Dysphagia as a predictor of voice handicap and voice restoration in unilateral vocal fold immobility.

OBJECTIVE: Dysphagia is multifactorial in unilateral vocal fold immobility (UVFI). Severe dysphagia could indicate greater functional deficits in UVFI. The purpose of this study is to evaluate the association of dysphagia with the need for surgical voice restoration in patients with UVFI. STUDY DESIGN: Retrospective chart review. SETTING: Single-institution, tertiary referral center. METHODS: Records of UVFI patients from 2008 to 2018 were examined. Dysphagia severity was extracted from patient history. Etiology of UVFI and other relevant variables were analyzed to determine their association with dysphagia. Dysphagia severity and other clinical variables were then analyzed for their association with surgical voice restoration. RESULTS: Eighty patients met selection criteria out of 478 patients with UVFI. There was significant concordance between dysphagia severity extracted from patient history and patient-reported EAT-10 scores (R = 0.59, p = 0.000035). Patients' EAT-10 scores were correlated with VHI-10 scores (R = 0.45, p = 0.011). Severe dysphagia (p = 0.037), high VHI-10 score on presentation (p = 0.0009), and longer duration of hoarseness before presentation (p = 0.008) were associated with surgical voice restoration in UVFI patients. CONCLUSION: In this pilot study, severe dysphagia and increased voice handicap on presentation were associated with the need for surgical voice restoration in UVFI patients. Presenting dysphagia may be an additional variable for clinicians to consider for management of UVFI.

Does forced whisper have an impact on voice parameters?

OBJECTIVES: There has been the assumption that whispering may impact vocal function, leading to the widespread recommendation against its practice after phonosurgery. However, the extent to which whispering affects vocal function and vocal fold oscillation patterns remains unclear. METHODS: 10 vocally healthy subjects (5 male, 5 female) were instructed to forcefully whisper a standardized text for 10 min at a sound level of 70 dB(A), measured at a microphone distance of 30 cm to the mouth. Prior to and following the whisper loading, the dysphonia severity index was assessed. Simultaneously, recordings of high speed videolaryngoscopy (HSV), electroglottography, and audio signals during sustained phonation on the vowel /i/ (250 Hz for females and 125 Hz for males) were analyzed after segmentation of the HSV material. RESULTS: The pre-post analysis revealed only minor changes after the intervention. These changes included a rise in minimum intensity, an increase in the glottal area waveform-derived open quotient, and the glottal gap index. However, no statistically significant changes were observed in the harmonic-to-noise-ratio, the glottal- to-noise-excitation-ratio, and the electroglottographic open quotient. CONCLUSION: Overall, the study suggests that there are only small effects on vocal function in consequence of a forced whisper loading.

Asymmetric triangular body-cover model of the vocal folds with bilateral intrinsic muscle activation.

Many voice disorders are linked to imbalanced muscle activity and known to exhibit asymmetric vocal fold vibration. However, the relation between imbalanced muscle activation and asymmetric vocal fold vibration is not well understood. This study introduces an asymmetric triangular body-cover model of the vocal folds, controlled by the activation of bilateral intrinsic laryngeal muscles, to investigate the effects of muscle imbalance on vocal fold oscillation. Various scenarios were considered, encompassing imbalance in individual muscles and muscle pairs, as well as accounting for asymmetry in lumped element parameters. Measurements of amplitude and phase asymmetries were employed to match the oscillatory behavior of two pathological cases: unilateral paralysis and muscle tension dysphonia. The resulting simulations exhibit muscle imbalance consistent with expectations in the composition of these voice disorders, yielding asymmetries exceeding 30% for paralysis and below 5% for dysphonia. This underscores the relevance of muscle imbalance in representing phonatory scenarios and its potential for characterizing asymmetry in vocal fold vibration.

Vocal fold injection material does not preclude interpretation of laryngeal electromyography.

