decreasing voice loudness, especially in phonations below 75 dB and 80 dB. In soft and medium phonation, men were generally louder and showed significantly less shimmer. However, men had higher jitter measures when phonating softly. Gender differences in jitter and shimmer at medium loudness may be mainly linked to different habitual voice loudness levels.

CONCLUSION

This pragmatic study shows significant voice loudness and gender effects on perturbation. In clinical assessment, requesting phonations above 80 dB at comparable loudness between genders would enhance measurement reliability. However, voice loudness and gender effects in other age groups, in disordered voices, or when a minimal loudness is requested should be further investigated.

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.

Symptoms of Extraesophageal Reflux in a Community-Dwelling Sample

OBJECTIVES

Extraesophageal reflux disease (EERD) is linked with serious and varied health concerns. The authors' goal was to determine the prevalence of EERD and the effect on health-related quality of life in adults within a large community-based sample.

STUDY DESIGN

Survey study conducted in a community setting.

METHODS

In the Madison, Wisconsin area, 1845 adult subjects were surveyed. Main outcome measures were frequently of GERD and laryngeal symptoms, the Medical Outcomes Trust Short Form 12 (SF-12), Voice Handicap Index (VHI), and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires.

RESULTS

More than 66% of subjects reported either GERD or laryngeal symptoms, and 26% reported both GERD and laryngeal symptoms (which reflect symptoms commonly reported for EERD). In addition, 39% of our sample took medicine for heartburn. Forty-four percent of subjects with both GERD and laryngeal symptoms reported occasional breathing difficulties, and 38% of these subjects reported a voice disorder. Significant reductions in perceived quality of general health, digestive health, and voice-related quality of life were found in subjects with both GERD and laryngeal symptoms, in comparison with subjects manifesting each symptom group alone, or in subjects with no symptoms.

CONCLUSIONS

The presence of GERD and laryngeal symptoms, and their concurrence, was identified in a substantial number of subjects. The GERD and laryngeal symptoms surveyed represent those most commonly reported for EERD. Because EERD has been linked with tissue damage and reductions in health-related quality of life, it is important to identify these persons and provide treatment before progression of the condition.

Acid reflux treatment for hoarseness

BACKGROUND

Acid reflux is a common problem, and is thought to occur in 4% to 10% of patients presenting to ENT clinics. A recent study of reflux and voice disorders suggests that up to 55% of patients with hoarseness (dysphonia) have laryngopharyngeal reflux. Anti-reflux therapy is often used empirically in treating patients with hoarseness, where no other cause has been identified by examination.

OBJECTIVES

The aim of the review was to assess the effectiveness of anti-reflux therapy for patients with hoarseness, in the absence of other identifiable causes, whether or not a definitive diagnosis of laryngopharyngeal and gastro-oesophageal reflux has been made. This was assessed by evaluation of prospective randomised controlled studies that were identified by a systematic review of the literature. Both medical and surgical treatments were evaluated.

SEARCH STRATEGY

The Cochrane ENT Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 3, 2005), MEDLINE (1966 to 2005), EMBASE (1974 to 2005) and conference proceedings were searched with prespecified terms. The date of the last search was September 2005.

SELECTION CRITERIA

Randomised controlled trials recruiting patients with hoarseness in the absence of other identifiable causes, such as malignancy, cord palsy or nodules, whether or not a definitive diagnosis of laryngopharyngeal and gastro-oesophageal reflux has been made.

DATA COLLECTION AND ANALYSIS

Three reviewers examined the search results and identified studies before deciding which would be included in the review.

MAIN RESULTS

302 potential studies were identified by the search strategy. No trials were identified which met our inclusion criteria. Six randomised controlled trials were identified in which some, but not all patients presented with hoarseness, and were treated with proton pump inhibition. As we could not determine with certainty whether all these patients had hoarseness among the other laryngeal symptoms, these were excluded. However, these studies suggest a significant placebo response, which is comparable to the benefit derived from anti-reflux therapy in some studies. As no trials met our criteria, we are unable to reach any firm conclusions regarding the effectiveness of anti-reflux treatment for hoarseness.

