A comparison of Dysphonia Severity Index and Acoustic Voice Quality Index measures in differentiating normal and dysphonic voices.

PURPOSE: The aim of the study was to investigate and compare the feasibility and robustness of the Acoustic Voice Quality Index (AVQI) and the Dysphonia Severity Index (DSI) in diagnostic accuracy, differentiating normal and dysphonic voices. METHODS: A group of 264 subjects with normal voices (n = 105) and with various voice disorders (n = 159) were asked to read aloud a text and to sustain the vowel /a/. Both speech tasks were concatenated, and perceptually rated for dysphonia severity by five voice clinicians. They rated the Grade (G) and the overall dysphonia severity with a visual analog scale (VAS). All concatenated voice samples were acoustically analyzed to receive an AVQI score. For DSI analysis, the required voice parameters were obtained from the sustained phonation of the vowel /a/. RESULTS: The results achieved significant and marked concurrent validity between both auditory-perceptual judgment procedures and both acoustic voice measures. The DSI threshold (i.e., DSI = 3.30) pertaining to Gmean obtained reasonable sensitivity of 85.8% and specificity of 83.4%. For VASmean, the DSI threshold of 3.30 was determined also with reasonable sensitivity of 70.3% and excellent specificity of 93.9%. Also, the AVQI threshold (i.e., AVQI = 3.31) pertaining to Gmean demonstrated reasonable sensitivity of 78.1% and excellent specificity of 92.0%. For VASmean, an AVQI threshold of 3.33 was determined with excellent sensitivity of 97.0% and reasonable specificity of 81.8%. CONLUSION: The outcomes of the present study indicate comparable results between DSI and AVQI with a high level of validity to discriminate between normal and dysphonic voices. However, a higher level of accuracy was yielded for AVQI as a correlate of auditory perceptual judgment suggesting a reliable voice screening potential of AVQI.

The improvement of internal consistency of the Acoustic Voice Quality Index.

PURPOSE: This investigation aims to explore the improvement of the relatively new hoarseness severity quantification method, called Acoustic Voice Quality Index (AVQI), which measures the concatenation of continuous speech (CS) and sustained phonation (SP) segments. Earlier investigations indicated that the proportion of the SP is more dominant in the final AVQI result than the CS. METHOD: Sixty voice samples were selected with different voice pathologies and equal distribution of hoarseness severity ranged from normal to severe. Every voice sample varied in three different durations: voice duration-one (VD-1) with seventeen syllables text plus three seconds of SP, voice duration-two (VD-2) with customized length of CS plus three seconds of SP, and voice duration-three (VD-3) with a whole text plus three seconds SP. All voice samples were perceptually judged on overall voice quality by five experienced voice clinicians. AVQI's precision and concurrent validity were assessed in all three VDs. Finally, the internal consistency across all three VDs was analyzed. RESULTS: No significant differences were found in the perceptual evaluation of overall voice quality across all three VDs by acceptable rater reliability. The concurrent validity distinguished in all three VDs as a marked degree of correlation (i.e., ranged from rs=0.891 to rs=0.929) with no significant differences across all three VDs. The best precision was found in VD-2. Finally, the internal consistency showed in VD-2 a balanced out impact of the final AVQI score with no significant differences from both speech tasks. CONCLUSION: Although AVQI currently uses the speech material of VD-1, the present study demonstrated the best results in VD-2 (i.e., precision and internal consistency). These features of VD-2 facilitate higher representativity and improve the validity of this objective diagnostic instrument.

The value of the acoustic voice quality index as a measure of dysphonia severity in subjects speaking different languages.

The Acoustic Voice Quality Index (AVQI) is a relatively new clinical method to quantify dysphonia severity. Since it partially relies on continuous speech, its performance may vary with voice-related phonetic differences and thus across languages. The present investigation therefore assessed the AVQI's performance in English, Dutch, German, and French. Fifty subjects were recorded reading sentences in the four languages, as well as producing a sustained vowel. These recordings were later edited to calculate the AVQI. The samples were also perceptually rated on overall dysphonia severity by three experienced voice clinicians. The AVQI's cross-linguistic concurrent validity and diagnostic precision were assessed. The results support earlier data, and confirm good cross-linguistic validity and diagnostic accuracy. Although no statistical differences were observed between languages, the AVQI performed better in English and German and less well in French. These results validate the AVQI as a potentially robust and objective dysphonia severity measure across languages.