INTRODUCTION/AIMS: Temporary vocal fold injection (VFI) is a common treatment for acute and subacute vocal fold paralysis (VFP). Laryngeal electromyography (LEMG) is useful for diagnosing neurogenic causes of VFP. This study evaluated whether the presence of VFI material prevents interpretation of LEMG in patients with acute and subacute VFP. METHODS: Patients with acute and subacute unilateral VFP (onset ≤6 mo) who underwent temporary VFI within 3 mo preceding LEMG were evaluated. A matched control group that did not undergo VFI was also studied. The LEMG team (laryngologist and electromyographer) performed and interpreted LEMG using a pre-specified protocol, including qualitative and quantitative motor unit analysis. RESULTS: Eighteen patients with VFI underwent LEMG successfully with interpretation of spontaneous activity and motor unit recruitment. Fourteen patients were seen in follow-up to determine accuracy of established LEMG prognosis. Seven of seven subjects with poor LEMG prognosis did not recover vocal fold motion. Five of seven subjects with fair LEMG prognosis recovered vocal fold motion. Findings were similar for the control group. DISCUSSION: VFI augmentation material did not prevent interpretation of meaningful LEMG data in patients with acute and subacute VFP, and accurate prognoses of vocal fold motion recovery were established.

Value of Neurostimulation Plus Laryngeal Palpation to Predict Postoperative Vocal Fold Motility.

BACKGROUND: The aim of this study was to evaluate the reliability of intraoperative neuromonitoring through recurrent laryngeal nerve stimulation and simultaneous laryngeal palpation (NSLP) in predicting postoperative vocal cord palsy and in providing useful information in the decision to perform a staged surgery in initially planned total thyroidectomy. MATERIALS AND METHODS: A retrospective review was performed involving 552 patients for whom a total thyroidectomy was planned. In all patients, preoperative and postoperative laryngoscopy was performed. The incidence of vocal cord palsy was calculated on 1104 nerves at risk. RESULTS: Sensitivity and specificity of NSLP were 0.9411 and 0.9925 respectively. The positive predictive value was 0.7804, the negative predictive value was 0.9981, the false positive rate was 0.8%. In 41 patients (7.4%) the initial surgical strategy was changed into a staged procedure. Nine patients (21.9%) were false positive, 32 patients (78.1%) were true positive. Finally, a two-stage thyroidectomy was performed in 27 of 41 patients. CONCLUSIONS: High sensitivity and specificity confirm the validity of NSLP in predicting postoperative vocal cord palsy and in driving a possible staged thyroidectomy, both in benign thyroid disease and in differentiated thyroid carcinoma.

Pre- and post-operative high-speed videolaryngoscopy in unilateral vocal cord paralysis following autologous fat augmentation.

PURPOSE: To compare high-speed videolaryngoscopy (HSV) parameters such as open quotient (OQ), amplitude symmetry index (ASI), phase symmetry index (PSI), and frequency symmetry index (FSI), of the unilateral vocal cord paralysis (UVCP) patients pre and post (after 6 months) autologous fat augmentation. MATERIALS AND METHODS: This retrospective study evaluated all age and gender patients with UVCP that underwent autologous fat augmentation from July 2016 to July 2019. The OQ, ASI, PSI, and FSI were calculated from the HSV recordings by using the montage and fast Fourier transform point analysis. The pre-and post-operative means were compared using a paired student t-test, with a p-value less than 0.05 considered significant. RESULT: A total of 37 patients, age 41.2 ± 11.3 years (21 to 67 years), 59.4% females and 40.6% males, were included in the study. The average duration of symptom onset was 2.3 ± 0.87 months. The post-operative mean values of OQ, ASI, PSI, and FSI following the fat augmentation were significantly improved compared to the pre-operative mean values with p-values <0.0001, 0.0018, 0.0011, and 0.0006, respectively. CONCLUSION: There was a significant improvement in the OQ, ASI, PSI, and FSI in UVCP patients after 6 months of autologous fat augmentation, signifying an enhanced vibratory function. The ability of HSV to measure the minute details of vocal cord vibration by providing quantitative measurements has also been highlighted. The need for future prospective research with an increased sample size and longer duration of follow up is recommended.