AUTHORS' CONCLUSIONS

There is a need for high quality randomised controlled trials to evaluate the effectiveness of anti-reflux therapy for patients with hoarseness which may be due to laryngopharyngeal and gastro-oesophageal reflux.

Perception of aperiodicity in pathological voice

Although jitter, shimmer, and noise acoustically characterize all voice signals, their perceptual importance in naturally produced pathological voices has not been established psychoacoustically. To determine the role of these attributes in the perception of vocal quality, listeners were asked to adjust levels of jitter, shimmer, and the noise-to-signal ratio in a speech synthesizer, so that synthetic voices matched naturally produced tokens. Results showed that, although listeners agreed well in their judgments of the noise-to-signal ratio, they did not agree with one another in their chosen settings for jitter and shimmer. Noise-dependent differences in listeners' ability to detect changes in amounts of jitter and shimmer implicate both listener insensitivity and inability to isolate jitter and shimmer as separate dimensions in the overall pattern of aperiodicity in a voice as causes of this poor agreement. These results suggest that jitter and shimmer are not useful as independent indices of perceived vocal quality, apart from their acoustic contributions to the overall pattern of spectrally shaped noise in a voice.

Perceptual and Acoustic Assessment of Voice Pathology and the Efficacy of Endolaryngeal Phonomicrosurgery

Values for acoustic voice measurements were obtained from 88 normal individuals and 98 pathological cases of mass lesions of vocal fold and 50 cases of unilateral vocal fold paralysis. Overall, all items reflecting perturbations of pitch and amplitude as well as glottal noise were significantly higher in the groups of patients compared with the normal group. The measurement of normalized noise energy (NNE) was found to be an optimum parameter for discrimination of normal/abnormal voices. The voices of patients with vocal fold nodules and vocal fold polyps were analyzed before endolaryngeal phonomicrosurgery (EPM) and 2 weeks after. Statistically significant (p < 0.01) improvement was achieved both in perceptual and acoustic analysis. EPM resulted in a significant decrease of mean jitter, shimmer, and NNE. Clinically, these measures provided documentable and measurable evidence of vocal function and were helpful for comparing patients with normal speakers. They also were useful for a thorough documentation of patient's voice pathology and for evaluation of the presurgical and postsurgical voice status.

Suitability of Acoustic Perturbation Measures in Analysing Periodic and Nearly Periodic Voice Signals

In recent years, acoustic perturbation measurement has gained clinical and research popularity due to the ease of availability of commercial acoustic analysing software packages in the market. However, because the measurement itself depends critically on the accuracy of frequency tracking from the voice signal, researchers argue that perturbation measures are not suitable for analysing dysphonic voice samples, which are aperiodic in nature. This study compares the fundamental frequency, relative amplitude perturbation, shimmer percent and noise-to-harmonic ratio between a group of dysphonic and non-dysphonic subjects. One hundred and twelve dysphonic subjects (93 females and 19 males) and 41 non-dysphonic subjects (35 females and 6 males) participated in the study. All the 153 voice samples were categorized into type I (periodic or nearly periodic), type II (signals with subharmonic frequencies that approach the fundamental frequency) and type III (aperiodic) signals. Only the type I (periodic and nearly periodic) voice signals were acoustically analysed for perturbation measures. Results revealed that the dysphonic female group presented significantly lower fundamental frequency, significantly higher relative amplitude perturbation and shimmer percent values than the non-dysphonic female group. However, none of these three perturbation measures were able to differentiate between male dysphonic and male non-dysphonic subjects. The noise-to-harmonic ratio failed to differentiate between the dysphonic and non-dysphonic voices for both gender groups. These results question the sensitivity of acoustic perturbation measures in detecting dysphonia and suggest that contemporary acoustic perturbation measures are not suitable for analysing dysphonic voice signals, which are even nearly periodic.

