Vocal Changes of Men and Women from Different Age Decades: An Analysis from 30 Years of Age

OBJECTIVE

To verify the modifications in auditory-perceptual and acoustic parameters of the fundamental frequency, short-term perturbation, noise, and cepstral measures of voice in young and elderly were distributed over the age of decades.

METHODS

The study was conducted on 265 subjects (140 females and 125 males), aged 30 to 79 years, without a history of vocal complaints or dysphonia, distributed in five age groups for females and males (30-39 years until 70-79 years). Three speech therapists voice specialists performed the perceptual-auditory analysis using a 100-mm visual analog scale, based on the overall dysphonia grade (overall grade), roughness, and breathiness from the sustained vowel /a/. The smoothed cepstral peak prominence (CPPS), average fundamental frequency (F0), standard deviation of the fundamental frequency (std-F0), jitter percentage (%), shimmer percentage (%), noise-to-harmonic ratio (NHR), voice turbulence index (VTI), and soft phonation index (SPI) were extracted for the acoustic analysis RESULTS: In the case of the auditory-perceptual characteristics, the comparison between aged groups showed that, in men, the vocal quality did not show significant differences in the overall grade, roughness, and breathiness. However, women in the 3rd decade of life presented higher breathiness than those in the 5th, 6th, and 7th decades. Men had a higher overall grade and roughness than women. In the case of the acoustic data, the cepstral measure showed that in the 3rd decade, men presented higher CPPS than females. The noise measures, in the comparison by age groups, only VTI and SPI were different for women: VTI was higher in the 7th decade than in the 4th, whereas SPI was higher in the 4th decade than in older women. In the male population, the SPI in the 4th decade was also higher than that in the older population CONCLUSION: The analysis by age groups of life allowed the identification of breathiness as a sensitive parameter in the different stages of adult life in women. The CPPS analysis showed that the 7th age decade is the period of the appearance of vocal changes for females, characterized by higher CPPS. The results related to traditional short-term perturbation and noise measurements showed that changes in F0, jitter, shimmer, and NHR were not found. Among the other noise measurements, VTI and SPI demonstrated some changes in different decades of life.

Are Occupational Voice Disorders Accurately Measured? A Systematic Review of Prevalence and Methodologies in Schoolteachers to Report Voice Disorders

PURPOSE

Different measuring instruments have been described to determine the prevalence of voice disorders in schoolteachers. However, the heterogeneity of prevalence figures has made it difficult in determining the impact of voice disorders in this group. This investigation aims to review and identify scientific evidence of methodological analysis of voice disorders in teachers, the relevance of measuring instruments, the prevalence of dysphonia, and the impact on the development of vocal health prevention programs.

METHODS

A systematic review was conducted by searching six important scientific databases. Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were carried out. Articles were included whether they presented data related to the prevalence of dysphonia and the impact of therapy programs on teachers.

RESULTS

Twenty articles out of 8,998 were selected. The cross-sectional design type was predominant throughout the investigations. Differences were observed in the number of participants across studies, leading to heterogeneous prevalence figures - which ranged from 10.5% to 69.1%. The assessment instruments are not standardly used to effectively determine the disease burden. Despite the fact of the extensive evidence of the effectiveness of programs that address dysphonia in teachers, the scarcity of literature is yet evident on systematic programs promoted by either the government or educational institutions.

CONCLUSION

Findings suggest that future investigations should consider the consensus of a global definition for occupational dysphonia in teachers in order to develop accurately measuring instruments and to assist with voice care programs and treatment approaches in this population. This might be crucial since it could also assist with the implementation of Delphi-type studies that could support the development of further evidence-based agreements around these programs (voice care and treatment approaches) in schoolteachers.

Injection laryngoplasty of human adipose-derived stem cell spheroids with hyaluronic acid-based hydrogel improves the morphological and functional characteristics of geriatric larynx

Aim

As the geriatric population increased, the need of treatment for laryngeal atrophy and dysfunction increased. This study was performed to evaluate the effects of injection of human adipose-derived stem cell (hASC) spheroid-loaded catechol-conjugated hyaluronic acid (HA-CA) hydrogel on therapeutic rejuvenation of the geriatric larynx.

Methods

Stem cell spheroids with hyaluronic acid-based hydrogel were injected into the laryngeal muscles of 18-month-old Sprague–Dawley rats. The effects of hASC spheroids were examined in the following four groups: SHAM, injected with PBS; GEL, injected with HA-CA hydrogel; MONO, injected with single hASCs in HA-CA hydrogel; and SP, injected with hASCs spheroids in HA-CA hydrogel. The rejuvenation efficacy in geriatric laryngeal muscle tissues at 12 weeks postinjection was evaluated and compared by histology, immunofluorescence staining, and functionality analysis.

