Neonatal hearing screening - does failure in TEOAE screening matter when the AABR test is passed?

PURPOSE: Newborns who fail the transient evoked otoacoustic emissions (TEOAE) but pass the automatic auditory brainstem response (AABR) in universal newborn hearing screening (UNHS), frequently have no further diagnostic test or follow-up. The present study aimed to investigate whether hearing loss might be missed by ignoring neonatal TEOAE failure in the presence of normal AABR. METHODS: A retrospective analysis was conducted in newborns presenting between 2017 and 2021 to a tertiary referral centre due to failure in the initial UNHS. The main focus was on infants who failed TEOAE tests, but passed AABR screening. The clinical characteristics and audiometric outcomes were analysed and compared with those of other neonates. RESULTS: Among 1,095 referred newborns, 253 (23%) failed TEOAE despite passing AABR screening. Of the 253 affected infants, 154 returned for follow-up. At 1-year follow-up, 46 (28%) achieved normal audiometric results. 32 (21%) infants had permanent hearing loss (HL) confirmed by diagnostic ABR, 58 (38%) infants had HL solely due to middle ear effusion (MEE), and for 18 (12%) infants HL was suspected without further differentiation. The majority of permanent HL was mild (78% mild vs. 13% moderate vs. 9% profound). The rate of spontaneous MEE clearance was rather low (29%) leading to early surgical intervention in 36 children. The profile of the risk factors for hearing impairment was similar to that of newborns with failure in both, TEOAE and AABR; however, there was a stronger association between the presence of risk factors and the incidence of HL (relative risk 1.55 vs. 1.06; odds ratio 3.61 vs. 1.80). CONCLUSION: In newborns, the discordance between a "refer" in TEOAE and a "pass" in AABR screening is associated with a substantial prevalence of hearing impairment at follow-up, especially in the presence of risk factors.

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.

Machine learning based estimation of hoarseness severity using sustained vowelsa).

Auditory perceptual evaluation is considered the gold standard for assessing voice quality, but its reliability is limited due to inter-rater variability and coarse rating scales. This study investigates a continuous, objective approach to evaluate hoarseness severity combining machine learning (ML) and sustained phonation. For this purpose, 635 acoustic recordings of the sustained vowel /a/ and subjective ratings based on the roughness, breathiness, and hoarseness scale were collected from 595 subjects. A total of 50 temporal, spectral, and cepstral features were extracted from each recording and used to identify suitable ML algorithms. Using variance and correlation analysis followed by backward elimination, a subset of relevant features was selected. Recordings were classified into two levels of hoarseness, H<2 and H≥2, yielding a continuous probability score y∈[0,1]. An accuracy of 0.867 and a correlation of 0.805 between the model's predictions and subjective ratings was obtained using only five acoustic features and logistic regression (LR). Further examination of recordings pre- and post-treatment revealed high qualitative agreement with the change in subjectively determined hoarseness levels. Quantitatively, a moderate correlation of 0.567 was obtained. This quantitative approach to hoarseness severity estimation shows promising results and potential for improving the assessment of voice quality.

Articulatory and acoustic differences between lyric and dramatic singing in Western classical music.

Within the realm of voice classification, singers could be sub-categorized by the weight of their repertoire, the so-called "singer's Fach." However, the opposite pole terms "lyric" and "dramatic" singing are not yet well defined by their acoustic and articulatory characteristics. Nine professional singers of different singers' Fach were asked to sing a diatonic scale on the vowel /a/, first in what the singers considered as lyric and second in what they considered as dramatic. Image recording was performed using real time magnetic resonance imaging (MRI) with 25 frames/s, and the audio signal was recorded via an optical microphone system. Analysis was performed with regard to sound pressure level (SPL), vibrato amplitude, and frequency and resonance frequencies as well as articulatory settings of the vocal tract. The analysis revealed three primary differences between dramatic and lyric singing: Dramatic singing was associated with greater SPL and greater vibrato amplitude and frequency as well as lower resonance frequencies. The higher SPL is an indication of voice source changes, and the lower resonance frequencies are probably caused by the lower larynx position. However, all these strategies showed a considerable individual variability. The singers' Fach might contribute to perceptual differences even for the same singer with regard to the respective repertoire.

