Sensitivity of Videolaryngostroboscopic Rating Tools to Differences in Dysphonia Severity

OBJECTIVES

This study evaluated the validity of two videolaryngostroboscopic (VLS) rating tools to detect differences in VLS ratings between normophonic speakers, mild, and moderate-severely dysphonic speakers.

METHODS

Sixteen rigid VLS exams were obtained from four normophonic controls and 12 speakers with dysphonia (8 =mild, 4 =moderate-severe) secondary to laryngeal pathology. Eight clinicians rated nine vibratory VLS parameters for each exam using both the Voice-vibratory Assessment of Laryngeal Imaging (VALI) tool and a 100 mm visual analog scales (VAS). Ratings obtained for both right and left vocal folds (eg, mucosal wave, amplitude of vibration, nonvibrating portion) were averaged. One rating of overall severity of laryngeal function using a 100 mm VAS also was obtained. ANOVAs were used to evaluate differences in VLS parameters between three speaker groups (normophonic, mildly dysphonic, moderate-severely dysphonic) using these two rating tools.

RESULTS

There were statistically significant differences between controls and moderate-severely dysphonic speakers and for all VLS parameters except phase symmetry (P < 0.05) for both VALI and VAS ratings. Differences between mildly dysphonic and moderate-severely dysphonic and speakers were observed for 4/6 VALI ratings (mucosal wave, nonvibratory portions, phase closure, and regularity) and 5/6 parameters (mucosal wave, amplitude of vibration, nonvibratory portions, phase closure, and regularity) for VAS ratings. Significant differences between controls and mildly dysphonic speakers were not observed for VLS parameter rated using the VALI. There were significant differences between controls and mildly dysphonic speakers for 3/6 parameters (mucosal wave, amplitude of vibration, nonvibratory portion) using a VAS. Ratings of overall severity of laryngeal function differed between all levels of dysphonia severity.

CONCLUSIONS

Significant differences in VLS ratings were observed for comparisons of normophonic and moderate-severely dysphonic speakers and mild to moderately dysphonic speakers using the VALI and the VAS. However, the VAS scale appeared to better differentiate differences in VLS measures between normophonic speakers and those with mild dysphonia. Future studies should consider rating scale sensitivity when VLS rating tools are selected for clinical and research purposes.

Test-Retest Reliability of Behavioral Assays of Feedforward and Feedback Auditory-Motor Control of Voice and Articulation

PURPOSE

Behavioral assays of feedforward and feedback auditory-motor control of voice and articulation frequently are used to make inferences about underlying neural mechanisms and to study speech development and disorders. However, no studies have examined the test-retest reliability of such measures, which is critical for rigorous study of auditory-motor control. Thus, the purpose of the present study was to assess the reliability of assays of feedforward and feedback control in voice versus articulation domains.

METHOD

Twenty-eight participants (14 cisgender women, 12 cisgender men, one transgender man, one transmasculine/nonbinary) who denied any history of speech, hearing, or neurological impairment were measured for responses to predictable versus unexpected auditory feedback perturbations of vocal (fundamental frequency, fo) and articulatory (first formant, F1) acoustic parameters twice, with 3-6 weeks between sessions. Reliability was measured with intraclass correlations.

RESULTS

Opposite patterns of reliability were observed for fo and F1; fo reflexive responses showed good reliability and fo adaptive responses showed poor reliability, whereas F1 reflexive responses showed poor reliability and F1 adaptive responses showed moderate reliability. However, a criterion-referenced categorical measurement of fo adaptive responses as typical versus atypical showed substantial test-retest agreement.

CONCLUSIONS

Individual responses to some behavioral assays of auditory-motor control of speech should be interpreted with caution, which has implications for several fields of research. Additional research is needed to establish reliable criterion-referenced measures of F1 adaptive responses as well as fo and F1 reflexive responses. Furthermore, the opposite patterns of test-retest reliability observed for voice versus articulation add to growing evidence for differences in underlying neural control mechanisms.

The Effect of Rating Method on Reliability of Judgments of Strain Across Populations

PURPOSE

Variability in auditory-perceptual ratings of voice limits their utility, with the poorest reliability often noted for vocal strain. The purpose of this study was to determine whether an experimental method, called visual sort and rate (VSR), promoted stronger rater reliability than visual analog scale (VAS), for ratings of strain in two clinical populations: adductor laryngeal dystonia (ADLD) and vocal hyperfunction (VH).

METHOD

Connected speech samples from speakers with ADLD and VH as well as age- and sex-matched controls were selected from a database. Fifteen inexperienced listeners rated strain for two speaker sets (25 ADLD speakers and five controls; 25 VH speakers and five controls) across four rating blocks: VAS-ADLD, VSR-ADLD, VAS-VH, and VSR-VH. For the VAS task, listeners rated each speaker for strain using a vertically oriented 100-mm VAS. For the VSR task, stimuli were distributed into sets of samples with a range of severities in each set. Listeners sorted and ranked samples for strain within each set, and final ratings were captured on a vertically oriented 100-mm VAS. Intrarater reliability (Pearson's r) and interrater variability (mean of the squared differences between a listener's ratings and group mean ratings) were compared across rating methods and populations using two repeated-measures analyses of variance.

RESULTS

Intrarater reliability of strain was significantly stronger when listeners used VSR compared to VAS; listeners also showed significantly better intrarater reliability in ADLD than VH. Listeners demonstrated significantly less interrater variability (better reliability) when using VSR compared to VAS. No significant effect of population or interactions was found between listeners for measures of interrater variability.

CONCLUSIONS

VSR increases intrarater reliability for ratings of vocal strain in speakers with VH and ADLD. VSR decreases variability of auditory-perceptual judgments of strain between inexperienced listeners in these clinical populations. Future research should determine whether benefits of VSR extend to voice clinicians and/or clinical settings.

Clinical Cutoff Scores for Acoustic Indices of Vocal Hyperfunction That Combine Relative Fundamental Frequency and Cepstral Peak Prominence

PURPOSE

This study examined the discriminative ability of acoustic indices of vocal hyperfunction combining smoothed cepstral peak prominence (CPPS) and relative fundamental frequency (RFF).

METHOD

Demographic, CPPS, and RFF parameters were entered into logistic regression models trained on two 1:1 case-control groups: individuals with and without nonphonotraumatic vocal hyperfunction (NPVH; n = 360) and phonotraumatic vocal hyperfunction (PVH; n = 240). Equations from the final models were used to predict group membership in two independent test sets (n = 100 each).