A Retrospective Study of Acoustic Measures of Glottal Stop Production to Assess Vocal Function in Unilateral Vocal Fold Paresis/Paralysis Patients.

PURPOSE: The aim of this study was to determine (a) diagnostic accuracy of acoustic measures of glottal stop production (GSP; intensity differences, slopes, complete voicing cessation) to distinguish between unilateral vocal fold paresis/paralysis (UVFP) patients and controls; (b) if acoustic measures of GSP significantly correlated with an acoustic measure of voice disorder severity, acoustic voice quality index (AVQI); and (c) if acoustic measures from another type of voicing cessation, voiceless consonant production, also significantly differed between groups. METHOD: Ninety-seven patients with unilateral paresis/paralysis and 35 controls with normal laryngostroboscopic signs produced two sets of five repeated [i] and four repeated [isi]. Tokens were randomized by type between groups and analyzed blinded using a customized Praat program that computed intensity differences and slopes between vowel maxima and glottal stop minima for inter-[i] tokens and vowel maxima and voiceless consonant minima for intra-[isi] tokens. The number of voicing cessations for inter-[i] tokens was obtained. RESULTS: Onset and offset intensity differences and number of voicing cessations from inter-[i] tokens had the greatest areas under the curve (.854, .856, and .835, respectively). Correlation coefficients were significant (p < .01) between AVQI and all GSP acoustic measures with weak/medium effect sizes. No significant differences were found between controls and participants with UVFP for acoustic measures from intra-[isi]. CONCLUSIONS: Acoustic GSP measures demonstrated good diagnostic accuracy and some relationship to severity of voice disorder. No significant differences in acoustic measures for medial voiceless fricative consonants between controls and participants with UVFP suggested that voicing cessation for voiceless fricatives differs from voicing cessation for GSP.

Are Acoustic Markers of Voice and Speech Signals Affected by Nose-and-Mouth-Covering Respiratory Protective Masks?

BACKGROUND: Worldwide use of nose-and-mouth-covering respiratory protective mask (RPM) has become ubiquitous during COVID19 pandemic. Consequences of wearing RPMs, especially regarding perception and production of spoken communication, are gradually emerging. The present study explored how three prevalent RPMs affect various speech and voice sound properties. METHODS: Pre-recorded sustained [a] vowels and read sentences from 47 subjects were played by a speech production model ('Voice Emitted by Spare Parts', or 'VESPA') in four conditions: without RPM (C1), with disposable surgical mask (C2), with FFP2 mask (C3), and with transparent plastic mask (C4). Differences between C1 and masked conditions were assessed with Dunnett's t test in 26 speech sound properties related to voice production (fundamental frequency, sound intensity level), voice quality (jitter percent, shimmer percent, harmonics-to-noise ratio, smoothed cepstral peak prominence, Acoustic Voice Quality Index), articulation and resonance (first and second formant frequencies, first and second formant bandwidths, spectral center of gravity, spectral standard deviation, spectral skewness, spectral kurtosis, spectral slope, and spectral energy in ten 1-kHz bands from 0 to 10 kHz). RESULTS: C2, C3, and C4 significantly affected 10, 15, and 19 of the acoustic speech markers, respectively. Furthermore, absolute differences between unmasked and masked conditions were largest for C4 and smallest for C2. CONCLUSIONS: All RPMs influenced more or less speech sound properties. However, this influence was least for surgical RPMs and most for plastic RPMs. Surgical RPMs are therefore preferred when spoken communication is priority next to respiratory protection.

Two Cases of Atraumatic Laryngeal Fractures.