Multidimensional voice analysis of reflux laryngitis patients

The aim of the study was to analyze and quantify the voice characteristics of reflux laryngitis (RL) patients and to determine the most important voice tests and voice-quality parameters in the functional diagnostics of RL. The voices of 83 RL patients and 31 persons in the control group were evaluated. Vocal function was assessed using a multidimensional set of video laryngostroboscopic, perceptual, acoustic, aerodynamic and subjective measurements according to the protocol elaborated by the Committee on Phoniatrics of the European Laryngological Society. The mean values of the hoarseness visual analogue scale assessment and voice handicap index were significantly higher (P<0.05) in the group of RL patients as compared to the controls. Objective voice assessment revealed a significant increase in mean values of jitter, shimmer and normalized noise energy (NNE), along with a significant decrease in pitch range, maximum frequency, phonetogram area (S) and maximum phonation time (MPT) in RL patients, both in the male and female subgroups. According to the results of discriminant analysis, the NNE, MPT, S and intensity range were determined as an optimum set for functional diagnostics of RL. The derived function (equation) makes it possible to assign the person to the group of RL patients with an accuracy of 86.7%. The sensitivity and specificity of eight voice parameters were found to be higher than 50%. The results of the present study demonstrate a reduction of phonation capabilities and voice quality in RL patients. Multidimensional voice evaluation makes it possible to detect significant differences in mean values of perceptual, subjective and objective voice quality parameters between RL patients and controls groups. Therefore, multidimensional voice analysis is an important tool in the functional diagnostics of RL.

Objective assessment of hoarseness by measuring jitter

The objective measurement of hoarseness by measuring 'jitter' (the average percentage pitch-period variation between consecutive pitch-cycles) using an inverse filtering technique is described. Twenty-five patients with a variety of causes of hoarseness were studied, together with five individuals who had mild hoarseness induced by histamine challenge and 12 normal individuals. The mean severity of jitter in the patient group (9.8%) was significantly different from the normals. (1.04%) In addition, there was a significant correlation (R2 = 0.53; P < 0.0001) between jitter and subjective assessment of hoarseness. The mean values of jitter with histamine challenge before and after recovery (1.03%, and 1.18%) were significantly different (P < 0.0001) to the mean maximum value during the challenge (2.64%). These data suggest that jitter is an objective and repeatable measurement of hoarseness-even small changes in hoarseness in individual patients. It is likely to prove most effective for monitoring treatment response.

Role of esophageal pH recording in management of chronic laryngitis: an overview

Chronic laryngitis typically produces symptoms of frequent throat-clearing, soreness, decreased voice quality with use, nonproductive cough, globus sensation, and odynophagia. The endoscopic laryngeal examination usually demonstrates posterior glottic edema, erythema, and increased vascularity and nodularity. There is increasing support for the hypothesis that reflux of acidic gastric contents is often responsible for the symptoms and findings of chronic laryngitis. Prospective trials of acid suppression therapy demonstrate not only efficacy in symptom reduction, but also objective improvement in measurements of voice quality and mucosal erythema. Although traditionally considered the "gold standard" for diagnosis of reflux causing laryngitis, routine esophageal pH recording may result in false negatives in up to 50% of patients. This may confound the diagnosis of chronic laryngitis and delay treatment. Conversely, a positive study during comprehensive therapy may help identify patients who need additional treatment. A single distal probe is probably insufficient for evaluation of a supraesophageal disorder. Current recommendations for double-probe pH study in the evaluation of chronic laryngitis fall into 2 categories: 1) a double-probe pH study is indicated if there is ongoing moderate-to-severe laryngitis despite antireflux precautions and proton pump inhibitor treatment for at least 6 to 12 weeks; and 2) a double-probe pH study is indicated as a baseline measurement before Nissen or Toupet fundoplication. The pH study would also be indicated in patients who have symptoms after fundoplication. There is clearly much more work to be done on the technical issues of obtaining accurate objective data related to laryngeal acidification. In addition, although acid reflux appears to be causative in many cases of chronic laryngitis, further work is indicated to identify reliable testing methods that will predict treatment success.

Diagnosis and management of chronic laryngitis associated with reflux

Chronic laryngitis symptoms are commonly seen in otherwise healthy people. This article reviews recent progress in our understanding and effective treatment of chronic laryngitis. Clinical experience and prospective treatment and outcome studies have demonstrated objective evidence of the efficacy of treating patients with chronic laryngitis symptoms with nocturnal antireflux precautions and acid-suppressing medications. The role of pH testing and most common errors in treatment are reviewed.