Results

Total myofiber cross-sectional area and myofiber number/density, evaluated by detection of myosin heavy chain with antibodies against laminin and fast myosin heavy chain, were significantly higher in the SP group than in the other groups. The lamina propria of the larynx was evaluated by alcian blue staining, which showed that the HA was increased significantly in the SP group compared to the other groups. In functional analysis, the glottal gap area was significantly reduced in the SP group compared to the other groups. The phase difference in the vocal fold during vibration was also smaller in the SP group than in the other groups, but the difference did not reach statistical significance.

Conclusion

Injection of hASC spheroids with hyaluronic acid-based hydrogel improves the morphological and functional characteristics of geriatric larynx.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40824-022-00261-x.

Comparison of 24-month voice outcomes after injection laryngoplasty with calcium hydroxylapatite or hyaluronic acid in patients with unilateral vocal fold paralysis

PURPOSE

The objective was to evaluate the long-term voice outcomes in pa-tients with unilateral vocal fold paralysis treated with injection laryngoplasty using either cal-cium hydroxylapatite (CaHA) or hyaluronic acid (HA).

METHODS

A single-centre retrospective study was performed. There were 75 patients with dysphonia due to unilateral vocal fold paralysis: injected with CaHA or injected with HA. We analysed Voice Handicap Index-30 (VHI), videostroboscopic images, auditory-perceptual (GRBAS), and acoustic measures (MDVP) in 6, 12, and 24 months after augmentation.

RESULTS

The mean change in VHI 24 months after augmentation was 29.14 in the CaHA group, and 22.88 in the HA group. There was an improvement of glottal gap 6, 12, and 24 months after augmentation in both groups. The GRBAS parameters were similar in both groups throughout the whole period. The MDVP pa-rameters decreased 6 and 12 months after augmentation and were similar in both groups. There were 4 patients augmented with CaHA (12.5%) who needed reintervention within 2 years of surgery and another 4 (9.3%) augmented with HA.

CONCLUSION

This study demonstrates that there are no long-term differences in voice outcomes or number of reaugmentations for injection laryn-goplasty with CaHA compared to HA.

Employing Extracellular Matrix-Based Tissue Engineering Strategies for Age-Dependent Tissue Degenerations

Tissues and organs are not composed of solely cellular components; instead, they converge with an extracellular matrix (ECM). The composition and function of the ECM differ depending on tissue types. The ECM provides a microenvironment that is essential for cellular functionality and regulation. However, during aging, the ECM undergoes significant changes along with the cellular components. The ECM constituents are over- or down-expressed, degraded, and deformed in senescence cells. ECM aging contributes to tissue dysfunction and failure of stem cell maintenance. Aging is the primary risk factor for prevalent diseases, and ECM aging is directly or indirectly correlated to it. Hence, rejuvenation strategies are necessitated to treat various age-associated symptoms. Recent rejuvenation strategies focus on the ECM as the basic biomaterial for regenerative therapies, such as tissue engineering. Modified and decellularized ECMs can be used to substitute aged ECMs and cell niches for culturing engineered tissues. Various tissue engineering approaches, including three-dimensional bioprinting, enable cell delivery and the fabrication of transplantable engineered tissues by employing ECM-based biomaterials.

Can preoperative results predict the need for future reintervention following injection laryngoplasty for unilateral vocal fold paralysis?

Purpose

The objective was to investigate whether a patient’s preoperative test results can predict the need for future reoperation in unilateral vocal fold paralysis (UVFP).

Methods

A single-centre retrospective study was performed. The study group consisted of 18 patients with UVFP who had been treated with injection laryngoplasty but who required further treatment and were augmentated again within 36 months. The control group consisted of 33 injected patients who had not required reintervention up to 36 months later.

Results

Only glottal gap was associated with a relative risk for reinjection. Glottal gap was found to be severe in 77.8% of the patients from the study group compared to 42.4% of the controls, and the difference was statistically significant. The kind of injected material (calcium hydroxylapatite or hyaluronic acid), age, and voice assessment (perceptual, objective, or subjective) did not seem to affect the likelihood of reoperation being needed. There were no between-group statistically significant differences in individual aspects of the GRBAS scale. The global score was slightly higher in the study group, but it did not reach statistical significance (U = 198.5; p = 0.09). A comparison of VHI scores did not yield statistically significant differences between the study and control groups. No significant differences in objective acoustic voice parameters were observed between the groups.

Conclusion

Only glottal gap occurred to be associated with a relative risk for reinjection. A kind of injected material (CaHA or HA), age, perceptual, objective and subjective voice assessment do not seem to impact the likelihood of reoperation in patients with UVFP.

