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Sherman T, Schlegel P, Santuray R, Zhang Z, Long JL. Vocal Fold Injury Produces Similar Biomechanical Outcomes in Male and Female Rabbits. J Voice 2024:S0892-1997(24)00261-3. [PMID: 39227273 DOI: 10.1016/j.jvoice.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/12/2024] [Accepted: 08/14/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVE Sex differences in response to trauma and physiologic stressors have been identified in numerous organ systems but have not yet been defined in the larynx. The objective of this study was to develop an endoscopic vocal fold injury model in rabbits and to compare structural and functional outcomes between male and female subjects. STUDY DESIGN Basic science study. METHODS Two male and two female rabbits underwent unilateral endoscopic cordectomy. Animals were intubated with a size 3-0 neonatal endotracheal tube, and laryngoscopy was performed with a 4 mm Hopkins rod telescope. While visualizing, a 2 mm cupped forceps grasped and resected the mid-membranous portion of the right true vocal fold. Larynges were then harvested after 8weeks. Excised larynx phonation with high-speed videography and kymography was used to assess vibrational quality. Tissue elastic (Young's) modulus was measured by indentation. RESULTS Injured larynges phonated with fundamental frequencies between 237-415 Hz. In both males and females, the scarred vocal fold exhibited an increased Young's modulus compared to the contralateral nonoperated vocal fold. There were no notable differences in glottal closure pattern or vocal fold oscillation symmetry between sexes. CONCLUSION We have demonstrated a model for vocal fold scarring in rabbits. Vibrational and structural outcomes were similar between the examined male and female larynges.
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Affiliation(s)
- Trent Sherman
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Patrick Schlegel
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Rodell Santuray
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Zhaoyan Zhang
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Jennifer L Long
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California.
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Bouhabel S, Park S, Kolosova K, Latifi N, Kost K, Li-Jessen NYK, Mongeau L. Functional Analysis of Injectable Substance Treatment on Surgically Injured Rabbit Vocal Folds. J Voice 2023; 37:829-839. [PMID: 34353684 PMCID: PMC8807745 DOI: 10.1016/j.jvoice.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the efficacy of immediate injection treatments of dexamethasone, hyaluronic acid (HA)/gelatin (Ge) hydrogel and glycol-chitosan solution on the phonatory function of rabbit larynges at 42 days after surgical injury of the vocal folds, piloting a novel ex vivo phonatory functional analysis protocol. METHODS A modified microflap procedure was performed on the left vocal fold of 12 rabbits to induce an acute injury. Animals were randomized into one of four treatment groups with 0.1 mL injections of dexamethasone, HA/Ge hydrogel, glycol-chitosan or saline as control. The left mid vocal fold lamina propria was injected immediately following injury. The right vocal fold served as an uninjured control. Larynges were harvested at Day 42 after injection, then were subjected to airflow-bench evaluation. Acoustic, aerodynamic and laryngeal high-speed videoendoscopy (HSV) analyses were performed. HSV segments of the vibrating vocal folds were rated by three expert laryngologists. Six parameters related to vocal fold vibratory characteristics were evaluated on a Likert scale. RESULTS The fundamental frequency, one possible surrogate of vocal fold stiffness and scarring, was lower in the dexamethasone and HA/Ge hydrogel treatment groups compared to that of the saline control (411.52±11.63 Hz). The lowest fundamental frequency value was observed in the dexamethasone group (348.79±14.99 Hz). Expert visual ratings of the HSV segments indicated an overall positive outcome in the dexamethasone treatment group, though the impacts were below statistical significance. CONCLUSION Dexamethasone injections might be used as an adjunctive option for iatrogenic vocal fold scarring. An increased sample size, histological correlate, and experimental method improvements will be needed to confirm this finding. Results suggested a promising use of HSV and acoustic analysis techniques to identify and monitor post-surgical vocal fold repair and scarring, providing a useful tool for future studies of vocal fold scar treatments.
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Affiliation(s)
- Sarah Bouhabel
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada.