INTRODUCTION AND AIM: Atraumatic laryngeal fractures are extremely rare and are most commonly provoked by sneezing or coughing. Only seven cases have been described in medical literature, and only one case described a fracture after swallowing. We present two cases of atraumatic laryngeal fracture after swallowing. CASE REPORT: A 37-year-old male presented to the outpatient ENT clinic with severe dysphonia and odynophagia. He reported feeling a crack in the throat after swallowing with a flexed head. The patient's physical examination showed diffuse swelling and tenderness over the thyroid cartilage without subcutaneous emphysema. Flexible nasolaryngoscopy showed a large right true vocal fold hematoma with normal vocal fold movement. Computed tomography (CT) showed a fracture of the thyroid. Treatment consisted of corticosteroids and pantoprazole. Two years later he presented again at the emergency department with extreme odynophagia after suffering a knee punch on the larynx. CT showed a new fracture line, slightly off midline to the left in the thyroid cartilage. A 42-year-old male presented at the emergency department with odynophagia, dysphonia, and fever after feeling a crack in the throat during forceful swallowing in an extended neck position. Physical examination demonstrated a painful thyroid cartilage with subcutaneous emphysema. Flexible nasolaryngoscopy was normal but CT scan showed a slightly displaced fracture line of the median thyroid cartilage. Complaints gradually disappeared with conservative treatment with corticosteroids and antibiotics. CONCLUSION: Congenital anomalies by abnormal mineralization and ossification could lead to focal weakness of the thyroid cartilage and thus predispose to non-traumatic fractures. The double triad of odynophagia, dysphagia, and dysphonia after sneezing, coughing or swallowing should raise the physician's attention to the possibility of thyroid cartilage fracture, especially after feeling or hearing a crack. Further investigation is obligatory with high-resolution CT of the neck and examination by an ENT specialist.

Glottal Stop Production in Controls and Patients With Unilateral Vocal Fold Paresis/Paralysis.

PURPOSES: The purposes of this study were to determine whether the acoustic measures from glottal stops distinguished between controls and patients with unilateral vocal fold paresis/paralysis (UVFP) at initial evaluation and posttreatment/observation, to explore the types of false vocal fold (FVF) movement during glottal stop production in UVFP, and to assess the agreement between normalization of various measures and reported voice normalization. METHOD: Patients with UVFP and controls were recorded acoustically and laryngoscopically speaking two sets of five repeated /i/s, controls once and patients with UVFP initially and posttreatment/observation. Averaged intensity differences and slopes for offsets (maximum voicing intensity to minimum glottal stop intensity) and onsets (minimum glottal stop intensity to maximum voicing intensity) were measured. FVF movements were rated separately for paretic and nonparetic sides. Patients were asked to report voice normalization posttreatment/observation. Cohen's kappas were calculated for agreements between patient-reported voice normalization and normalization of Voice-Related Quality of Life (V-RQOL), translaryngeal flow, four acoustic measures of glottal stop production, and FVF movement. RESULTS: Significant differences (analysis of variance [ANOVA]; p < .014) were found for all acoustic measures between controls and patients with UVFP and between patients with UVFP initially and posttreatment/observation (paired t tests; p < .05). In addition, 78% of UVFP patients had no FVF movement on the paretic side initially, and 42% had bilateral dynamic FVF movement posttreatment/observation. Cohen's kappa showed moderate agreement between voice normalization and V-RQOL, slight agreement with offset measures, and fair agreement with onset measures. CONCLUSION: This study provided proof of concept for using acoustic measures of glottal stops to distinguish between controls and patients with UVFP, both initially and posttreatment/observation.

Meta-Analysis on the Validity of the Acoustic Voice Quality Index.

BACKGROUND: Acoustic measurements are useful tools to objectively measure overall voice quality. The Acoustic Voice Quality Index (AVQI) has shown to be a valid multiparametric tool to objectify dysphonia severity. The increasing number of validity studies investigating AVQI's validity demands a comprehensive synthesis of the available outcomes. OBJECTIVE OF REVIEW: The aim of the present meta-analysis is to quantify the evidence for the diagnostic accuracy of the AVQI, including its sensitivity, specificity and likelihood ratio statistics, and its concurrent validity and sensitivity to changes in auditory-perceptual voice quality ratings. TYPE OF REVIEW: Meta-analysis SEARCH STRATEGY: MEDLINE, EMBASE, the Cochrane library and Web of Science were searched from 2010 till April 2021 with an additional manual search, using keywords related to AVQI and common terminologies of validity outcomes. Studies considering the clinical validity of AVQI (ie, diagnostic accuracy, concurrent validity and sensitivity to change), using auditory-perceptual voice quality evaluation as reference, were included. EVALUATION METHOD: The Preferred Reporting Items for Systematic reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines were used. Quality assessment of included studies was conducted using the QUADAS-2 tool. For the diagnostic accuracy of AVQI, the pooled sensitivity, specificity and likelihood ratio statistics were determined using a summary receiver operating characteristic approach. Weighted correlation coefficient measures (rW¯) were used to assess the concurrent validity and sensitivity to change. RESULTS: A total of 198 studies were screened and 33 articles were included. In total, voice samples of 11447, 10272, and 367 different subjects were considered for analysis of diagnostic accuracy, concurrent validity and change responsiveness, respectively. Satisfying diagnostic accuracy results were found with a pooled sensitivity of 0.83 (95% CI: 0.82-0.83), a pooled specificity of 0.89 (95% CI: 0.88-0.90), a pooled positive LR of 7.75 (95% CI: 6.04-9.95), a pooled negative LR of 0.20 (95% CI: 0.16-0.23), and a pooled diagnostic odds ratio of 47.13 (95% CI: 34.82-63.79). Summary receiver operating characteristic curve analysis showed an excellent AUC value of 0.937 and Q* index of 0.874. Strong correlations of rW¯ = 0.838 for concurrent validity and rW¯ = 0.796 for sensitivity to change were found. CONCLUSIONS: Our results confirm the general clinical utility of the AVQI as a robust and valid objective measure for evaluating overall dysphonia severity across languages and study methods.