RESULTS

Both CPPS and RFF parameters significantly improved model fits for NPVH and PVH after accounting for demographics. CPPS explained unique variance beyond RFF in both models. RFF explained unique variance beyond CPPS in the PVH model. Final models included CPPS and RFF offset parameters for both NPVH and PVH; RFF onset parameters were significant only in the PVH model. Area under the receiver operating characteristic curve analysis for the independent test sets revealed acceptable classification for NPVH (72%) and good classification for PVH (86%).

CONCLUSIONS

A combination of CPPS and RFF parameters showed better discriminative ability than either measure alone for PVH. Clinical cutoff scores for acoustic indices of vocal hyperfunction are proposed for assessment and screening purposes.

Effect of Noise on Speech Intelligibility and Perceived Listening Effort in Head and Neck Cancer

Purpose This study (a) examined the effect of different levels of background noise on speech intelligibility and perceived listening effort in speakers with impaired and intact speech following treatment for head and neck cancer (HNC) and (b) determined the relative contribution of speech intelligibility, speaker group, and background noise to a measure of perceived listening effort. Method Ten speakers diagnosed with nasal, oral, or oropharyngeal HNC provided audio recordings of six sentences from the Sentence Intelligibility Test. All speakers were 100% intelligible in quiet: Five speakers with HNC exhibited mild speech imprecisions (speech impairment group), and five speakers with HNC demonstrated intact speech (HNC control group). Speech recordings were presented to 30 inexperienced listeners, who transcribed the sentences and rated perceived listening effort in quiet and two levels (+7 and +5 dB SNR) of background noise. Results Significant Group × Noise interactions were found for speech intelligibility and perceived listening effort. While no differences in speech intelligibility were found between the speaker groups in quiet, the results showed that, as the signal-to-noise ratio decreased, speakers with intact speech (HNC control) performed significantly better (greater intelligibility, less perceived listening effort) than those with speech imprecisions in the two noise conditions. Perceived listening effort was also shown to be associated with decreased speech intelligibility, imprecise speech, and increased background noise. Conclusions Speakers with HNC who are 100% intelligible in quiet but who exhibit some degree of imprecise speech are particularly vulnerable to the effects of increased background noise in comparison to those with intact speech. Results have implications for speech evaluations, counseling, and rehabilitation.

The Effect of Visual Sort and Rate Versus Visual Analog Scales on the Reliability of Judgments of Dysphonia

Purpose The reliability of auditory-perceptual judgments between listeners is a long-standing problem in the assessment of voice disorders. The purpose of this study was to determine whether a relatively novel experimental scaling method, called visual sort and rate (VSR), yielded stronger reliability than the more frequently used method of visual analog scales (VAS) for ratings of overall severity (OS) and breathiness (BR) in speakers with voicedisorders. Method Fifty speech samples were selected from a database of speakers with voice disorders. Twenty-two inexperienced listeners provided ratings of OS or BR in four rating blocks: VSR-OS, VSR-BR, VAS-OS, and VSR-BR. For the VAS task, listeners rated each speaker for BR or OS using a vertically oriented 100-mm VAS. For the VSR task, stimuli were distributed into sets of samples with a range of speaker severities in each set. Listeners sorted and ranked samples for OS or BR within each set, and final ratings were captured on a vertically oriented 100-mm VAS. Interrater variability, defined as the mean of the squared differences between a listener's ratings and group mean ratings, and intrarater reliability (Pearson r) were compared across rating tasks for OS and BR using paired t tests. Results Results showed that listeners had significantly less interrater variability (better reliability) when using VSR methods compared to VAS for judgments of both OS and BR. Intrarater reliability was high across rating tasks and dimensions; however, ratings of BR were significantly more consistent within individual listeners when using VAS than when using VSR. Conclusions VSR is an experimental method that decreases variability of auditory-perceptual judgments between inexperienced listeners when rating speakers with a range of dysphonic severities and disorders. Future research should determine whether a clinically viable tool may be developed based on VSR principles and whether such benefits extend to experienced listeners.

Acoustic Model of Perceived Overall Severity of Dysphonia in Adductor-Type Laryngeal Dystonia

Purpose This study is a secondary analysis of existing data. The goal of the study was to construct an acoustic model of perceived overall severity of dysphonia in adductory laryngeal dystonia (AdLD). We predicted that acoustic measures (a) related to voice and pitch breaks and (b) related to vocal effort would form the primary elements of a model corresponding to auditory-perceptual ratings of overall severity of dysphonia. Method Twenty inexperienced listeners evaluated the overall severity of dysphonia of speech stimuli from 19 individuals with AdLD. Acoustic features related to primary signs of AdLD (hyperadduction resulting in pitch and voice breaks) and to a potential secondary symptom of AdLD (vocal effort, measures of relative fundamental frequency) were computed from the speech stimuli. Multiple linear regression analysis was applied to construct an acoustic model of the overall severity of dysphonia. Results The acoustic model included an acoustic feature related to pitch and voice breaks and three acoustic measures derived from relative fundamental frequency; it explained 84.9% of the variance in the auditory-perceptual ratings of overall severity of dysphonia in the speech samples. Conclusions Auditory-perceptual ratings of overall severity of dysphonia in AdLD were related to acoustic features of primary signs (pitch and voice breaks, hyperadduction associated with laryngeal spasms) and were also related to acoustic features of vocal effort. This suggests that compensatory vocal effort may be a secondary symptom in AdLD. Future work to generalize this acoustic model to a larger, independent data set is necessary before clinical translation is warranted.

Perceived listener effort as an outcome measure for disordered speech

PURPOSE

Perceived listening effort is a perceptual dimension used to identify the amount of work necessary to understand disordered speech. The purpose of this study was to investigate the utility of perceived listening effort to provide unique information about disordered speech. The relationships between perceived listening effort and two current outcome measures (speech acceptability, intelligibility) were examined for listeners rating electrolaryngeal speech, along with their reliability and intra-rater agreement.

METHODS

Ten healthy male speakers read low-context sentences using an electrolarynx. Twenty-five inexperienced listeners orthographically transcribed and rated the stimuli for perceived listening effort and speech acceptability using a visual analog scale. Strict reliability and agreement criteria were set.