Primary injection laryngoplasty after chordectomy for small glottic carcinomas.

OBJECTIVES: The purpose of this study was to analyze the short- and middle-term effects of primary injection laryngoplasty in patients having tumor resection within the same surgery concerning the vocal outcome. Injection laryngoplasty was performed after harvesting autologous adipose tissue via lipoaspiration. METHODS: A prospective study was performed with 16 patients (2 female; 14 male) who received tumor resection and an injection laryngoplasty using autologous adipose tissue during a single stage procedure. Multidimensional voice evaluation including videostroboscopy, patient self-assessment, voice perception, aerodynamics, and acoustic parameters was performed preoperatively, as well as 1.5, 3 and 6 months postoperatively. RESULTS: Results show an improvement in the roughness-breathiness-hoarseness (RBH) scale, voice dynamics and subjective voice perception 6 months postoperatively. Maintenance of Voice Handycap Index, jitter and shimmer could be observed 6 months postoperatively. There was no deterioration in RBH and subjective voice perception 2 and 6 weeks postoperatively. No complications occurred in the fat harvesting site. CONCLUSIONS: Using the lipoaspiration and centrifugation approach, primary fat injection laryngoplasty shows short-term maintenance und middle-term improvement in voice quality in patients with vocal fold defect immediately after chordectomy 6 months postoperatively. Cancer recurrence rate is comparable to the reported cancer recurrence rate for laryngeal carcinoma and thus not elevated through primary augmentation.

Dynamic changes of vocal tract dimensions with sound pressure level during messa di vocea).

The messa di voce (MdV), which consists of a continuous crescendo and subsequent decrescendo on one pitch is one of the more difficult exercises of the technical repertoire of Western classical singing. With rising lung pressure, regulatory adjustments both on the level of the glottis and the vocal tract are required to keep the pitch stable. The dynamic changes of vocal tract dimensions with the bidirectional variation of sound pressure level (SPL) during MdV were analyzed by two-dimensional real-time magnetic resonance imaging (25 frames/s) and synchronous audio recordings in 12 professional singer subjects. Close associations in the respective articulatory kinetics were found between SPL and lip opening, jaw opening, pharynx width, uvula elevation, and vertical larynx position. However, changes in vocal tract dimensions during plateaus of SPL suggest that perceived loudness could have been varied beyond the dimension of SPL. Further multimodal investigation, including the analysis of sound spectra, is needed for a better understanding of the role of vocal tract resonances in the control of vocal loudness in human phonation.

Sub-millisecond 2D MRI of the vocal fold oscillation using single-point imaging with rapid encoding.

OBJECTIVE: The slow spatial encoding of MRI has precluded its application to rapid physiologic motion in the past. The purpose of this study is to introduce a new fast acquisition method and to demonstrate feasibility of encoding rapid two-dimensional motion of human vocal folds with sub-millisecond resolution. METHOD: In our previous work, we achieved high temporal resolution by applying a rapidly switched phase encoding gradient along the direction of motion. In this work, we extend phase encoding to the second image direction by using single-point imaging with rapid encoding (SPIRE) to image the two-dimensional vocal fold oscillation in the coronal view. Image data were gated using electroglottography (EGG) and motion corrected. An iterative reconstruction with a total variation (TV) constraint was used and the sequence was also simulated using a motion phantom. RESULTS: Dynamic images of the vocal folds during phonation at pitches of 150 and 165 Hz were acquired in two volunteers and the periodic motion of the vocal folds at a temporal resolution of about 600 µs was shown. The simulations emphasize the necessity of SPIRE for two-dimensional motion encoding. DISCUSSION: SPIRE is a new MRI method to image rapidly oscillating structures and for the first time provides dynamic images of the vocal folds oscillations in the coronal plane.