Validation and Test-Retest Reliability of Acoustic Voice Quality Index Version 02.06 in the Turkish Language.

OBJECTIVES: The aim of the present study was to investigate the validity (both concurrent and diagnostic) and test-retest reliability of Acoustic Voice Quality Index (AVQI) version 2 (AVQI 02.06) in Turkish speaking population. MATERIALS AND METHODS: Two hundred and fifty five native Turkish subjects with normal voices (n = 128) and with voice disorders (n = 127) were asked to sustain the vowel [a:] and read aloud the Turkish phonetically balanced text. To determine the test-retest reliability of AVQI, 20 dysphonic (ie, around 15% of the group), and 20 normophonic (ie, around 15% of the group) were reassessed 15 minutes after the first AVQI determination. A three middle seconds of sustained vowel [a:] and a sentence with 25 syllables was concatenated, and AVQI analysis was conducted. The auditory-perceptual evaluation was performed by five experienced raters with Grade (G) from GRBAS Protocol. RESULTS: There was a statistically significant correlation between AVQI scores and auditory-perceptual evaluation of overall voice quality (rs = 0.717, P < 0.001). AVQI gave a threshold of 2.98 for the dysphonic voice. The values of intraclass correlation coefficient with two-way mixed-effects model, single-measures type, absolute agreement definition showed an excellent test-retest reliability for AVQI in Turkish language (intraclass correlation coefficient = 0.986). CONCLUSION: AVQI v.02.06 is a valid and robust tool in differentiating dysphonic and normal voice, and has excellent test-retest reliability in Turkish language.

Validation of the acoustic breathiness index to the Brazilian Portuguese language.

OBJECTIVE: To assess the concurrent validity and the diagnostic accuracy of the Acoustic Breathiness Index (ABI) in Brazilian Portuguese. METHODS: The counting numbers 1-20 and the vowel /a/ of 150 subjects were recorded (37 vocally healthy and 113 with dysphonia). The analyzed samples were the counting number 1-11 and 3 s of the sustained vowel. Nine voice specialists performed the perceptual judgment of the degree of breathiness. The Spearman Correlation and the receiver operating characteristic (ROC) curve were used to assess ABI's concurrent validity and diagnosis accuracy. RESULTS: Results from five listeners were chosen for the study analyses due to moderate and substantial intra-rater reliability (Cohen's Kappa values = 0.520-0.772) and moderate inter-rater reliability (Fleiss Kappa = 0.353). The ABI presented a high concurrent validity (r = 0.746); 55.6% of the breathiness vocal deviation can be explained by the acoustic analysis (r2 = 0.556). The ROC curve presented good diagnostic accuracy (85.2%). At a threshold of 2.94, the sensitivity was 75.3% and the specificity was 93.4%. CONCLUSION: The ABI is a valid tool for screening and patient's follow-up regarding breathy vocal qualities in the Brazilian Portuguese language.

The Acoustic Voice Quality Index (AVQI) in People with Parkinson's Disease Before and After Intensive Voice and Articulation Therapies: Secondary Outcome of a Randomized Controlled Trial.