RESULTS

Perceived listening effort was moderately to strongly correlated with intelligibility (r = -0.76) and acceptability (r = -0.80), each of which contributed uniquely to ratings of perceived listening effort. However, only 17 listeners met stringent reliability and agreement criteria.

CONCLUSIONS

Ratings of perceived listening effort may provide unique information about the communicative success of individuals with communication disorders. There is great variability, however, among inexperienced listeners' perceptual ratings of electrolaryngeal speech. Future research should investigate variables that may affect perceived listening effort specifically and auditory-perceptual ratings in general.

Internally Versus Externally Cued Speech in Parkinson's Disease and Cerebellar Disease

PURPOSE

The purpose of this study was to examine the effects of an internally versus externally cued speech task on perceived understandability and naturalness in speakers with Parkinson's disease (PD) and cerebellar disease (CD).

METHOD

Sentences extracted from a covertly recorded conversation (internally cued) were compared to the same sentences read aloud (externally cued) by speakers with PD and a clinical comparison group of speakers with CD. Experienced listeners rated the speech samples using a visual analog scale for the perceptual dimensions of understandability and naturalness.

RESULTS

Results suggest that experienced listeners rated the speech of participants with PD as significantly more natural and more understandable during the reading condition. Participants with CD were also rated as significantly more understandable during the reading condition, but ratings of naturalness did not differ between conversation and reading.

CONCLUSIONS

Speech tasks can have a pronounced impact on perceived speech patterns. For individuals with PD, both understandability and naturalness can improve during reading tasks versus conversational tasks. The speech benefits from reading may be attributed to several mechanisms, including possible improvement from an externally cued speech task. These findings have implications for speech task selection in evaluating individuals with dysarthria.

The Effect of Information and Severity on Perception of Speakers With Adductor Spasmodic Dysphonia

PURPOSE

The purpose of this study was to examine the effect of severity of adductor spasmodic dysphonia (ADSD) and information about it on unfamiliar listeners' attitudes about speakers' personal characteristics, perceived vocal effort, and listener comfort on the basis of ratings of speech recordings.

METHOD

Fifteen women with ADSD and 5 controls provided speech samples. Forty-five unfamiliar listeners were randomized into 3 groups. Listeners in Group 1 received no information, listeners in Group 2 were told that some speakers had voice disorders or had no voice concerns, and listeners in Group 3 were provided diagnostic labels for each speaker and information about ADSD. Listeners then rated speech samples for attitudes, perceived vocal effort, and listener comfort.

RESULTS

Speakers with ADSD were judged significantly worse than controls for attitudes related to "social desirability" and "intellect." There was no effect of severity on "personality" attributes. However, provision of a diagnostic label resulted in significantly more favorable personality ratings than when no label was provided. Perceived vocal effort and comfort became significantly more negative as ADSD severity increased. Finally, most listener ratings were unaffected by provision of additional information about ADSD.

CONCLUSIONS

Listeners' perceptions about speakers with ADSD are difficult to change. Directions for counseling and public education need future study.

Employer Reactions to Adductor Spasmodic Dysphonia: Exploring the Influence of Symptom Severity and Disclosure of Diagnosis During a Simulated Telephone Interview

PURPOSE

The purpose of this study was to determine the influence of symptom severity and disclosure of adductor spasmodic dysphonia (ADSD) on the perceptions of human resource personnel members (HRPs) during a simulated phone interview.

METHOD

One female speaker with ADSD was recorded reading an interview script at two time points: (a) pre-BOTOX injection (severe), and (b) post-BOTOX injection (mild). Thirty-two HRPs evaluated the recording in one of the two conditions via a qualitative structured interview. HRPs gave their recommendations regarding when and how to disclose ADSD.

RESULTS

In the mild condition, no HRP perceived that the applicant had a voice disorder. Disclosure was not recommended as often, as an impairment was not initially noticed. However, 15/16 HRPs commented on the applicant's voice in the severe condition, with most suspecting she was a smoker or had lung/throat cancer. Disclosure in the severe condition was recommended more often, as it clarified symptoms that were noted at the outset.

CONCLUSIONS

Symptom severity in ADSD influences employer perceptions during the phone interview process. Incorrect assumptions may be made about applicants with severe symptoms, and apparentness of symptoms influences whether or not disclosure is recommended. Results have implications for counseling individuals with ADSD who are navigating the job interview process.

The Effect of Noise on Relationships Between Speech Intelligibility and Self-Reported Communication Measures in Tracheoesophageal Speakers

PURPOSE

The purpose of this study was to examine how sentence intelligibility relates to self-reported communication in tracheoesophageal speakers when speech intelligibility is measured in quiet and noise.

METHOD

Twenty-four tracheoesophageal speakers who were at least 1 year postlaryngectomy provided audio recordings of 5 sentences from the Sentence Intelligibility Test. Speakers also completed self-reported measures of communication-the Voice Handicap Index-10 and the Communicative Participation Item Bank short form. Speech recordings were presented to 2 groups of inexperienced listeners who heard sentences in quiet or noise. Listeners transcribed the sentences to yield speech intelligibility scores.

RESULTS

Very weak relationships were found between intelligibility in quiet and measures of voice handicap and communicative participation. Slightly stronger, but still weak and nonsignificant, relationships were observed between measures of intelligibility in noise and both self-reported measures. However, 12 speakers who were more than 65% intelligible in noise showed strong and statistically significant relationships with both self-reported measures (R2 = .76-.79).

CONCLUSIONS

Speech intelligibility in quiet is a weak predictor of self-reported communication measures in tracheoesophageal speakers. Speech intelligibility in noise may be a better metric of self-reported communicative function for speakers who demonstrate higher speech intelligibility in noise.

Effect of Experience on Judgments of Adductor Spasmodic Dysphonia

Objectives:

We performed a prospective, exploratory study 1) to determine differences in judgments of overall severity (OS) and vocal effort (VE) in adductor spasmodic dysphonia (ADSD) when judgments are made by experienced listeners, naive listeners, and speakers with ADSD; 2) to determine differences in judgments of listener comfort (LC) in ADSD when judgments are made by experienced and naive listeners; and 3) to determine relationships between auditory-perceptual ratings of voice and speakers' voice handicap.

Methods:

Twenty speakers with ADSD provided speech recordings. They judged their own speech samples for OS and VE and completed the Voice Handicap Index (VHI). Twenty naive and 8 experienced listeners evaluated speech samples for OS, VE, and LC using rating scales.