Velocity differences in laryngeal adduction and abduction gestures.

The periodic repetitions of laryngeal adduction and abduction gestures were uttered by 16 subjects. The movement of the cuneiform tubercles was tracked over time in the laryngoscopic recordings of these utterances. The adduction velocity and abduction velocity were determined objectively by means of a piecewise linear model fitted to the cuneiform tubercle trajectories. The abduction was found to be significantly faster than the adduction. This was interpreted in terms of the biomechanics and active control by the nervous system. The biomechanical properties could be responsible for a velocity of abduction that is up to 51% higher compared to the velocity of adduction. Additionally, the adduction velocity may be actively limited to prevent an overshoot of the intended adduction degree when the vocal folds are approximated to initiate phonation.

Are source-filter interactions detectable in classical singing during vowel glides?

In recent studies, it has been assumed that vocal tract formants (Fn) and the voice source could interact. However, there are only few studies analyzing this assumption in vivo. Here, the vowel transition /i/-/a/-/u/-/i/ of 12 professional classical singers (6 females, 6 males) when phonating on the pitch D4 [fundamental frequency (ƒo) ca. 294 Hz] were analyzed using transnasal high speed videoendoscopy (20.000 fps), electroglottography (EGG), and audio recordings. Fn data were calculated using a cepstral method. Source-filter interaction candidates (SFICs) were determined by (a) algorithmic detection of major intersections of Fn/nƒo and (b) perceptual assessment of the EGG signal. Although the open quotient showed some increase for the /i-a/ and /u-i/ transitions, there were no clear effects at the expected Fn/nƒo intersections. In contrast, ƒo adjustments and changes in the phonovibrogram occurred at perceptually derived SFICs, suggesting level-two interactions. In some cases, these were constituted by intersections between higher nƒo and Fn. The presented data partially corroborates that vowel transitions may result in level-two interactions also in professional singers. However, the lack of systematically detectable effects suggests either the absence of a strong interaction or existence of confounding factors, which may potentially counterbalance the level-two-interactions.

Investigation of resonance strategies of high pitch singing sopranos using dynamic three-dimensional magnetic resonance imaging.

Resonance-strategies with respect to vocal registers, i.e., frequency-ranges of uniform, demarcated voice quality, for the highest part of the female voice are still not completely understood. The first and second vocal tract resonances usually determine vowels. If the fundamental frequency exceeds the vowel-shaping resonance frequencies of speech, vocal tract resonances are tuned to voice source partials. It has not yet been clarified if such tuning is applicable for the entire voice-range, particularly for the top pitches. We investigated professional sopranos who regularly sing pitches above C6 (1047 Hz). Dynamic three-dimensional (3D) magnetic resonance imaging was used to calculate resonances for pitches from C5 (523 Hz) to C7 (2093 Hz) with different vowel configurations ([a:], [i:], [u:]), and different contexts (scales or octave jumps). A spectral analysis and an acoustic analysis of 3D-printed vocal tract models were conducted. The results suggest that there is no exclusive register-defining resonance-strategy. The intersection of fundamental frequency and first vocal tract resonance was not found to necessarily indicate a register shift. The articulators and the vocal tract resonances were either kept without significant adjustments, or the fR1:fo-tuning, wherein the first vocal tract resonance enhances the fundamental frequency, was applied until F6 (1396 Hz). An fR2:fo-tuning was not observed.

[Long-term course after inpatient speech therapy: educational and language development of children with severe specific language impairment (SLI)]. / Langzeitverlauf nach stationärer Sprachtherapie: schulische und sprachliche Entwicklung von Kindern mit schwerer spezifischer Sprachentwicklungsstörung (SES).