| | - Scott Park
- Department of Mechanical Engineering, McGill University, Montreal, Quebec, Canada
| | - Ksenia Kolosova
- Department of Physics, McGill University, Montreal, Quebec, Canada
| | - Neda Latifi
- Department of Mechanical Engineering, McGill University, Montreal, Quebec, Canada
| | - Karen Kost
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Nicole Y K Li-Jessen
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada; School of Communication Sciences and Disorders, McGill University, Montreal, Quebec, Canada
| | - Luc Mongeau
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada; Department of Mechanical Engineering, McGill University, Montreal, Quebec, Canada
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Jakubaß B, Peters G, Kniesburges S, Semmler M, Kirsch A, Gerstenberger C, Gugatschka M, Döllinger M. Effect of functional electric stimulation on phonation in an ex vivo aged ovine model. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2023; 153:2803. [PMID: 37154554 DOI: 10.1121/10.0017923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/07/2023] [Indexed: 05/10/2023]
Abstract
With age, the atrophy of the thyroarytenoid muscle (TAM), and thus atrophy of the vocal folds, leads to decreased glottal closure, increased breathiness, and a loss in voice quality, which results in a reduced quality of life. A method to counteract the atrophy of the TAM is to induce hypertrophy in the muscle by functional electric stimulation (FES). In this study, phonation experiments were performed with ex vivo larynges of six stimulated and six unstimulated ten-year-old sheep to investigate the impact of FES on phonation. Electrodes were implanted bilaterally near the cricothyroid joint. FES treatment was provided for nine weeks before harvesting. The multimodal measurement setup simultaneously recorded high-speed video of the vocal fold oscillation, the supraglottal acoustic signal, and the subglottal pressure signal. Results of 683 measurements show a 65.6% lower glottal gap index, a 22.7% higher tissue flexibility (measured by the amplitude to length ratio), and a 473.7% higher coefficient of determination (R2) of the regression of subglottal and supraglottal cepstral peak prominence during phonation for the stimulated group. These results suggest that FES improves the phonatory process for aged larynges or presbyphonia.
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Affiliation(s)
- Bernhard Jakubaß
- Division of Phoniatrics and Pediatric Audiology at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldstrasse 1, 91054 Erlangen, Germany
| | - Gregor Peters
- Division of Phoniatrics and Pediatric Audiology at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldstrasse 1, 91054 Erlangen, Germany
| | - Stefan Kniesburges
- Division of Phoniatrics and Pediatric Audiology at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldstrasse 1, 91054 Erlangen, Germany
| | - Marion Semmler
- Division of Phoniatrics and Pediatric Audiology at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldstrasse 1, 91054 Erlangen, Germany
| | - Andrijana Kirsch
- Division of Phoniatrics, ENT University Hospital Graz, Medical University of Graz, Auenbruggerplatz 26, Graz 8036, Austria
| | - Claus Gerstenberger
- Division of Phoniatrics, ENT University Hospital Graz, Medical University of Graz, Auenbruggerplatz 26, Graz 8036, Austria
| | - Markus Gugatschka
- Division of Phoniatrics, ENT University Hospital Graz, Medical University of Graz, Auenbruggerplatz 26, Graz 8036, Austria
| | - Michael Döllinger
- Division of Phoniatrics and Pediatric Audiology at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldstrasse 1, 91054 Erlangen, Germany
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Döllinger M, Schraut T, Henrich LA, Chhetri D, Echternach M, Johnson AM, Kunduk M, Maryn Y, Patel RR, Samlan R, Semmler M, Schützenberger A. Re-Training of Convolutional Neural Networks for Glottis Segmentation in Endoscopic High-Speed Videos. APPLIED SCIENCES (BASEL, SWITZERLAND) 2022; 12:9791. [PMID: 37583544 PMCID: PMC10427138 DOI: 10.3390/app12199791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
Endoscopic high-speed video (HSV) systems for visualization and assessment of vocal fold dynamics in the larynx are diverse and technically advancing. To consider resulting "concepts shifts" for neural network (NN)-based image processing, re-training of already trained and used NNs is necessary to allow for sufficiently accurate image processing for new recording modalities. We propose and discuss several re-training approaches for convolutional neural networks (CNN) being used for HSV image segmentation. Our baseline CNN was trained on the BAGLS data set (58,750 images). The new BAGLS-RT data set consists of additional 21,050 images from previously unused HSV systems, light sources, and different spatial resolutions. Results showed that increasing data diversity by means of preprocessing already improves the segmentation accuracy (mIoU + 6.35%). Subsequent re-training further increases segmentation performance (mIoU + 2.81%). For re-training, finetuning with dynamic knowledge distillation showed the most promising results. Data variety for training and additional re-training is a helpful tool to boost HSV image segmentation quality. However, when performing re-training, the phenomenon of catastrophic forgetting should be kept in mind, i.e., adaption to new data while forgetting already learned knowledge.