Results:

No differences were found for judgments of OS, VE, or LC across the groups. However, the strategies used by the speakers seemed to differ from those used by the other listeners in making OS and VE judgments. The speakers' self-judged VE correlated moderately with voice handicap; experienced and naive listeners' judgments were only weakly related to VHI scores.

Conclusions:

Speakers with ADSD and listeners appear to use auditory-perceptual dimensions differently. Voice handicap is best predicted by patient-perceived VE, and not by clinician or naive listeners' judgments.

The relationship between communicative participation and postlaryngectomy speech outcomes

BACKGROUND

The purpose of this study was to examine relationships between communicative participation and postlaryngectomy speech outcomes, including listener-rated speech intelligibility and acceptability, and patient-rated speech acceptability and voice handicap.

METHODS

Thirty-six laryngectomized individuals completed the Communicative Participation Item Bank (CPIB) short form and the Voice Handicap Index-10 (VHI-10). They provided recordings from the Sentence Intelligibility Test (SIT) and a reading passage, and rated their own speech acceptability. Forty-eight inexperienced listeners transcribed the SIT sentences to derive intelligibility scores. Eighteen additional listeners judged the speech acceptability using the rating scales.

RESULTS

Listeners judged tracheoesophageal speakers as significantly more intelligible and acceptable than electrolaryngeal speakers (p < .05). Speech acceptability was significantly more acceptable to speakers than listeners (p < .05). Weak, nonsignificant relationships were found between communicative participation and listener-rated outcomes. Stronger, significant relationships were found between communicative participation and self-rated speech acceptability and voice handicap (p < .05).

CONCLUSION

Patient-reported communication outcomes are complementary to listener-rated outcomes. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1955-E1961, 2016.

Individual Monitoring of Vocal Effort With Relative Fundamental Frequency: Relationships With Aerodynamics and Listener Perception

PURPOSE

The acoustic measure relative fundamental frequency (RFF) was investigated as a potential objective measure to track variations in vocal effort within and across individuals.

METHOD

Twelve speakers with healthy voices created purposeful modulations in their vocal effort during speech tasks. RFF and an aerodynamic measure of vocal effort, the ratio of sound pressure level to subglottal pressure level, were estimated from the aerodynamic and acoustic signals. Twelve listeners also judged the speech samples for vocal effort using the visual sort and rate method.

RESULTS

Relationships between RFF and both the aerodynamic and perceptual measures of vocal effort were weak across speakers (R2 = .06-.26). Within speakers, relationships were variable but much stronger on average (R2 = .45-.56).

CONCLUSIONS

RFF showed stronger relationships between both the aerodynamic and perceptual measures of vocal effort when examined within individuals versus across individuals. Future work is necessary to establish these relationships in individuals with voice disorders across the therapeutic process.

Communicative participation and quality of life in head and neck cancer

OBJECTIVE

The purpose of this study was to determine how a new self-report outcome measure of communicative participation, the Communicative Participation Item Bank (CPIB), related to disease- and discipline-specific quality of life (QOL) outcomes in a head and neck cancer (HNC) population.

METHODS

One hundred ninety-five individuals treated for HNC completed the CPIB, the University of Washington Quality of Life questionnaire (UW-QOL), and the Voice Handicap Index-10 (VHI-10).

RESULTS

Results revealed moderate QOL scores across the UW-QOL (mean scores: global QOL = 66; physical subscale = 70; social-emotional subscale = 73) and VHI-10 (mean = 16). Correlations between the CPIB and the UW-QOL scores were statistically significant (P < .001) but relatively weak (r = .37-.38). As hypothesized, a stronger correlation was found between the CPIB and the VHI-10 (r = -0.79; P < .001).

CONCLUSION

Clinicians may consider adopting the CPIB to complement existing tools in assessing communication outcomes after HNC.

Inferring speaker attributes in adductor spasmodic dysphonia: ratings from unfamiliar listeners

PURPOSE

To determine whether unfamiliar listeners' perceptions of speakers with adductor spasmodic dysphonia (ADSD) differ from control speakers on the parameters of relative age, confidence, tearfulness, and vocal effort and are related to speaker-rated vocal effort or voice-specific quality of life.

METHOD

Twenty speakers with ADSD (including 6 speakers with ADSD plus tremor) and 20 age- and sex-matched controls provided speech recordings, completed a voice-specific quality-of-life instrument (Voice Handicap Index; Jacobson et al., 1997), and rated their own vocal effort. Twenty listeners evaluated speech samples for relative age, confidence, tearfulness, and vocal effort using rating scales.

RESULTS

Listeners judged speakers with ADSD as sounding significantly older, less confident, more tearful, and more effortful than control speakers (p < .01). Increased vocal effort was strongly associated with decreased speaker confidence (rs = .88-.89) and sounding more tearful (rs = .83-.85). Self-rated speaker effort was moderately related (rs = .45-.52) to listener impressions. Listeners' perceptions of confidence and tearfulness were also moderately associated with higher Voice Handicap Index scores (rs = .65-.70).

CONCLUSION

Unfamiliar listeners judge speakers with ADSD more negatively than control speakers, with judgments extending beyond typical clinical measures. The results have implications for counseling and understanding the psychosocial effects of ADSD.

Does the presence or location of graphic markers affect untrained listeners' ratings of severity of dysphonia?

OBJECTIVE

To determine the effect of presence and location of severity labels for different types of visual analog scales (VAS) on overall severity (OS) ratings in dysphonic speech.

STUDY DESIGN

Experimental, between group comparisons.

METHODS

Dysphonic and normal voice samples from male and female speakers were presented to inexperienced listeners for judgments of OS. To rate samples, listeners used an undifferentiated 100-mm VAS labeled at the extremes, a VAS with nonlinearly distributed labels as in the "beta" version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), or a VAS with symmetrically distributed labels as in the "official" version of the CAPE-V.

RESULTS

Overall, mean OS ratings did not differ significantly across scale types, although ratings using the nonlinearly marked VAS were generally lower than those from other scales. This effect was significant for female speakers whose samples tended toward moderate OS. The ratings distribution, when compiled into 10-mm bins, differed significantly by scale type, with users of the nonlinearly marked scales skewing their ratings toward normal.