BACKGROUND: Studies from primarily English-speaking countries have shown that specific language impairments can lead to disadvantages in educational and professional development. Corresponding studies for Germany have not been published. This study surveys the educational and language outcomes of adolescents and young adults who were treated in an inpatient setting during childhood. MATERIALS AND METHODS: A total of 193 young adults who had received inpatient treatment between 1998 and 2005 at the Department of Communication Disorders of the Department of Otorhinolaryngology, Head, and Neck Surgery (ENT) of the Mainz University Medical Center were assessed. The cohort was contacted by telephone and interviewed about aspects of their educational and language development using a specially developed questionnaire. It was possible to include 70 participants in the study. RESULTS: Almost half (48.6%; n = 34) of the participants had attended a regular elementary school and 50% (n = 35) attended a special school with a focus on speech-language development (others: 1.4%, n = 1). Regarding school-leaving qualifications, 31.5% (n = 22) finished school with an Abitur/Fachabitur (high-school-level certificate), 33% (n = 23) with a Realschulabschluss (secondary school certificate), 30% (n = 21) with a Hauptschulabschluss (lower secondary certificate), and 4% (n = 3) with a special school certificate. Only one participant left school without a qualification. Of the interviewed participants, 71% (n = 50) do not feel any speech language limitations anymore. CONCLUSION: The results indicate a positive educational and language development of children with SLI after inpatient treatment in Germany. Over 90% of the participants finished school with a regular certification and most of them do not feel any speech and language limitations anymore.

Magnetic resonance imaging of the vocal fold oscillations with sub-millisecond temporal resolution.

PURPOSE: The temporal resolution of the MRI acquisition is intrinsically limited by the duration of the spatial encoding, which is typically on the order of milliseconds. Faster motion such as the vibration of the vocal folds during phonation cannot be imaged with conventional MRI as this would require sampling frequencies in the kilo-Hertz range. Here, a faster MRI acquisition strategy is presented that encodes a 1D periodic motion at a temporal resolution that is an order of magnitude higher compared to conventional MRI. METHODS: The proposed method encodes the position of an object moving along 1 dimension by applying very short phase encoding gradients along the same direction. This reduces the temporal resolution from the repetition time (TR) to the duration of the phase encoding gradients, which in this work was well below 1 ms. The technique is applied to the vocal fold oscillations and the position of the vocal folds is measured simultaneously using electroglottography (EGG). Simulations of the point spread function for regular encoding and the proposed method are performed as well. RESULTS: With this new phase, encoding strategy oscillations of the human vocal folds up to a frequency of 145 Hz could be dynamically imaged at 10 images per cycle. Simulations show the advantage of this method over conventional imaging of fast moving objects. CONCLUSION: A new method for MR imaging of fast moving spins is presented allowing a temporal resolution below 1 ms at a spatial resolution below 1 mm, circumventing TR as the limit for temporal resolution.

The impact of a standardized vocal loading test on vocal fold oscillations.

INTRODUCTION: Vocal loading capacity is an important aspect of vocal health and is measured using standardized vocal loading tests. However, it remains unclear how vocal fold oscillation patterns are influenced by a standardized vocal loading task. METHODS: 21 (10 male, 11 female) vocally healthy subjects were analyzed concerning the dysphonia severity index (DSI) and high speed videolaryngoscopy (HSV) on the vowel /i/ at a comfortable pitch and loudness before and after a standardized vocal loading test (10 min standardized text reading, at a level higher than 80 dB (A) measured at 30 cm from the mouth). RESULTS: Changes in DSI were statistically significant, diminishing by 1.2 points after the vocal loading test, which was mainly caused by an increase of the minimum intensity. However, the pre-post comparison of HSV derived measures failed to show any statistically significant changes. CONCLUSION: It seems necessary to analyze the effects of a standardized vocal loading test on vocal fold oscillation patterns with respect to softest phonation and phonation threshold pressure rather than comfortable pitch and loudness. Level of evidence 2c.

Immediate effects of water resistance therapy on patients with vocal fold mass lesions.