Traction Injury of Recurrent Laryngeal Nerve During Thyroidectomy.

BACKGROUND: Loss of the neuromonitoring signal (LOS) during thyroidectomy signifies recurrent laryngeal nerve (RLN) injury, which is one of the common complications, especially by traction injury. Transient intraoperative LOS means spontaneous recovery of nerve function during surgery or within 6-month post-surgery. Few articles discuss intraoperative recovery time and transient LOS, and there is no consensus on the risk factors for RLN traction injury and its recovery course; thus, we wanted to determine the maximum intraoperative recovery time. MATERIALS AND METHODS: This retrospective study included patients who had undergone thyroidectomies at Tainan National Cheng Kung University Hospital between January 2015 and August 2018. A total of 775 patients (with 1000 nerves at risk) who underwent intermittent intraoperative neuromonitoring during thyroidectomy were included in this study. The LOS nerves were divided into 4 groups based on the LOS subtype and the intraoperative status of the recovery. The postoperative vocal cord function was determined by thyroid ultrasound and/or laryngoscope. All the patients would be followed up postoperatively in 2-3 days, 1 week, 2 weeks, and 4-6 weeks. RESULTS: LOS occurred in 67 of 775 (8.6%) patients and in 70 of 1000 nerves at risk (7.0%). There were 2 in 70 nerves (2.9%) with LOS type 1 (segmental nerve traction injury) with intraoperative recovery (Group 1), 5 (7.1%) with LOS type 1 without intraoperative recovery (Group 2), 47 (67.1%) with LOS type 2 (global injury) with intraoperative recovery (Group 3), and 16 (22.8%) with LOS type 2 without intraoperative recovery (Group 4). All LOS type 1 (segmental nerve injury) nerves had pathologic lesions near the RLN or vagus nerve, but none had invaded the nerves (p < 0.05). The resolving time intraoperatively in the 2 patients in Group 1 was 5 min and 10 min, respectively. The resolving time intraoperatively in Group 3 was 1-20 min, and the average time was 4.8 min. In Group 2, 3 injured nerves recovered within 6 weeks postoperatively, and 2 nerves in 12 weeks. In Group 4, all the 16 injured nerves recovered within 6 weeks postoperatively. CONCLUSION: Applying intermittent intraoperative neuromonitoring during thyroidectomy, traction recurrent laryngeal nerve injury still happened in 7.0%. 70% of the injured nerves recovered the function intraoperatively after releasing the traction, and the longest duration of recovery is 20 min.

Can Ultrasound Identify Paradoxical Vocal Fold Movement? A Pilot Study.

OBJECTIVE: Vocal cord dysfunction (VCD) is characterized by paradoxical vocal fold movement (PVFM) during inspiration. The aim of this study was to determine whether ultrasound could accurately differentiate between normal and PVFM during respirations in a resting state. DESIGN: Prospective, single-subject design. SETTING: Academic medical center. PATIENTS: A speech-language pathologist who was able to volitionally alternate between normal and PVFM when breathing at rest was recruited to participate in the study. INTERVENTIONS: The subject was instructed to randomly alternate between normal and PVFM 20 times (10 times each). A single investigator imaged the vocal folds using ultrasound and reported when the subject alternated between the 2 respiratory states. MAIN OUTCOME MEASURES: The subject recorded when they changed between the 2 respiratory states, whether the investigator identified with the change occurred, and if the correct respiratory state was identified. RESULTS: The investigator recognized when the subject changed respiratory states and correctly identified the new respiratory state 100% of the time. CONCLUSIONS: The findings of the current study were promising and suggest that ultrasound may have utility in the diagnosis of VCD. However, because of the preliminary nature of these results, further research is required before recommending its clinical implementation.

Effects of Age on Voice Onset Time and Variability in Children with Repaired Cleft Palate.