The German Restructured Vocal Fatigue Index and Characteristics of Dysphonic and Vocally Healthy Populations

OBJECTIVE

The Vocal Fatigue Index (VFI), a 19-item psychometric self-report questionnaire, enables individuals with vocal fatigue (VF) to be identified and their complaints to be characterized. The purpose of this study was to improve the German-language version (VFI-G) and to evaluate further vocal fatigue-related characteristics of dysphonic and control populations.

METHODS

The VFI-G was restructured by replacing the three factors that structured the original: (1) tiredness of voice and voice avoidance; (2) physical discomfort; and (3) improvement of symptoms with rest, with two clusters developed on the basis of the results of a factor analysis by Nanjundeswaran et al. (2019). The two new clusters are: (1) tiredness and avoidance plus physical discomfort; and (2) symptom improvement through rest. One hundred one (101) individuals with voice disorders and 100 vocally healthy controls from a previous study that cross-validated the VFI-G participated in this study. In order to assess the validity of our newly adjusted VFI-G, independent samples t test, receiver operating characteristic curve, likelihood ratios and the Youden Index were calculated. The association of the two VF clusters with subject characteristics such as age, sex, type of voice disorder, and level of vocal usage was also analyzed using either a Pearson correlation or a one-way ANOVA for each of the two populations.

RESULTS

Significantly higher scores were obtained in voice-disordered subjects in both clusters (all P values < 0.001) than in healthy-voice subjects. The threshold for cluster 1 of the VFI-G was determined as ≥17.5 (74.3% sensitivity and 88.0% specificity). The results of cluster 2 are identical to that of factor 3 of the previous cross-validation study of the VFI-G. Most subject characteristics show no significant association with cluster 1 of the VFI-G, but cluster 2 seems to be moderately associated with age, type of voice disorder and level of vocal usage in the dysphonic population.

CONCLUSIONS

The restructured VFI-G showed improved validity and can be recommended for use in the assessment of VF. Cluster 2 is also moderately associated with several vocal fatigue-related subject characteristics of the dysphonic population.

Correlation of Glottic Gap and Voice Impairment in Presbyphonia

OBJECTIVE/HYPOTHESIS

The objective of this study was to investigate the glottic gap area as a significant marker for the severity of presbyphonia as it relates to patient-reported outcome measures (Voice Handicap Index-10 [VHI-10]) and stroboscopic findings.

STUDY DESIGN

Retrospective case-control study conducted in an academic tertiary voice center.

METHODS

Patients seen at a tertiary voice clinic who were diagnosed with presbyphonia without other organic laryngeal pathology from January 2014 to December 2017 were included. Clinical data and laryngeal videostroboscopy videos were collected. Still images at the point of vocal process approximation during adduction were captured, and the glottic gap area was measured using ImageJ. These were compared to a control cohort. Correlations were made using Wilcoxon rank sum test, Mann-Whitney U test, and Pearson correlation coefficients.

RESULTS

Thirty-three patients were included. Inter-rater reliability of glottic area measurement was strong (intraclass correlation coefficient = 0.73, P < .001). Compared to controls, presbyphonia patients had a larger glottic gap area (P < .001) and greater open-phase quotient on laryngeal videostroboscopy (P < .001). Larger glottic gap area did not correlate with patient-reported vocal function as measured by VHI-10 (P = .79) and did not correlate with presence of secondary muscle tension dysphonia (P = .99). In the presbyphonia cohort, the glottic gap area did not correlate with age (P = .29).

CONCLUSIONS

Glottic gap area at the point of vocal process approximation during phonation can be reliably measured. Patients with presbyphonia have a larger glottic gap area and greater open-phase quotient on stroboscopy, but these do not correlate with patient-reported voice impairment or the presence of secondary muscle tension dysphonia (MTD). These data suggest that dysphonia severity in presbyphonia is not fully explained by a glottic gap or secondary MTD alone.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1594-1598, 2021.

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.

Effects of Injection Laryngoplasty with Hyaluronic Acid in Patients with Vocal Fold Paralysis

Objectives

The purpose of this study was to explore the effects of injection laryngoplasty (IL) with hyaluronic acid in patients with vocal fold paralysis (VFP).

Methods

A total of 50 patients with VFP participated in this study. Pre- and post-IL assessments were performed, which included analyzing the sustained vowel /a/ phonation, and the patient reading 1 Korean sentence from the "Walk" passage that comprised 25 syllables in 10 words. To investigate the effect of IL on vocal fold function, acoustic analysis (acoustic voice quality index, cepstral peak prominence, maximum phonation time, speaking fundamental frequency) was conducted and auditory-perceptual (grade and overall severity), visual judgment (gap), and self-questionnaire (voice handicap index-10) assessments were performed.