INTRODUCTION: Semi-occluded vocal tract exercises, such as water resistance therapy (WRT), are widely used in voice therapy. However, the potential positive effects of such a therapy on vocal fold oscillation patterns in patients indicating a need for phonomicrosurgery have not yet been explored. The presented study aims to analyze the effect of WRT in patients suffering from vocal fold mass lesions. MATERIALS AND METHODS: Eight participants with vocal fold mass lesions were asked to sustain a phonation on the vowel /i/ at a comfortable loudness and a fundamental frequency of 250 Hz (females) or 125 Hz (males). During phonation the subjects were simultaneously recorded with transnasal high-speed videoendoscopy (HSV, 20.000 fps), electroglottography, and audio signals. These subjects then performed a WRT (phonation in a silicone tube of 30 cm length, 5 cm below the water surface) for 10 min. Repeated measurements of sustained phonation were performed 0, 10, and 30 min after exercising. From the HSV data the glottal area waveform (GAW) was segmented and GAW parameters were computed. RESULTS: During WRT there was an increase of the GAW related open quotient and closing quotient. Immediately after WRT, there was a drop of both values followed by a rise of these parameters up to 30 min after the intervention. Furthermore, there was no correlation between GAW and electroglottographical open quotients. CONCLUSIONS: The effects observed after a single session of WRT on participants with vocal fold mass lesions showed a similar pattern to vocal fatigue.

How the peak glottal area affects linear predictive coding-based formant estimates of vowels.

The estimation of formant frequencies from acoustic speech signals is mostly based on Linear Predictive Coding (LPC) algorithms. Since LPC is based on the source-filter model of speech production, the formant frequencies obtained are often implicitly regarded as those for an infinite glottal impedance, i.e., a closed glottis. However, previous studies have indicated that LPC-based formant estimates of vowels generated with a realistically varying glottal area may substantially differ from the resonances of the vocal tract with a closed glottis. In the present study, the deviation between closed-glottis resonances and LPC-estimated formants during phonation with different peak glottal areas has been systematically examined both using physical vocal tract models excited with a self-oscillating rubber model of the vocal folds, and by computer simulations of interacting source and filter models. Ten vocal tract resonators representing different vowels have been analyzed. The results showed that F1 increased with the peak area of the time-varying glottis, while F2 and F3 were not systematically affected. The effect of the peak glottal area on F1 was strongest for close-mid to close vowels, and more moderate for mid to open vowels.

Frontal lobe epileptic seizures are accompanied by elevated pitch during verbal communication.

The objective of our study was to assess alterations in speech as a possible localizing sign in frontal lobe epilepsy. Ictal speech was analyzed in 18 patients with frontal lobe epilepsy (FLE) during seizures and in the interictal period. Matched identical words were analyzed regarding alterations in fundamental frequency (ƒo) as an approximation of pitch. In patients with FLE, ƒo of ictal utterances was significantly higher than ƒo in interictal recordings (p = 0.016). Ictal ƒo increases occurred in both FLE of right and left seizure origin. In contrast, a matched temporal lobe epilepsy (TLE) group showed less pronounced increases in ƒo, and only in patients with right-sided seizure foci. This study for the first time shows significant voice alterations in ictal speech in a cohort of patients with FLE. This may contribute to the localization of the epileptic focus. Increases in ƒo were interestingly found in frontal lobe seizures with origin in either hemisphere, suggesting a bilateral involvement to the planning of speech production, in contrast to a more right-sided lateralization of pitch perception in prosodic processing.

A comparison of electroglottographic and glottal area waveforms for phonation type differentiation in male professional singers.