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Affiliation(s)
- Michael Döllinger
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhino-laryngology Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Tobias Schraut
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhino-laryngology Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Lea A. Henrich
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhino-laryngology Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Dinesh Chhetri
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Matthias Echternach
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology, Munich University Hospital (LMU), 80331 Munich, Germany
| | - Aaron M. Johnson
- NYU Voice Center, Department of Otolaryngology–Head and Neck Surgery, New York University, Grossman School of Medicine, New York, NY 10001, USA
| | - Melda Kunduk
- Department of Communication Sciences and Disorders, Louisiana State University, Baton Rouge, LA 70801, USA
| | - Youri Maryn
- Department of Speech, Language and Hearing Sciences, University of Ghent, 9000 Ghent, Belgium
| | - Rita R. Patel
- Department of Speech, Language and Hearing Sciences, Indiana University, Bloomington, IA 47401, USA
| | - Robin Samlan
- Department of Speech, Language, & Hearing Sciences, University of Arizona, Tucson, AZ 85641, USA
| | - Marion Semmler
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhino-laryngology Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Anne Schützenberger
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhino-laryngology Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
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Falk S, Kniesburges S, Schoder S, Jakubaß B, Maurerlehner P, Echternach M, Kaltenbacher M, Döllinger M. 3D-FV-FE Aeroacoustic Larynx Model for Investigation of Functional Based Voice Disorders. Front Physiol 2021; 12:616985. [PMID: 33762964 PMCID: PMC7982522 DOI: 10.3389/fphys.2021.616985] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/09/2021] [Indexed: 12/02/2022] Open
Abstract
For the clinical analysis of underlying mechanisms of voice disorders, we developed a numerical aeroacoustic larynx model, called simVoice, that mimics commonly observed functional laryngeal disorders as glottal insufficiency and vibrational left-right asymmetries. The model is a combination of the Finite Volume (FV) CFD solver Star-CCM+ and the Finite Element (FE) aeroacoustic solver CFS++. simVoice models turbulence using Large Eddy Simulations (LES) and the acoustic wave propagation with the perturbed convective wave equation (PCWE). Its geometry corresponds to a simplified larynx and a vocal tract model representing the vowel /a/. The oscillations of the vocal folds are externally driven. In total, 10 configurations with different degrees of functional-based disorders were simulated and analyzed. The energy transfer between the glottal airflow and the vocal folds decreases with an increasing glottal insufficiency and potentially reflects the higher effort during speech for patients being concerned. This loss of energy transfer may also have an essential influence on the quality of the sound signal as expressed by decreasing sound pressure level (SPL), Cepstral Peak Prominence (CPP), and Vocal Efficiency (VE). Asymmetry in the vocal fold oscillations also reduces the quality of the sound signal. However, simVoice confirmed previous clinical and experimental observations that a high level of glottal insufficiency worsens the acoustic signal quality more than oscillatory left-right asymmetry. Both symptoms in combination will further reduce the quality of the sound signal. In summary, simVoice allows for detailed analysis of the origins of disordered voice production and hence fosters the further understanding of laryngeal physiology, including occurring dependencies. A current walltime of 10 h/cycle is, with a prospective increase in computing power, auspicious for a future clinical use of simVoice.
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Affiliation(s)
- Sebastian Falk
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology, Head & Neck Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Kniesburges
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology, Head & Neck Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schoder
- Institute of Fundamentals and Theory in Electrical Engineering, Division Vibro- and Aeroacoustics, Graz University of Technology, Graz, Austria
| | - Bernhard Jakubaß
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology, Head & Neck Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Paul Maurerlehner
- Institute of Fundamentals and Theory in Electrical Engineering, Division Vibro- and Aeroacoustics, Graz University of Technology, Graz, Austria
| | - Matthias Echternach
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology, Munich University Hospital (LMU), Munich, Germany
| | - Manfred Kaltenbacher
- Institute of Fundamentals and Theory in Electrical Engineering, Division Vibro- and Aeroacoustics, Graz University of Technology, Graz, Austria
| | - Michael Döllinger
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology, Head & Neck Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
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Semmler M, Berry DA, Schützenberger A, Döllinger M. Fluid-structure-acoustic interactions in an ex vivo porcine phonation model. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2021; 149:1657. [PMID: 33765793 PMCID: PMC7952141 DOI: 10.1121/10.0003602] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/29/2021] [Accepted: 02/07/2021] [Indexed: 05/02/2023]
Abstract
In the clinic, many diagnostic and therapeutic procedures focus on the oscillation patterns of the vocal folds (VF). Dynamic characteristics of the VFs, such as symmetry, periodicity, and full glottal closure, are considered essential features for healthy phonation. However, the relevance of these individual factors in the complex interaction between the airflow, laryngeal structures, and the resulting acoustics has not yet been quantified. Sustained phonation was induced in nine excised porcine larynges without vocal tract (supraglottal structures had been removed above the ventricular folds). The multimodal setup was designed to simultaneously control and monitor key aspects of phonation in the three essential parts of the larynx. More specifically, measurements will comprise (1) the subglottal pressure signal, (2) high-speed recordings in the glottal plane, and (3) the acoustic signal in the supraglottal region. The automated setup regulates glottal airflow, asymmetric arytenoid adduction, and the pre-phonatory glottal gap. Statistical analysis revealed a beneficial influence of VF periodicity and glottal closure on the signal quality of the subglottal pressure and the supraglottal acoustics, whereas VF symmetry only had a negligible influence. Strong correlations were found between the subglottal and supraglottal signal quality, with significant improvement of the acoustic quality for high levels of periodicity and glottal closure.