CONCLUSIONS

The presence and placement of labels on VAS did not significantly affect OS ratings overall, but values were significantly lower when rating female voices with the nonlinearly labeled VAS. Results indicate that professionals should specify the scale type used for rating OS and use scales consistently when comparing voices.

Acoustic Correlate of Vocal Effort in Spasmodic Dysphonia

Objectives:

This study characterized the relationship between relative fundamental frequency (RFF) and listeners' perceptions of vocal effort and overall spasmodic dysphonia severity in the voices of 19 individuals with adductor spasmodic dysphonia.

Methods:

Twenty inexperienced listeners evaluated the vocal effort and overall severity of voices using visual analog scales. The squared correlation coefficients (R2) between average vocal effort and overall severity and RFF measures were calculated as a function of the number of acoustic instances used for the RFF estimate (from 1 to 9, of a total of 9 voiced-voiceless-voiced instances).

Results:

Increases in the number of acoustic instances used for the RFF average led to increases in the variance predicted by the RFF at the first cycle of voicing onset (onset RFF) in the perceptual measures; the use of 6 or more instances resulted in a stable estimate. The variance predicted by the onset RFF for vocal effort (R2 range, 0.06 to 0.43) was higher than that for overall severity (R2 range, 0.06 to 0.35). The offset RFF was not related to the perceptual measures, irrespective of the sample size.

Conclusions:

This study indicates that onset RFF measures are related to perceived vocal effort in patients with adductor spasmodic dysphonia. These results have implications for measuring outcomes in this population.

The relationship between perception of vocal effort and relative fundamental frequency during voicing offset and onset

PURPOSE

In this study, the authors aimed to determine the relationship between relative fundamental frequency (RFF) and listener perception of vocal effort in individuals with varying degrees of vocal hyperfunction.

METHOD

Thirty women diagnosed with voice disorders commonly associated with vocal hyperfunction and 10 healthy women provided speech samples that were used to obtain parameters of RFF. Twelve listeners judged the speech samples for overall severity and vocal effort (VE) using rating scales.

RESULTS

Significant but relatively weak negative correlations were found between perceptual measures and offset RFF parameters. Although offset RFF was increased in healthy participants relative to speakers with voice disorders, no differences were seen in RFF as a function of severity of VE in individuals with voice disorders.

CONCLUSIONS

Although a statistically significant correlation between offset RFF and VE was found, examination of data as a function of both VE and health status indicated that RFF more accurately classifies the presence of a voice disorder than does severity of voice quality or VE. There is a need for further research to investigate the clinical utility of RFF measures for assessment of rehabilitation progress.

Auditory-perceptual speech outcomes and quality of life after total laryngectomy

OBJECTIVE

(1) To determine potential relationships between speech intelligibility, acceptability, and self-reported quality of life (QOL) after total laryngectomy and (2) to determine whether relationships are stronger when QOL is measured by a head and neck cancer-specific or discipline-specific QOL scale.

STUDY DESIGN

Cross-sectional.

SETTING

University-based laboratory and speech clinic.

SUBJECTS AND METHODS

Twenty-five laryngectomized individuals completed disease-specific (University of Washington Quality of Life; UW-QOL) and discipline-specific (Voice Handicap Index-10; VHI-10) QOL scales. They also provided audio recordings that included the Sentence Intelligibility Test (SIT) and a reading passage. Thirty-three listeners transcribed the SIT sentences to yield intelligibility scores. Fifteen additional listeners judged speech acceptability of the reading passage using rating scales.

RESULTS

The QOL scores were moderate across the UW-QOL physical (mean = 77.63) and social-emotional (mean = 78.02) subscales and the VHI-10 (mean = 17.91). Speech acceptability and intelligibility varied across the samples, with acceptability only moderately related to intelligibility (r = 0.41, P < .05). Relationships were weak between ratings of intelligibility and self-reported QOL (range, r = 0.00-0.22) and weak to moderate between acceptability with QOL (range, r = 0.01-0.46). The only statistically significant, but moderate, relationship was found between speech acceptability with the UW-QOL speech subscore (r = 0.46, P < .05).

CONCLUSION

Listeners' ratings of speech acceptability and intelligibility were not strongly predictive of disease-specific or voice-related QOL, suggesting that listener-rated and patient-reported outcomes are complementary.

Effect of fundamental frequency on judgments of electrolaryngeal speech

PURPOSE

To determine (a) the effect of fundamental frequency (f₀) on speech intelligibility, acceptability, and perceived gender in electrolaryngeal (EL) speakers, and (b) the effect of known gender on speech acceptability in EL speakers.

METHOD

A 2-part study was conducted. In Part 1, 34 healthy adults provided speech recordings using electrolarynges set at 75 Hz, 130 Hz, and 175 Hz, and 36 listeners transcribed the recordings. In Part 2, 22 speech samples were presented to 16 listeners. First, listeners identified the gender of each speaker and judged his or her speech acceptability using rating scales. Second, listeners judged the same samples for speech acceptability when gender information was provided.

RESULTS

In Part 1, speakers were significantly more intelligible when using 75-Hz devices. In Part 2, the f₀ of the speech signal significantly impacted listeners' accuracy in perceiving the speaker's gender: In gender-incongruent conditions (males using 175-Hz devices, females using 75-Hz devices), listeners were unable to identify female speakers. Speech acceptability judgments were directly related to intelligibility. Finally, listeners differentially penalized female speakers who used 75-Hz devices when gender information was known.

CONCLUSION

Low f₀ facilitated speech intelligibility. However, at low f₀, listeners were unable to identify females as female, and females were differentially penalized for speech acceptability. Results may have implications for rehabilitation.

Listener effort for highly intelligible tracheoesophageal speech

The purpose of this study was to determine whether: (a) inexperienced listeners can reliably judge listener effort and (b) whether listener effort provides unique information beyond speech intelligibility or acceptability in tracheoesophageal speech. Twenty inexperienced listeners made judgments of speech acceptability and amount of effort required to listen to 14 male tracheoesophageal speakers using a paired comparison paradigm. Intelligibility was controlled to limit the analysis to the relationship between ratings of listener effort and speech acceptability. Results showed that as a group, inexperienced listeners reliably rated both speech acceptability and listener effort. In addition, ratings of speech acceptability and listener effort were strongly correlated (r>.99); however, there was evidence that some individual listeners assigned different ratings for each dimension for the same speech samples. Results have important implications for communication success for tracheoesophageal speakers.