OBJECTIVE: To examine the effect of age on voice onset time (VOT) and VOT variability in children with repaired cleft palate. METHODS: Twenty-two children with repaired cleft palate were allocated into two age groups: younger children (YC: n = 13) and older children (OC: n = 9). VOT measurements from monosyllabic words (/pɑ/, /tɑ/, and /kɑ/) and intraspeaker VOT variability estimated by coefficients of variation (CoV) of two age groups were compared. RESULTS: Age was found to have a statistically significant effect on VOT and VOT variability. Specifically, OC had significantly longer VOT (F(1,66) = 4.196, p < 0.05) and less VOT variability (F(1,66) = 6.007, p < 0.05) for English voiceless stops than YC. No statistically significant main effect for speech sample or age by speech sample interaction was observed. CONCLUSIONS: Our data supplement the existing literature by adding VOT and VOT variability information for older children/adolescents with repaired cleft palate. Findings from the study suggest VOT patterns acquired at younger age appear to be further exaggerated and stabilized during the adolescent period among children with repaired cleft palate. A future study is necessary to determine different sources of VOT variability in children with a history of cleft palate, which may have clinical therapeutic implications.

[A CASE OF BRONCHIAL ASTHMA IN A YOUNGER PATIENT WITH VOCAL CORD DYSFUNCTION].

We present a case of a 17-year-old woman with a history of bronchial asthma since two years of age. She had daily asthma attacks from the age of fourteen, and the addition of oral corticosteroids and omalizumab to regular inhaled corticosteroid inhalation failed to relieve symptoms. She was referred to our hospital for detailed examination. On admission, physical examination was normal, but she had complained of dyspnea at the round. Monophonic wheezes and stridor were heard over the anterior neck, while no rales were audible over any part of the chest. Laryngoscopy revealed paradoxical movement of the vocal cords, and a diagnosis of vocal cord dysfunction (VCD) was made. The apparent severe asthma symptoms were considered to reflect VCD, and the treatment for bronchial asthma was stepped down without any recurrence of asthma attacks. Although the etiology of the VCD was unknown, VCD is more common in young women, so stress and personality factors are thought to be involved. It has been noted that childhood asthma often improves between childhood and adolescence, but refractory cases have been noted. In intractable bronchial asthma cases, it is necessary to consider the complications of other diseases, such as VCD, and to perform appropriate management.

Exploring stimulation patterns for electrical stimulation of the larynx using surface electrodes.

PURPOSE: Functional electrical stimulation (FES) is considered an upcoming treatment modality for a number of laryngeal diseases. However, sound data are scarce when it comes to surface FES to treat voice disorders. Aim of the present study was to identify and differentiate suitable surface FES patterns to activate internal laryngeal muscles. METHODS: Non-invasive FES was performed in a cohort of 17 elderly woman. Our user-customized electrical stimulation setup allowed us to deliver ten different stimulation patterns (rectangular and sawtooth shaped) with variation of frequency and amplitude. Stimulation outcome, i.e., vocal fold (VF) reaction, was continuously verified by transnasal endoscopy. RESULTS: Responses to FES using ten different stimulation patterns varied inter-individually. None of the stimulation parameter sets could elicit a VF reaction in all participants. CONCLUSION: Based on our findings we conclude that individual fitting is necessary when defining surface stimulation parameters. To overcome limitations of previous studies, devices with freely programmable patterns are required as shown here. Endoscopic control of VF reaction is absolutely essential to ensure effectiveness of the delivered patterns.

The incidence and recovery rate of idiopathic vocal fold paralysis: a population-based study.

PURPOSE: To determine the incidence and spontaneous recovery rate of idiopathic vocal fold paralysis (IVFP) and paresis (IVFp), and the impact of steroid treatment on rates of recovery. METHODS: This retrospective cohort study included all patients with IVFP or IVFp within a large integrated health-care system between January 1, 2008 and December 31, 2014. Patient demographics and clinical characteristics, including time to diagnosis, spontaneous recovery status, time to recovery, and treatment, were examined. RESULTS: A total of 264 patients were identified, 183 (69.3%) with IVFP and 81 (30.7%) with IVFp. Nearly all cases (96.6%) were unilateral and 89.8% of patients were over the age of 45. The combined (IVFP and IVFp) 7-year mean incidence was 1.04 cases per 100,000 persons each year with the highest 7-year mean annual incidence in white patients (1.60 per 100,000). The total rate of spontaneous recovery was 29.5%, where 21.2% had endoscopic evidence of resolution and 8.3% had clinical improvement in their voice without endoscopic confirmation. The median time to symptom resolution was 4.0 months. Use of steroids was not linked with spontaneous recovery in multivariable analyses. CONCLUSION: The annual incidence of VFP (IVFP and IVFp) was 1.04 cases per 100,000 persons, with spontaneous recovery occurring in nearly a third of patients, regardless of steroid use.