This study compares the use of electroglottograms (EGGs) and glottal area waveforms (GAWs) to study phonation in different vibratory states as produced by professionally trained singers. Six western classical tenors were asked to phonate pitch glides from modal to falsetto phonation, or from modal to their stage voice above the passaggio (SVaP). For each pitch glide the sample entropy (SampEn) of the EGG signal was calculated to detect the occurrence of phonatory instabilities and establish a "ground truth" for the performed phonation type. The cycles before the maximum SampEn were labeled as modal, and the cycles after the peak were labeled as either falsetto, or SVaP. Three automatic categorizations of vibratory state were performed using clustering: one based only on the EGG, one based on the GAW, and one based on their combination. The error rate (clustering vs ground truth) was, on average, lower than 10% for all of the three settings, revealing no special advantage of the GAW over EGG, and vice versa. Modal voice cycles exhibited a larger contact quotient, larger normalized derivative peak ratio, and lower rise time, compared to SVaP and falsetto. The GAW-based normalized maximum area declination rate was larger in SVaP compared to modal voice.

[An across-scales analysis of the voice self-concept questionnaire (FESS)]. / Skalenübergreifende Auswertung des Fragebogens zur Erfassung des stimmlichen Selbstkonzepts (FESS).

BACKGROUND: The questionnaire for the assessment of the voice selfconcept (FESS) contains three sub-scales indicating the personal relation with the own voice. The scales address the relationship with one's own voice, the awareness of the use of one's own voice, and the perception of the connection between voice and emotional changes. A comprehensive approach across the three scales supporting a simplified interpretation of the results was still missing. MATERIAL AND METHOD: The FESS questionnaire was used in a sample of 536 German teachers. With a discrimination analysis, commonalities in the scale characteristics were investigated. For a comparative validation with voice health and psychological and physiological wellbeing, the Voice Handicap Index (VHI), the questionnaire for Work-related Behavior and Experience Patterns (AVEM), and the questionnaire for Health-related Quality of Life (SF-12) were additionally collected. RESULTS: The analysis provided four different groups of voice self-concept: group 1 with healthy values in the voice self-concept and wellbeing scales, group 2 with a low voice self-concept and mean wellbeing values, group 3 with a high awareness of the voice use and mean wellbeing values and group 4 with low values in all scales. CONCLUSION: The results show that a combined approach across all scales of the questionnaire for the assessment of the voice self-concept enables a more detailed interpretation of the characteristics in the voice self-concept. The presented groups provide an applicable use supporting medical diagnoses.

One-second MRI of a three-dimensional vocal tract to measure dynamic articulator modifications.

PURPOSE: To enable three-dimensional (3D) vocal tract imaging of dynamic singing or speech tasks at voxel sizes of 1.6 × 1.6 × 1.3 mm3 at 1.3 s per image. MATERIALS AND METHODS: A Stack-of-Stars method was implemented and enhanced to allow for fast and efficient k-space sampling of the box-shaped vocal tract using a 3 Tesla MRI system. Images were reconstructed using an off-line image reconstruction using compressed sensing theory, leading to the abovementioned spatial and temporal resolutions. To validate spatial resolution, a phantom with holes of defined sizes was measured. The applicability of the imaging method was validated in an eight-subject study of amateur singers that were required to sustain phonation at a constant pitch, past their comfortable expiratory level. A segmentation of the vocal tract over all phonation time steps was done for one subject. Anatomical distances (larynx position and pharynx width) were calculated and compared for all subjects. RESULTS: Analysis of the phantom study revealed that the imaging method could provide at least 1.6 mm isotropic resolution. Visual inspection of the segmented vocal tract during phonation showed modifications of the lips, tongue, and larynx position in all three dimensions. The mean larynx position per subject amounted to 52-85 mm, deviating up to 5% over phonation time. Parameter pharynx width was 32-181 mm2 on average per subject, deviating up to 16% over phonation time. Visual inspection of the parameter course revealed no common compensation strategy for long sustained phonation. CONCLUSION: The results of both phantom and in vivo measurements show the applicability of the fast 3D imaging method for voice research and indicate that modifications in all three dimensions can be observed and quantified. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 1 J. MAGN. RESON. IMAGING 2017;46:94-101.