LEARNING OUTCOMES

Readers will be able to describe: (a) the measurement of listener burden in speech and (b) the differences and relationships among listener effort, speech acceptability and speech intelligibility.

Coping and quality of life after total laryngectomy

OBJECTIVE

To investigate how ways of coping and traditional factors (age, sex, time postlaryngectomy, stage of disease, radiation, alaryngeal speech method) predict global quality of life, head and neck cancer-specific quality of life, and voice-related quality-of-life outcomes after total laryngectomy.

STUDY DESIGN

Cross-sectional survey.

SETTING

University-based laboratory and speech clinic.

SUBJECTS AND METHODS

Sixty-seven individuals who underwent total laryngectomy secondary to cancer were recruited from support groups and professional contacts. Individuals were at minimum 9 months postlaryngectomy. All outcomes were patient reported and included demographic data as well as a number of validated questionnaires: the Ways of Coping-Cancer Version (WOC-CV) scale, the Voice-Related Quality of Life (V-RQOL) scale, and the University of Washington Quality of Life (UW-QOL) composite and global QOL scores.

RESULTS

Fifty-three individuals identified a stressful aspect of their laryngectomy. As a set, traditional variables (age, time postlaryngectomy, alaryngeal speech method) accounted for only 5% of global QOL scores but between 25% and 30% of the variance of composite UW-QOL and V-RQOL scores. Time postlaryngectomy was the strongest traditional predictor. Ways of coping accounted for 23% to 32% of all QOL scores. Avoidant coping strategies (both cognitive and behavioral escape) were among the strongest predictors of poorer QOL. When traditional variables were combined with ways of coping, they together accounted for 26% to 46% of the variance of QOL outcomes.

CONCLUSION

Coping is important to consider when evaluating postlaryngectomy outcomes, above and beyond traditionally investigated factors.

The effect of listener experience and anchors on judgments of dysphonia

PURPOSE

To determine the effect of auditory anchors on judgments of overall severity (OS) and vocal effort (VE) in dysphonic speech when judgments are made by experienced and inexperienced listeners, and when self-rated by individuals with dysphonia (speaker-listeners).

METHOD

Twenty individuals with dysphonia and 4 normal controls provided speech recordings. Speaker-listeners judged their own speech samples for OS and VE without auditory anchors, and then in the presence of anchors, using 100-mm visual analog scales (VAS). Twenty inexperienced and 10 experienced listeners evaluated the same speech samples for OS and VE in similar rating conditions. Twenty inexperienced listeners also made judgments of the speech samples solely in anchored conditions.

RESULTS

All listeners judged the speech samples as significantly less severe and effortful in the anchored conditions. No significant effects of anchors or experience were found for intrarater agreement within 7.14 mm on the VAS. Both inexperienced and experienced listeners were significantly less variable and showed improved interrater agreement in the anchored conditions. Anchors significantly improved agreement across groups of listeners, particularly between inexperienced and speaker-listeners.

CONCLUSION

Listeners systematically shift judgments of voice quality in response to auditory anchors. Anchors reduce interrater variability and may improve agreement across some types of listeners.

Developing the communicative participation item bank: Rasch analysis results from a spasmodic dysphonia sample

PURPOSE

The purpose of this study was to conduct the initial psychometric analyses of the Communicative Participation Item Bank-a new self-report instrument designed to measure the extent to which communication disorders interfere with communicative participation. This item bank is intended for community-dwelling adults across a range of communication disorders.

METHOD

A set of 141 candidate items was administered to 208 adults with spasmodic dysphonia. Participants rated the extent to which their condition interfered with participation in various speaking communication situations. Questionnaires were administered online or in a paper version per participant preference. Participants also completed the Voice Handicap Index (B. H. Jacobson et al., 1997) and a demographic questionnaire. Rasch analyses were conducted using Winsteps software (J. M. Linacre, 1991).

RESULTS

The results show that items functioned better when the 5-category response format was recoded to a 4-category format. After removing 8 items that did not fit the Rasch model, the remaining 133 items demonstrated strong evidence of sufficient unidimensionality, with the model accounting for 89.3% of variance. Item location values ranged from -2.73 to 2.20 logits.

CONCLUSIONS

Preliminary Rasch analyses of the Communicative Participation Item Bank show strong psychometric properties. Further testing in populations with other communication disorders is needed.

Influence of Speaker Gender on Listener Judgments of Tracheoesophageal Speech

The objectives of this prospective and exploratory study are to determine: (1) naïve listener preference for gender in tracheoesophageal (TE) speech when speech severity is controlled; (2) the accuracy of identifying TE speaker gender; (3) the effects of gender identification on judgments of speech acceptability (ACC) and naturalness (NAT); and (4) the acoustic basis of ACC and NAT judgments. Six male and six female adult TE speakers were matched for speech severity. Twenty naïve listeners made auditory-perceptual judgments of speech samples in three listening sessions. First, listeners performed preference judgments using a paired comparison paradigm. Second, listeners made judgments of speaker gender, speech ACC, and NAT using rating scales. Last, listeners made ACC and NAT judgments when speaker gender was provided coincidentally. Duration, frequency, and spectral measures were performed. No significant differences were found for preference of male or female speakers. All male speakers were accurately identified, but only two of six female speakers were accurately identified. Significant interactions were found between gender and listening condition (gender known) for NAT and ACC judgments. Males were judged more natural when gender was known; female speakers were judged less natural and less acceptable when gender was known. Regression analyses revealed that judgments of female speakers were best predicted with duration measures when gender was unknown, but with spectral measures when gender was known; judgments of males were best predicted with spectral measures. Naïve listeners have difficulty identifying the gender of female TE speakers. Listeners show no preference for speaker gender, but when gender is known, female speakers are least acceptable and natural. The nature of the perceptual task may affect the acoustic basis of listener judgments.

The Effect of Perceptual Training on Inexperienced Listeners' Judgments of Dysphonic Voice

OBJECTIVES/HYPOTHESIS

The purpose of this study was (1) to determine whether changes in intra- and interrater reliability occur for inexperienced listeners' judgments of overall severity, roughness, and breathiness in dysphonic and normal speakers after 2 hours of listener training; and (2) to determine the acoustic bases of inexperienced listeners' judgments before and after training.

STUDY DESIGN

Prospective, single group, pre- and postdesign.