Ultrasonography-guided electromagnetic needle tracking in laryngeal electromyography.

PURPOSE: The clinical evaluation of vocal fold movement disorders should contain the electromyography of the laryngeal muscles (LEMG). The most challenging point in LEMG is the right positioning of the EMG needle in the small target muscles. As the results of the EMG have great influence in the decision of treatment it is important to confirm the results of this examination. Anatomical structures of the larynx should be identified with laryngeal ultrasonography and the ultrasonography (US)-guided electromagnetic needle tracking should guide the LEMG needle to the target muscle. METHODS: The thyroarytenoid (TA) and cricothyroid (CT) muscles had been evaluated in 19 patients (20 examinations). The US-guided transcutaneous LEMG using electromagnetic needle tracking was performed by one ENT doctor and all examinations had been video monitored. The videos were analyzed for the accuracy rate and the visibility of the important laryngeal structures. RESULTS: The laryngeal structures were identified in all the cases using laryngeal ultrasonography. The examination times of the US-guided LEMG were acceptable (8 min, 32 s). The US-guided LEMG was feasible in 56 (36 TA, 20 CT) examinations. The TA and CT could be visualized successfully but in 17 examinations (30%) the signal was not stable. We could still reach the target muscles in more than 50% of these cases. CONCLUSION: US-guided electromagnetic needle tracking in LEMG helps to determine the exact position of the laryngeal structures. With further technical improvement of the stability of the electromagnetic needle tracking signal the US-guided electromagnetic needle tracking of the target muscles in the larynx could help to improve the accuracy of the transcutaneous LEMG.

Inter-rater reliability of seven neurolaryngologists in laryngeal EMG signal interpretation.

PURPOSE: Laryngeal electromyography (LEMG) has been considered as gold standard in diagnostics of vocal fold movement impairment, but is still not commonly implemented in clinical routine. Since the signal interpretation of LEMG signals (LEMGs) is often a subjective and semi-quantitative matter, the goal of this study was to evaluate the inter-rater reliability of neurolaryngologists on LEMGs of volitional muscle activity. METHODS: For this study, 52 representative LEMGs of 371 LEMG datasets were selected from a multicenter registry for a blinded evaluation by 7 experienced members of the neurolaryngology working group of the European Laryngological Society (ELS). For the measurement of the observer agreement between two raters, Cohen's Kappa statistic was calculated. For the interpretation of agreements of diagnoses among the seven examiners, we used the Fleiss' Kappa statistic. RESULT: When focusing on the categories "no activity", "single fiber pattern", and "strongly decreased recruitment pattern", the inter-rater agreement varied from Cohen's Kappa values between 0.48 and 0.84, indicating moderate to near-perfect agreement between the rater pairs. Calculating with Fleiss' Kappa, a value of 0.61 showed good agreement among the seven raters. For the rating categories, the Fleiss' Kappa value ranged from 0.52 to 0.74, which also showed a good agreement. CONCLUSION: A good inter-rater agreement between the participating neurolaryngologists was achieved in the interpretation of LEMGs. More instructional courses should be offered to broadly implement LEMG as a reliable diagnostic tool in evaluating vocal fold movement disorders in clinical routine and to develop future algorithms for therapy and computer-assisted examination.

Bilateral vocal fold injection with autologous fat in patients with vocal fold atrophy with or without sulcus.