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Affiliation(s)
- Marion Semmler
- Division of Phoniatrics and Pediatric Audiology at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, Medical School at Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldstrasse 1, 91054 Erlangen, Germany
| | - David A Berry
- Laryngeal Dynamics Laboratory, Department of Head and Neck Surgery, David Geffen School of Medicine, UCLA, Los Angeles, California 90024, USA
| | - Anne Schützenberger
- Division of Phoniatrics and Pediatric Audiology at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, Medical School at Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldstrasse 1, 91054 Erlangen, Germany
| | - Michael Döllinger
- Division of Phoniatrics and Pediatric Audiology at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, Medical School at Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldstrasse 1, 91054 Erlangen, Germany
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Maryn Y, Verguts M, Demarsin H, van Dinther J, Gomez P, Schlegel P, Döllinger M. Intersegmenter Variability in High-Speed Laryngoscopy-Based Glottal Area Waveform Measures. Laryngoscope 2019; 130:E654-E661. [PMID: 31840827 DOI: 10.1002/lary.28475] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/26/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES/HYPOTHESIS High-speed videoendoscopy (HSV) has potential to objectively quantify vibratory vocal fold characteristics during phonation. Glottal Analysis Tools (GAT) version 2018, developed in Erlangen, Germany, is software for determining various glottal area waveform (GAW) quantities. Before having GAT analyze HSV videos, segmenters have to define glottis manually across videos in a semiautomatic segmentation protocol. Such interventions are hypothesized to induce variability of subsequent GAW measure computation across segmenters and may attenuate GAT measures' reliability to a certain point. This study explored intersegmenter variability in GAT's GAW measures based on semiautomatic image processing. STUDY DESIGN Cohort study of rater reliability. METHODS In total, 20 HSV videos from normophonic and dysphonic subjects with various laryngeal disorders were selected for this study and segmented by three trained segmenters. They separately segmented glottis areas in the same frame sets of the videos. Upon analysis of GAW, GAT offers 46 measures related to topologic GAW dynamic characteristics, GAW periodicity and perturbation characteristics, and GAW harmonic components. To address GAT's reliability, intersegmenter-based variability in these measures was examined with intraclass correlation coefficient (ICC). RESULTS In general, ICC behavior of the 46 GAW measures across three raters was highly acceptable. ICC of one parameter was moderate (0.5 < ICC < 0.75), good for seven parameters (0.75 < ICC < 0.9), and excellent for 38 parameters (0.9 < ICC). CONCLUSIONS Overall, high ICC values confirm clinical applicability of GAT for objective and quantitative assessment of HSV. Small intersegmenter differences with actual small parameter differences suggest that manual or semiautomatic segmentation in GAT does not noticeably influence clinical assessment outcome. To guarantee the software's performance, we suggest segmentation training before clinical application. LEVEL OF EVIDENCE 2b Laryngoscope, 130:E654-E661, 2020.
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Affiliation(s)
- Youri Maryn
- Department of Otorhinolaryngology-Head and Neck Surgery, European Institute for Otorhinolaryngology-Head and Neck Surgery, GasthuisZusters Antwerpen Sint-Augustinus, Wilrijk/Antwerp, Belgium.,Department of Speech, Language, and Hearing Sciences, University of Ghent, Ghent, Belgium.,Faculty of Education, Health, and Social Work, University College of Ghent, Ghent, Belgium.,Faculty of Psychology and Educational Sciences, School of Logopedics, Université Catholique de Louvain, Louvain-la-Neuve, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Phonanium, Lokeren, Belgium
| | - Monique Verguts
- Department of Otorhinolaryngology-Head and Neck Surgery, European Institute for Otorhinolaryngology-Head and Neck Surgery, GasthuisZusters Antwerpen Sint-Augustinus, Wilrijk/Antwerp, Belgium.,Department of Otorhinolaryngology and Voice Disorders, Diest General Hospital, Diest, Belgium
| | - Hannelore Demarsin
- Department of Otorhinolaryngology-Head and Neck Surgery, European Institute for Otorhinolaryngology-Head and Neck Surgery, GasthuisZusters Antwerpen Sint-Augustinus, Wilrijk/Antwerp, Belgium
| | - Joost van Dinther
- Department of Otorhinolaryngology-Head and Neck Surgery, European Institute for Otorhinolaryngology-Head and Neck Surgery, GasthuisZusters Antwerpen Sint-Augustinus, Wilrijk/Antwerp, Belgium
| | - Pablo Gomez
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Patrick Schlegel
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Döllinger
- Division of Phoniatrics and Pediatric Audiology, Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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