Effects of Vibratory Source on Auditory-Perceptual and Bio-Inspired Computational Measures of Pediatric Voice Quality

OBJECTIVE

The vibratory source for voicing in children with dysphonia is classified into three categories including a glottal vibratory source (GVS) observed in those with vocal lesions or hyperfunction; supraglottal vibratory sources (SGVS) observed secondary to laryngeal airway injuries, malformations, or reconstruction surgeries; and a combination of both glottal and supraglottal vibratory sources called mixed vibratory source (MVS). This study evaluated the effects of vibratory source on three primary dimensions of voice quality (breathiness, roughness, and strain) in children with GVS, SGVS, and MVS using single-variable matching tasks and computational measures obtained from bio-inspired auditory models.

METHODS

A total of 44 dysphonic voice samples from children aged 4-11 years were selected. Seven listeners rated breathiness, roughness, and strain of 1000-ms /ɑ/ samples using single-variable matching tasks. Computational estimates of pitch strength, amplitude modulation filterbank output, and sharpness were obtained through custom-designed MATLAB algorithms.

RESULTS

Perceived roughness and strain were significantly higher in children with SGVS and MVS compared to children with GVS. Among the computational measures, only the modulation filterbank output resulted in significant differences among vibratory sources; a posthoc test revealed that children with SGVS had greater amplitude modulation than children with GVS, as expected from their rougher voice quality.

CONCLUSIONS

The results indicate that the output of an auditory amplitude modulation filterbank model may capture characteristics of SGVS that are strongly related to the rough voice quality.

Perceptual Measures of Boychoir Voices During the Phases of Pubertal Voice Mutation

BACKGROUND/OBJECTIVES

Vocal changes in the male singing voice associated with puberty are variable and often unpredictable resulting in challenges for the singer and the choral director. Limited knowledge regarding the physiologic changes in the vocal mechanism as they correlate to perceptual variations observed in the male adolescent singer exists in the literature. The purpose of this study was to examine pitch breaks and perceptual characteristics of vocal quality during singing tasks for boys in various stages of the male changing voice.

STUDY DESIGN

Prospective Study.

METHODS

Twenty-eight boys were initially evaluated at Cooksey Stage 0 (Pubertal Unchanged; n = 15) or Cooksey Stage 1 (Mid-Voice; n = 13). Range of age was 8-13 years old. Participants performed vocal slide intervals (1-3-1, 1-5-1, 1-8-1) with discrete starting frequencies on G3, C4, F4, and A4 and sang the "Star-Spangled Banner" in the key of Ab. Pitch breaks and perceptual qualities were evaluated on the recorded tasks by expert raters. Seven boys were evaluated again when they progressed to Cooksey Stage 4 (Baritone) performing the same singing tasks.

RESULTS

For the participants evaluated at Cooksey Stage 0/1, pitch breaks were observed more in the higher frequencies and increased interval spacing regardless of starting frequency. Participants at Cooksey Stage 0 had more pitch breaks than Stage 1. At Cooksey Stage 4, an increase in the number of pitch breaks was observed in comparison to their tasks performed at Stage 0/1 and the perceptual quality of breathiness was significantly greater.

CONCLUSIONS

Pitch breaks are a characteristic perceptual change that indicates a young man may be transitioning through puberty. Findings from the present study demonstrate that in addition to perceived pitch breaks, breathiness was noted to significantly increase as the male progressed through puberty. Breathiness was noted to be more significant than vocal timbre and overall vocal quality. This research provides acoustic evidence to enhance the perceptual characteristics of voice change for those who teach and train male voices through puberty.

Comparison of Pediatric Voice Handicap Index Scores with Perceptual Voice Analysis in Patients following Airway Reconstruction

Objectives

We performed a retrospective review to compare a subjective parental proxy-derived voice handicap survey to an observer-derived method of measuring voice perturbation in children who have undergone airway reconstruction. The main outcome measures were the Pediatric Voice Handicap Index (pVHI) total score and the Overall Severity score on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).

Methods

The percent Overall Severity CAPE-V score (score divided by 100) and the percent pVHI score (score divided by 92) were calculated. A Wilcoxon signed rank test was used to compare CAPE-V scores with the pVHI total scores. The relationship between the pVHI scores and the CAPE-V scores was investigated with a Spearman correlation. Subgroup analysis was performed to determine the relationship of surgery type to CAPE-V and pVHI scores.