METHODS

Thirty adult dysphonic and six normal speaker samples were selected from a database. Samples included 21 test stimuli and 15 training stimuli of both sustained vowels and connected speech. Sixteen inexperienced listeners judged all samples for overall severity, roughness, and breathiness using visual analog scales. Each listener provided pretraining ratings at baseline. Listeners were then trained using 15 anchor voice samples and 15 training stimuli. During training, listeners were provided with definitions of rating dimensions, accuracy feedback, and anchor samples. Listeners then judged test stimuli in a posttraining session. Speaker samples also were analyzed acoustically.

RESULTS

Intrarater reliability was least variable for judgments of overall severity, but improved further with training. Listener judgments of roughness and breathiness in vowels were least reliable at baseline, but they significantly improved between listeners after training. Finally, measures of cepstral peak prominence significantly predicted all voice quality judgments except roughness in vowels, which was predicted by shimmer. The acoustic bases of group perceptual judgments did not seem to change with training.

CONCLUSIONS

These findings have implications for developing training programs in perceptual evaluation and mapping relationships between acoustic and perceptual characteristics of voice disorders.

Measuring communicative participation: a review of self-report instruments in speech-language pathology

PURPOSE

To assess the adequacy of self-report instruments in speech-language pathology for measuring a construct called communicative participation.

METHOD

Six instruments were evaluated relative to (a) the construct measured, (b) the relevance of individual items to communicative participation, and (c) their psychometric properties.

RESULTS

No instrument exclusively measured communicative participation. Twenty-six percent (n = 34) of all items (N = 132) across the reviewed instruments were consistent with communicative participation. The majority (76%) of the 34 items were associated with general communication, while the remaining 24% of the items were associated with communication at work, during leisure, or for establishing relationships. Instruments varied relative to psychometric properties.

CONCLUSIONS

No existing self-report instruments in speech-language pathology were found to be solely dedicated to measuring communicative participation. Developing an instrument for measuring communicative participation is essential for meeting the requirements of our scope of practice.

The psychosocial consequences of BOTOX injections for spasmodic dysphonia: a qualitative study of patients' experiences

OBJECTIVES/HYPOTHESIS

The purpose of this study is to examine the psychosocial consequences of BOTOX (Allergan, Inc. Irvine, CA) treatment for spasmodic dysphonia (SD). This article also explores how patients judge the success of treatment and make decisions about future treatment based on psychosocial issues relevant to them.

STUDY DESIGN

This study follows the phenomenological tradition of qualitative inquiry in which the objective is to explore the lived experiences of a group of persons who share a common phenomenon, in this case receiving BOTOX injections for SD.

METHODS

Six adults with SD who had been receiving BOTOX injections on a long-term basis participated in face-to-face interviews. The interviews were recorded, transcribed, and analyzed according to phenomenological guidelines to identify consistent themes as well as differences among participants' experiences.

RESULTS

The results are summarized in three primary themes that suggest (1) participants' experiences vary over time based on changes in factors such as lifestyle and personal priorities; (2) BOTOX has multidimensional psychosocial implications in physical, personal, and social domains; and (3) participants individualize their treatment regimens, taking into consideration the burden of treatment, scheduling priorities, and other strategies to maximize the benefits of BOTOX.

CONCLUSIONS

Based on this study, suggestions are provided for future research into a psychosocial outcome measurement, including longitudinal evaluations that accommodate changing patient priorities over time; multidimensional evaluations that incorporate physical, personal, and social issues; evaluations that include a measure of the burden of treatment; and evaluations that support a shared decision-making model with the voice clinicians.

The consequences of spasmodic dysphonia on communication-related quality of life: a qualitative study of the insider's experiences

The purpose of this study was to explore the biopsychosocial consequences of spasmodic dysphonia (SD) as experienced by people with SD. Qualitative research methods were used to investigate the insider's perspective of living with SD. Six adults with SD participated in face-to-face phenomenological interviews. The results are summarized in a model of personal experiences of SD which shows that communication-related quality of life (QOL) is shaped by experiences with multiple physiologic (voice quality, effort, voice dependability); personal (affective responses, changes in self-view, coping strategies) and social (physical environment, other people, participation in social roles) factors. Communication-related QOL is a complex and individualized construct with multidimensional contributors. This study suggests that understanding the nature of communication-related QOL for each individual requires exploration of each component of the model, exploration of the unique relationships among components for each person, and recognition of the multidimensional factors that shape the experience of SD.

LEARNING OUTCOMES

As a result of this activity the reader will be able to (1) identify general features of the phenomenological research method; (2) identify the three general categories of psychosocial consequences of SD; (3) identify those psychosocial consequences of SD that are under-represented in the literature; and (4) identify key conclusions of the communication-related quality of life model.

Scaling of Voice Pleasantness and Acceptability in Tracheoesophageal Speakers

The purpose of this study was (1) to determine the psychophysical character of auditory-perceptual ratings of voice pleasantness (VP) and voice acceptability (VA) for tracheoesophageal (TE) speakers using direct magnitude estimation (DME) and equal-appearing interval (EAI) scaling procedures and (2) to determine the relationship between listeners' ratings of VP and VA. Ten adult listeners judged overall VP and VA from connected speech samples produced by 20 adult male TE speakers. Although results yielded a prothetic continuum for VP and a metathetic continuum for VA, the amount of variance accounted for by a curvilinear model of VP was minimally more than that accounted for by a linear model. Results also revealed a significant relationship between VP and VA (r = 0.939). Findings from this study do not suggest any greater validity associated with VP and VA ratings obtained by the DME than the EAI method. As a result of the significant relationship between these ratings and to the ease of applying EAI scales, it is recommended that VA be used as a current clinical outcome measure. These data illustrate the need to identify attributes that best describe TE speech that are measured appropriately and are clinically useful.