PURPOSE: To evaluate voice outcome after bilateral vocal fold injection with autologous fat in patients with non-paralytic glottic insufficiency due to vocal fold atrophy with or without sulcus. METHODS: This is a retrospective cohort study from September 2012 to December 2017 including 23 patients undergoing bilateral vocal fold injection with autologous fat (24 procedures) for vocal fold atrophy (15 procedures) or atrophy with sulcus (Ford type II or III) (9 procedures). Voice data were collected and analyzed for the preoperative and the 3- and 12-month postoperative time points according to a standardized protocol, including Voice Handicap Index (VHI)-30 and perceptive, acoustic and aerodynamic parameters. Failure rate was defined as non-relevant improvement (< 10 points) in VHI-30 at 12 months and number of revisions within 12 months. RESULTS: There was a clinically relevant (≥ 15 points) and statistically significant improvement in the VHI-30 (preoperative: 49.1 points; postoperative at 12 months: 29.7 points). Change in dynamic range was also statistically significant over time (p = 0.028). There were no differences in voice parameters between patients with atrophy only and atrophy with sulcus, although grade tended to be lower in patients with atrophy only over all time points. CONCLUSION: This study shows that bilateral vocal fold injection with autologous fat is a beneficial treatment not only for patients with atrophy but also for patients with sulcus. A comparison of the results with those reported from other forms of sulcus surgery confirmed this finding. However, there is a need for further prospective studies comparing the short- and long-term effects of different techniques.

Automatic speech and singing classification in ambulatory recordings for normal and disordered voices.

Ambulatory voice monitoring is a promising tool for investigating phonotraumatic vocal hyperfunction (PVH), associated with the development of vocal fold lesions. Since many patients with PVH are professional vocalists, a classifier was developed to better understand phonatory mechanisms during speech and singing. Twenty singers with PVH and 20 matched healthy controls were monitored with a neck-surface accelerometer-based ambulatory voice monitor. An expert-labeled ground truth data set was used to train a logistic regression on 15 subject-pairs with fundamental frequency and autocorrelation peak amplitude as input features. Overall classification accuracy of 94.2% was achieved on the held-out test set.

Effect of three semi-occluded vocal tract therapy programmes on the phonation of patients with dysphonia: lip trill, water-resistance therapy and straw phonation.

BACKGROUND: To date, the immediate effects of a semi-occluded vocal tract (SOVT) configuration have been thoroughly demonstrated. However, it is not yet sufficiently confirmed whether a therapy programme (i.e. longer than one session) using SOVT exercises leads to an enhanced phonation and improved vocal quality. AIMS: The aim of this study was to investigate the effect of three SOVT therapy programmes: lip trill, water-resistance therapy (WRT) and straw phonation, on the vocal quality, vocal capacities, psychosocial impact and vocal tract discomfort of patients with dysphonia. METHODS & PROCEDURES: A blocked-randomized sham-controlled trial was used. Thirty-five patients with dysphonia (mean age = 21 years; 33 women, two men) were assigned to either a lip trill group, a WRT group, a straw phonation group or a control group using blocked randomization. The lip trill, WRT and straw phonation groups practised their respective SOVT exercise across 3 weeks, whereas the control group received a sham treatment across the same time span. A multidimensional voice assessment consisting of both objective (multiparametric indices: Dysphonia Severity Index (DSI), Acoustic Voice Quality Index (AVQI)) and subjective (subject's self-report, auditory-perceptual evaluation) vocal outcomes was performed by a blinded assessor pre- and post-therapy. OUTCOMES & RESULTS: Lip trill and straw phonation therapy led to a significant improvement in DSI. Auditory-perceptual grade and roughness significantly decreased after straw phonation. Lip trill and WRT both led to a significant decrease in Voice Handicap Index. Subjects reported a better self-perceived vocal quality and a more comfortable voice production after WRT. No changes were found after the sham treatment in the control group. CONCLUSIONS & IMPLICATIONS: Results suggest that SOVT therapy programmes including lip trill or straw phonation can improve the objective vocal quality in patients with dysphonia. Auditory-perceptual improvements were found after straw phonation therapy, whereas psychosocial improvements were found after lip trill and WRT. Patients seem to experience more comfort and a better self-perceived vocal quality after WRT. This study supports the use of the three SOVT therapy programmes in clinical practice. They all had a positive impact on one or more outcomes of the multidimensional voice assessment. Strikingly, vocal quality outcomes were not in line with the subject's opinion. Larger-scale investigation is needed to support these preliminary findings.