Results

Fifty subjects with a history of airway surgery who were evaluated between 2005 and 2008 were identified. Forty-two of the 50 subjects had complete data for review. Their median age was 7.1 years (range, 3.3 to 17.9 years). Their pVHI total scores had a median of 30 (range, 1 to 80). Their Overall Severity CAPE-V scores had a median of 50.5 (range, 0 to 98). Their median CAPE-V percent was higher than their median pVHI percent (50.5% versus 32.6%; p = 0.0003). A weak correlation was found between the Overall Severity CAPE-V score and the pVHI total score (rho = 0.41; p = 0.0003). There was a trend toward higher Overall Severity CAPE-V scores in patients who underwent cricotracheal resection. The total number of airway surgeries was significantly correlated with the Overall Severity CAPE-V score (rho = 0.6; p < 0.0001) but not with the pVHI score.

Conclusions

Children who undergo airway reconstruction often have a resulting voice disturbance that can affect their lives in multiple dimensions. The results of this study revealed a weak-to-fair correlation between the parent-reported pVHI total score and expert ratings of voice quality using the CAPE-V. In this patient population, both of these tools provided important information regarding the relationship of the severity of voice disturbance to its handicapping effects.

Characterization of Supraglottic Phonation in Children after Airway Reconstruction

Objectives

We examined select acoustic (signal type), aerodynamic, and perceptual measures and associated surgical data in a cohort of children who were endoscopically identified as using supraglottic phonation after undergoing airway reconstruction.

Methods

Twenty-one children (4 to 18 years of age) who were seen in the Cincinnati Children's Hospital Medical Center for Pediatric Voice Disorders and identified as using supraglottic phonation were included in this study. According to standard protocol, each of these children underwent acoustic, aerodynamic, and perceptual analyses and laryngeal imaging. Their medical records were reviewed for surgical history.

Results

Four primary supraglottic compression patterns and 3 distinct sound sources for voice were identified. Signal type classification revealed that 20 of 21 voice signals were either type II or type III. Signal type was moderately associated with compression pattern (p = 0.01). No statistically significant findings were found in testing the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) Overall Severity score against compression patterns and vibration source. The mean Strain scores for participants who used a combined source of vibration were significantly higher than for those who used their ventricular folds.

Conclusions

The compensatory compression patterns and alternate sources of vibration used by these children resulted in moderate to severe dysphonias. How children compensate after undergoing airway reconstruction has important implications for behavioral and surgical interventions aimed at improving voice quality. Not all aspects of traditional voice evaluation are suitable for this population.

Feasibility of Clinical Endoscopy and Stroboscopy in Children With Bilateral Vocal Fold Lesions

PURPOSE

The purpose of this study was to examine the utility of flexible and rigid endoscopy and stroboscopy for the identification of anatomical and physiological features in children with bilateral vocal fold lesions. The secondary purpose was to describe the age distribution of patients who could tolerate use of the different types of endoscopes.

METHOD

This cross-sectional clinic-based study included 38 children (ages 5 to 12 years) diagnosed with bilateral vocal fold lesions via videoendoscopy. Vocal fold vibratory characteristics (e.g., mucosal wave) were rated by 4 clinicians by consensus.

RESULTS

Bilateral vocal fold lesions could be well described anatomically after visualization with both flexible and rigid endoscopes and were most commonly described as symmetrical and broad based. However, the clinicians' confidence in the accuracy of stroboscopy for rating vocal fold vibratory characteristics was limited for both flexible and rigid stroboscopes.

CONCLUSIONS

Videoendoscopy was adequate for viewing and characterizing anatomical structures of bilateral vocal fold lesions in pediatric patients; however, vibratory characteristics were often not fully visualized with videostroboscopy. In view of the importance of visualizing vocal fold vibration in the differential diagnosis and treatment of vocal fold lesions, other imaging modalities, such as high-speed videoendoscopy, may provide more accurate descriptions of vocal fold vibratory characteristics in this population.

Examining the Impact of Video Modeling Techniques on the Efficacy of Clinical Voice Assessment

OBJECTIVES

The purpose of the current study was to determine whether or not presenting patients with a video model improves efficacy of the assessment as defined by efficiency and decreased variability in trials during the acoustic component of voice evaluations.