Results

The patients with VFP showed statistically significant differences between pre-and post-IL assessments for acoustic and auditory-perception, visual judgment, and self-questionnaire assessments.

Conclusion

The patients with VFP showed positive change in vocal fold function between pre- and post-IL measurements. The findings showed that IL with hyaluronic acid is an effective method to improve vocal fold function in patients with VFP.

Characterization of aged rat vocal fold fibroblasts

OBJECTIVES/HYPOTHESIS

To elucidate the aging physiology of the vocal folds, we examined the characters of aged vocal fold fibroblasts (VFFs) in various conditions.

STUDY DESIGN

In vitro study.

METHODS

VFFs from young (12-week-old) and aged (19-month-old) Sprague-Dawley rats were compared. Proliferative capacity, ratio of myofibroblast to fibroblast, myofibroblast function, and extracellular matrix production were examined in the following conditions: naïve, basic fibroblast growth factor (bFGF) supplemented, and hepatocyte growth factor (HGF) supplemented.

RESULTS

Aged VFFs demonstrated reduced proliferation by cell counting, though the ratio of Ki-67-positive cells showed no difference. Aged VFFs exhibited an increased expression of α-smooth muscle actin (α-SMA); however, they demonstrated no enhanced contractile ability in a gel contraction assay. Type I collagen protein was increased age dependently, accompanied with decreased Mmp1 and unchanged Col1a1 transcription. Type I collagen protein and α-SMA represented quite similar reduction patterns to bFGF or HGF administration.

CONCLUSIONS

The following possible characteristics of aged VFFs were implied: long duration of mitosis, increased myofibroblast population size with certain dysfunctions, reduced type I collagen turnover, and correlation between α-SMA expression and type I collagen metabolism. Further investigations of these features will help to clarify presbyphonia's pathology and establish treatment strategies.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E94-E101, 2019.

Volumetric analysis of vocal fold atrophy via magnetic resonance imaging

Objective

To quantitatively test the hypothesis that older patients have increased thyroarytenoid muscle atrophy by comparing thyroarytenoid muscle volumes across different age groups.

Methods

A retrospective chart review was conducted. The study included 111 patients with no history of laryngeal pathology. Two investigators reviewed magnetic resonance imaging studies of these patients and manually traced the thyroarytenoid muscles on multiple slices bilaterally. Thyroarytenoid muscle volumes were then computed using imaging analysis software. Patients were stratified into three age groups (18–50 years, 51–64 years, and 65 years or older) for comparison.

Results

Intra- and inter-rater reliabilities were excellent for all measurements (intraclass correlation co-efficient > 0.90). There was no statistically significant difference in the mean volumes of left and right thyroarytenoid muscles in all age and gender groups.

Conclusion

Given the lack of statistically significant difference in thyroarytenoid muscle volume between age groups on magnetic resonance imaging, the prevailing assumption that age-related thyroarytenoid muscle atrophy contributes to presbyphonia should be re-examined.

Pathological sulcus vocalis: treatment approaches and voice outcomes in 36 patients

PURPOSE

This is a retrospective study to evaluate the results of surgical treatment of patients with pathological sulcus vocalis.

METHODS

Thirty-six patients with pathological sulcus underwent surgery and in 33 cases were performed additional injection laryngoplasty. The pre- and postoperative evaluation of patients included the GRBAS scale, stroboscopic, and objective acoustic voice assessment. The Voice Handicap Index questionnaire (VHI-30) was also used and the scores were obtained from 33 patients.

RESULTS

The stroboscopic evaluation showed significant improvement of amplitude, mucosal wave, and glottal closure after treatment (p < 0.001). The VHI-30 scores decreased considerably indicating improvement due to the treatment for all aspects measured by VHI (p < 0.05, or p < 0.01). In all domains of GRBAS scale, the differences between preoperative and postoperative assessment were statistically significant (p < 0.001). We observed a significant change in Shim and APQ parameters (p < 0.05). Improvement was also observed in the sAPQ parameter, but it was not statistically significant (p = 0.051). For the remaining acoustic parameters, no changes were observed.

CONCLUSIONS

The surgical procedure with supplementary injection laryngoplasty of the vocal folds is a good treatment option for pathological sulcus vocalis. The post-treatment self-assessment indicates the significant improvement in VHI, just as perceptual-acoustic evaluation of voice does. Patients with pathological sulcus frequently present with amplitude disturbances, what explains their significant improvement after treatment.