Classification of Dysphonic Voice: Acoustic and Auditory-Perceptual Measures

The purpose of this study was (1) to determine the relationship between acoustic measures and auditory-perceptual dimensions of overall voice severity and pleasantness and (2) to evaluate the ability of acoustic and auditory-perceptual measures to discriminate normal from dysphonic voices. Thirty adult dysphonic speakers and six, age-matched normal control speakers were asked to provide oral reading samples of the Rainbow Passage. Acoustic analysis of the speech samples was used to identify abnormal phonatory events associated with dysphonia. The acoustic program calculated long-term average spectral measures, glottal noise measures, and those measures based on linear prediction (LP) modeling. Twelve adult listeners judged overall voice severity and pleasantness from the connected speech samples using direct magnitude estimation (DME) procedures. The acoustic measures accounted for 48% of overall voice severity and 40% of voice pleasantness for dysphonic speakers. The classification performance of the acoustic measures and auditory-perceptual measures was quantified using logistic regression analysis. When acoustic measures or auditory-perceptual measures were considered in isolation, classification was generally accurate and similar across measures. Classification accuracy improved to 100% when acoustic and auditory-perceptual measures were combined. These data provide further support for use of both auditory-perceptual evaluation and acoustic analyses for classifying and evaluating dysphonia.

Quality of life in male tracheoesophageal (TE) speakers

For this study, we determined the quality of life (QOL) in individuals who had undergone total laryngectomy (TL) and who used tracheoesophageal (TE) speech as their primary method of postlaryngectomy communication. We also descriptively compared present QOL outcomes with those found in an extension of the Department of Veterans Affairs' (VA) Laryngeal Cancer Study. Thirty laryngectomized men with TE speech as their primary mode of communication were recruited for participation in the investigation. Participants completed a general information form as well as the University of Michigan Head and Neck Quality of Life (HNQOL) instrument. Results revealed a high level of self-perceived QOL in the domains of communication, eating, pain, and emotion that was empirically better than results found in a previous study involving individuals who had undergone TL and who were treated in VA hospitals. Possible reasons for the improved self-reported QOL among individuals in the present group include use of TE speech for postlaryngectomy communication, a higher level of education, and membership in a support group. The results suggest to us that these factors should be considered in postlaryngectomy care in the veteran population to optimize rehabilitation outcomes.

Auditory-perceptual scaling and quality of life in tracheoesophageal speakers

OBJECTIVES/HYPOTHESIS

The purposes of the study were to determine listeners' auditory-perceptual ratings of tracheoesophageal speakers, to determine quality of life in tracheoesophageal speakers, and to determine the potential relationship between listeners' ratings of speech and tracheoesophageal speakers' self-rated quality of life.

STUDY DESIGN

Twenty-eight laryngectomized individuals who used tracheoesophageal speech as their primary mode of communication were studied. Fifteen naïve listeners provided auditory-perceptual ratings.

METHODS

Twenty-eight tracheoesophageal speakers (22 men and 6 women) completed a general information form, in addition to the University of Michigan Head and Neck Quality of Life (HNQOL) instrument; speakers also provided connected speech samples of a standard passage. Fifteen naïve listeners evaluated the tracheoesophageal speech samples for overall speech severity, naturalness, acceptability, and pleasantness using direct magnitude estimation procedures.

RESULTS

Listeners were able to discriminate among tracheoesophageal speech samples relative to the auditory-perceptual dimensions. Male tracheoesophageal speakers were judged as having significantly better, more acceptable, and more pleasant voices than women. Scores on the HNQOL instrument were determined to be higher among the group of tracheoesophageal speakers in the present study than those reported in previous studies. No significant differences were found among men and women for quality of life scores. Quality of life domains and auditory-perceptual judgments of tracheoesophageal speech were moderately correlated.

CONCLUSION

Women who use tracheoesophageal speech may be differentially penalized for dimensions related to voice quality. Limitations in voice did not necessarily translate into worse overall quality of life, indicating that auditory-perceptual evaluation and quality of life questionnaires are evaluating different aspects of function after laryngectomy.

The ICF: a proposed framework for comprehensive rehabilitation of individuals who use alaryngeal speech

The International Classification of Functioning, Disability and Health (ICF) provides a conceptual framework and common language for describing human functioning and disability (World Health Organization, 2001). The ICF provides direction for comprehensive rehabilitation by classifying individual functioning at the levels of (a) body functions and structures and (b) activities and participation. Consequently, the purpose of this article is (a) to summarize the ICF; (b) to apply a case example to the framework of the ICF, involving individuals who have undergone total laryngectomy; and (c) to examine implications for both research and clinical practice. This article demonstrates how speech-language pathologists may apply the ICF framework and endorses the adoption of the framework by the American Speech-Language-Hearing Association in the 2001 Scope of Practice in Speech-Language Pathology.

Direct magnitude estimation and interval scaling of pleasantness and severity in dysphonic and normal speakers

The purpose of this study was to determine the validity of voice pleasantness and overall voice severity ratings of dysphonic and normal speakers using direct magnitude estimation (DME) and equal-appearing interval (EAI) auditory-perceptual scaling procedures. Twelve naive listeners perceptually evaluated voice pleasantness and severity from connected speech samples produced by 24 adult dysphonic speakers and 6 normal adult speakers. A statistical comparison of the two auditory-perceptual scales yielded a linear relationship representative of a metathetic continuum for voice pleasantness. A statistical relationship that is consistent with a prothetic continuum was revealed for ratings of voice severity. These data provide support for the use of either DME or EAI scales when making auditory-perceptual judgments of pleasantness, but only DME scales when judging overall voice severity for dysphonic speakers. These results suggest further psychophysical study of perceptual dimensions of voice and speech must be undertaken in order to avoid the inappropriate and invalid use of EAI scales used in the auditory-perceptual evaluation of the normal and dysphonic voice.

Direct magnitude estimation and interval scaling of naturalness and severity in tracheoesophageal (TE) speakers

The purpose of this study was to determine the psychophysical character and validity of auditory-perceptual ratings of naturalness and overall severity for tracheoesophageal (TE) speech. This was achieved through use of direct magnitude estimation (DME) and equal-appearing interval (EAI) scaling procedures. Twenty adult listeners judged speech naturalness and overall severity from connected speech samples produced by 20 adult male TE speakers. A comparison of DME- and EAI-scaled judgments yielded a metathetic continuum for naturalness and a prothetic continuum for overall severity. These data provide support for the use of either DME or EAI scales in auditory-perceptual ratings of naturalness, but they provide support only for DME scales in judging overall severity for TE speech. The present results suggest that the nature of perceptual phenomena (prothetic vs. metathetic) for TE speakers is consistent with findings for the same dimensions produced by normal laryngeal speakers. These data also support a need for further study of perceptual dimensions associated with TE voice and speech in order to avoid the inappropriate and invalid use of EAI scales frequently found in diagnosis, assessment, and evaluation of this clinical population.