METHODS

Twenty pediatric participants with a mean age of 7.6 years (SD = 1.50; range = 6-11 years), 32 college-age participants with a mean age of 21.32 years (SD = 1.61; range = 18-30 years), and 17 adult participants with a mean age of 54.29 years (SD = 2.78; range = 50-70 years) were included in the study and divided into experimental and control groups. The experimental group viewed a training video prior to receiving verbal instructions and performing acoustic assessment tasks, whereas the control group received verbal instruction only prior to completing the acoustic assessment. Primary measures included the number of clinician cues required and instructional time. Standard deviations of acoustic measurements (eg, minimum and maximum frequency) were also examined to determine effects on stability.

RESULTS

Individuals in the experimental group required significantly less cues, P = 0.012, compared to the control group. Although some trends were observed in instructional time and stability of measurements, no significant differences were observed.

CONCLUSIONS

The findings of this study may be useful for speech-language pathologists in regard to improving assessment of patients' voice disorders with the use of video modeling.

Comparison of the Pediatric Voice Handicap Index with perceptual voice analysis in pediatric patients with vocal fold lesions

OBJECTIVE

To compare a subjective patient/family-derived voice handicap survey with an expert observer-derived method of evaluating voice disturbance in pediatric patients with vocal fold lesions (VFLs).

DESIGN

Retrospective review.

SETTING

Tertiary care referral center.

PATIENTS

Thirty-eight children with VFLs referred for voice evaluation.

MAIN OUTCOME MEASURES

Pediatric Voice Handicap Index (pVHI) scores and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores. Percentages for CAPE-V (100-point scale) and pVHI (92-point scale) were calculated for direct comparisons. Relationships between pVHI scores and CAPE-V scores were investigated using the Spearman rank correlation.

RESULTS

Thirty-eight patients with VFLs (median age, 8.3 years; age range, 4.2-17.2 years; 63% males) were included from a database of more than 600 children and evaluated between November 15, 2005, and June 15, 2010. The median CAPE-V overall score was 30.3 (range, 1-67), and the normalized total pVHI score was 29.3 (range, 0-73) (P = .90). The Spearman rank correlation showed significant fair correlations between CAPE-V overall and functional pVHI and between CAPE-V strain and breathiness, and the pVHI total, functional, but none higher than ρ = 0.44 (P ≤ .03). The correlation was higher in males for CAPE-V loudness to total pVHI (ρ = 0.40, P = .04) and in females for CAPE-V breathiness (ρ = 0.58, P = .03) and strain (ρ = 0.55, P = .04) to total pVHI.

CONCLUSIONS

The CAPE-V and the pVHI are useful tools in the measurement of voice outcomes in children with VFLs. There are fair correlations between the CAPE-V and the pVHI, and they likely evaluate important yet different aspects of voice disturbance. Significant gender differences in these correlations should be further evaluated in future studies.

Aerodynamic and acoustic assessment in children following airway reconstruction: an assessment of feasibility

OBJECTIVE

The purpose of this study was to examine the feasibility of conducting aerodynamic and acoustic assessment in children following airway reconstruction. Underlying etiologies, co-morbidities and age related factors can present challenges for meaningful instrumental data collection in this population.

METHODS

A chart review of 100 children who were seen for a complete voice evaluation at the Center for Pediatric Voice Disorders at the Cincinnati Children's Hospital Medical Center was conducted. Children who completed full or partial aerodynamic and acoustic protocols were identified. Data regarding the ability to participate in the assessment was tabulated, and vowel samples taken from the acoustic data were subjected to signal type classifications (e.g., Type I, II, III).

RESULTS

Fifty-three children met the inclusion/exclusion criteria of the chart review. Of those children, 58% (n=31/53) were able to complete the full acoustic and aerodynamic protocols without any modification. In regards to the aerodynamic protocol alone, 64% (n=34/53) could complete protocol. In regards to the acoustic protocol alone, 75% (n=40/53) could complete the entire acoustic protocol without any modification. There were 32% (n=17) who provided a Type I acoustic signal which was appropriate for measurement of F(0). There was a significant correlation between age and ability to complete the protocol for both the aerodynamic (p=.007) and acoustic (p=.004) protocols.

CONCLUSIONS

This study demonstrated that a majority of children were capable of completing aerodynamic and acoustic protocols. A significant proportion of children in this study had severe dysphonia, precluding the ability to extract fundamental frequency. Although aerodynamic and acoustic measures are feasible for many patients in this population, the severity of dysphonias observed in these patients causes the use of these measures to be limited in some cases for documenting behavioral and surgical outcomes measures.