OBJECTIVES: The majority of individuals with Parkinson's disease (PD) experience voice and speech problems during the course of the disease. Despite the importance of voice quality in communication and the documented disordered voice quality in PD, few studies have explored the effects of speech treatment on this variable. STUDY DESIGN/METHODS: A parallel arm, unblinded randomized controlled trial (RCT) was conducted with two active comparators, LSVT LOUD (n = 23) and LSVT ARTIC (n = 20), and an inactive comparator group of untreated individuals with PD (n = 22). A group of 20 healthy adults was also included for pre-treatment analysis. Voice recordings were obtained pre-treatment, immediately post-treatment and at 6-month follow-up. The acoustic voice quality index (AVQI) is reported here as a secondary outcome measure of the RCT. Linear mixed-effects regression analysis was performed with AVQI and sound pressure level (SPL) as dependent variables. Pearson correlation coefficient analysis was also conducted to explore the relationship between voice quality and SPL. RESULTS: Statistically significant improvements in AVQI and SPL from pre-treatment to post-treatment and follow-up were only observed in the LSVT LOUD group. Voice quality significantly improved only from pre-treatment to follow-up in the LSVT ARTIC group, whilst significant improvements in SPL were observed during maximum phonation only immediately post-treatment. No significant changes were observed in the untreated group. DISCUSSION: This study investigated the effects of intensive speech treatment targeting voice or targeting articulation on voice quality, as measured by the AVQI, in individuals with PD. Findings indicate that voice-focused treatment leads to greater improvements in voice quality in this population.

Neural Correlates of Healthy Sustained Vowel Phonation Tasks: A Systematic Review and Meta-Analysis of Neuroimaging Studies.

OBJECTIVE: This review of the methodology and results of studies involving a sustained vowel phonation task during functional Magnetic Resonance Imaging (fMRI) aims to contribute to the identification of brain regions involved in phonation for healthy subjects. DATA SOURCES: This review was performed using the PubMed electronic database. REVIEW METHODS: A review was conducted, according to PRISMA guidelines, between September and November 2020, using the following search term pairs: "fMRI and Phonation" and "fMRI and Voice." Activation likelihood estimation analysis was performed. A qualitative analysis was also performed to specify the frequency of activation of each region, as well as the various activation clusters within a single region. RESULTS: Seven studies were included and analyzed. Five of the seven studies were selected for the activation likelihood estimation meta-analysis which revealed significant convergent activation for only one cluster located in the left precentral gyrus (BA4). A qualitative review provides an overview of brain activation. Primary motor and premotor areas were the only activated areas in all studies included. Other regions previously considered to be implicated in phonation were often activated in sustained vowel phonation tasks. Additionally, areas generally associated with articulation or language also showed activation. CONCLUSION: Methodological recommendations are suggested to isolate the phonatory component and reduce variability between future studies. Based on the qualitative analysis, this review does not support a distinction between regions more related to phonation and regions more related to articulation. Further research is required seeking to isolate the vocal component and to improve insight into human brain network involved in phonation.

The acoustic voice quality index, version 2.06 and 3.01, for the Persian-speaking population.

INTRODUCTION: Dysphonia assessment includes approaches like acoustic analysis, which is non-invasive and easy to use and provides an understandable numerical output. The Acoustic Voice Quality Index (AVQI) is an acoustic model that can detect dysphonia. The Persian language is spoken by around 70,000,000 native speakers. Since AVQI versions 2.06 and 3.01 have not been validated for the Persian yet, this study investigated their concurrent validity and diagnostic accuracy among the Persian-speaking population. METHODS: This scale development study was conducted from 2020 to 2021 on 180 normophonic and dysphonic native Persian-speaking residents of Mashhad, Iran. Five raters rated the samples by auditory-perceptual-judgments, including Grade from the Grade-Rough-Breathy-Asthenic-Strained (an ordinal scale) and the overall dysphonia severity from the Persian version Consensus Auditory Perceptual Evaluation of Voice (a continuous scale) to investigate both versions' concurrent validity. The intra- and inter-rater reliability and concurrent validity were evaluated for both scales. Both versions' diagnostic accuracy was assessed by the receiver operating characteristic, and the optimal thresholds were determined. RESULTS: AVQI-version-2-Persian thresholds of 3.47 and 4.04 provided sensitivity of 88.30% and 85.53% and specificity of 79.07% and 85.58% by the ordinal and continuous scales, respectively. AVQI-version-3-Persian thresholds of 3.07 and 3.03 also rendered sensitivity of 74.47% and 85.53%, and specificity of 97.67% and 91.35% by the ordinal and continuous scales sequentially. CONCLUSION: The significant values of concurrent validities and diagnostic accuracies of both versions of AVQI-Persian confirmed that it can discriminate between normal and pathological voices among the Persian-speaking population. Hence, it can be used for screening or diagnosis purposes.