Management of Vocal Fold Scars by Concurrent Nanofat and Microfat Grafting.

Vocal fold scarring is the cause of severe dysphonia and represents a therapeutic challenge; dysphagia can also be present in case of soft tissue defect due to previous oncological surgery. The ideal surgical solution should concurrently provide vocal fold augmentation and re-establishment of tissue elasticity. Nanofat technique has given so far promising results in remodeling skin scars and improving tissue pliability. The present paper describes for the first time the use of nanofat injected into the vocal fold cover for pliability restoration, combined with traditional microfat for vocal fold augmentation. Seven patients (aged 23-77 years) affected by severe dysphonia, related to extensive vocal fold scarring (3 of them were also affected by dysphagia for liquid consistencies), underwent a single procedure of concurrent microfat and nanofat vocal fold injection under direct microlaryngoscopy in general anesthesia. Results were evaluated by objective outcome measures and auto evaluation performed by questionnaires concerning the phonatory and swallowing efficiency. The voice quality and the perceived swallowing capability of all patients improved after surgery and are stable at follow-up (4-8 months). The reported preliminary data show that nanofat, due to its regenerative potential related to adipose-derived stem cells and growth factors, can be a promising adjunct to traditional fat augmentation to improve elasticity of the delicate multilayered structure of the vocal fold and to enhance its vibratory capabilities. Further experience on a wider number of patients and long-term follow-up are necessary to confirm the validity of this technique.

Do I sound dry? Comparative voice analysis of primary Sjögren's syndrome.

OBJECTIVES: Desiccation of the vocal tract can cause many voice problems. Therefore, we aimed to investigate whether patients with primary Sjögren's syndrome (pSS) with dry mouth have more voice-related problems than controls without the disease and to determine the factors affecting voice in pSS patients. METHODS: Patients with pSS and controls complaining of voice-related symptoms underwent acoustic analysis, aerodynamic study and stroboscopic analysis. They also completed the voice handicap index (VHI) questionnaire and perceptual voice analysis (GRBAS). Various disease-related parameters were obtained from pSS registry data. RESULTS: Fifty-five pSS patients and 52 controls were analysed. The subjects were all female, and mean age was 53.9 years. VHI score was significantly higher in the pSS patient group (median [interquartile range], 11 [3-30] vs. 5.5 [0- 15.75], p=0.014). However, the results of acoustic analysis aerodynamic study and stroboscopic findings were not different between the two groups. Disease-related parameters were available in 47 pSS patients. Correlation analysis revealed that jitter value positively correlated with ESSDAI (spearman's rho = 0.29, p=0.048) and patient global assessment (rho=0.3, p= 0.04). High VHI score was associated with low quality of life measured by EQ5D (rho=-0.493, p=0.0001). Of note, patients with longer disease duration (≥ 40 months) showed higher noise-to-harmonics ratio (NHR). CONCLUSIONS: Patients with pSS had higher VHI score, which was associated with low quality of life and longer disease duration was associated with increased noise in pSS patients. The likelihood of voice problems should be addressed with pSS patients, and vocal hygiene education will be important in those patients.

Exploiting nonlinearity of the speech production system for voice disorder assessment by recurrence quantification analysis.

This work summarizes the research related to digital speech signal processing with recurrence quantification analysis (RQA) applied to voice disorder assessment. The main motivation for these studies is the fact that RQA is able to exploit the nonlinear dynamical nature of the speech production system. Due to the use of recurrence quantification measures to represent the behavior of speech signals, promising results were obtained in the characterization and classification of laryngeal pathologies and voice disorders. These contributions may help one to evaluate the usability and efficiency of RQA in vocal disorder assessment.