Brain adaptation following various unilateral vocal fold paralysis treatments: A magnetic resonance imaging based longitudinal case series.

Aim: Examination of central compensatory mechanisms following peripheral vocal nerve injury and recovery is essential to build knowledge about plasticity of the neural network underlying phonation. The objective of this prospective multiple-cases longitudinal study is to describe brain activity in response to unilateral vocal fold paralysis (UVFP) management and to follow central nervous system adaptation over time in three patients with different nervous and vocal recovery profiles. Materials and methods: Participants were enrolled within 3 months of the onset of UVFP. Within 1 year of the injury, the first patient did not recover voice or vocal fold mobility despite voice therapy, the second patient recovered voice and mobility in absence of treatment and the third patient recovered voice and vocal fold mobility following an injection augmentation with hyaluronic acid in the paralyzed vocal fold. These different evolutions allowed comparison of individual outcomes according to nervous and vocal recovery. All three patients underwent functional magnetic resonance imaging (fMRI task and resting-state) scans at three (patient 1) or four (patients 2 and 3) time points. The fMRI task included three conditions: a condition of phonation and audition of the sustained [a:] vowel for 3 s, an audition condition of this vowel and a resting condition. Acoustic and aerodynamic measures as well as laryngostroboscopic images and laryngeal electromyographic data were collected. Results and conclusion: This study highlighted for the first time two key findings. First, hyperactivation during the fMRI phonation task was observed at the first time point following the onset of UVFP and this hyperactivation was related to an increase in resting-state connectivity between previoulsy described phonatory regions of interest. Second, for the patient who received an augmentation injection in the paralyzed vocal fold, we subsequently observed a bilateral activation of the voice-related nuclei in the brainstem. This new observation, along with the fact that for this patient the resting-state connectivity between the voice motor/sensory brainstem nuclei and other brain regions of interest correlated with an aerodynamic measure of voice, support the idea that there is a need to investigate whether the neural recovery process can be enhanced by promoting the restoration of proprioceptive feedback.

Re-Training of Convolutional Neural Networks for Glottis Segmentation in Endoscopic High-Speed Videos.

Endoscopic high-speed video (HSV) systems for visualization and assessment of vocal fold dynamics in the larynx are diverse and technically advancing. To consider resulting "concepts shifts" for neural network (NN)-based image processing, re-training of already trained and used NNs is necessary to allow for sufficiently accurate image processing for new recording modalities. We propose and discuss several re-training approaches for convolutional neural networks (CNN) being used for HSV image segmentation. Our baseline CNN was trained on the BAGLS data set (58,750 images). The new BAGLS-RT data set consists of additional 21,050 images from previously unused HSV systems, light sources, and different spatial resolutions. Results showed that increasing data diversity by means of preprocessing already improves the segmentation accuracy (mIoU + 6.35%). Subsequent re-training further increases segmentation performance (mIoU + 2.81%). For re-training, finetuning with dynamic knowledge distillation showed the most promising results. Data variety for training and additional re-training is a helpful tool to boost HSV image segmentation quality. However, when performing re-training, the phenomenon of catastrophic forgetting should be kept in mind, i.e., adaption to new data while forgetting already learned knowledge.

How Reliable Is the Auditory-Perceptual Evaluation of Phonation Onset Hardness?

BACKGROUND: Generally, phonation onset hardness has been similarly defined and categorized throughout literature. There are typically three categories: soft, breathy, and hard onset. Phonation onset hardness is relevant in both assessment and treatment of various voice disorders and is usually determined on an auditory-perceptual basis. However, as far as we know, reliability of clinical auditory-perceptual indications of phonation onset hardness has not been investigated yet. Therefore, this study aimed at evaluating intrarater as well as interrater reliability of auditory-perceptual assessment of phonation onset hardness by speech and language pathologists. METHODS: After deidentification, the sentence-initial word [e.rst] was extracted from read text recordings of 20 subjects with various voice disorders and complaints. These 20 samples were purposefully selected to represent as much as possible the whole phonation onset hardness continuum. The auditory-perceptual rating protocol consisted of the paired comparison paradigm, in which all listeners were asked to perceptually compare phonation onset hardness of every fragment with the other 19 samples. This resulted in a ranking of the 20 samples, from hardest to softest phonation onset. Four speech and language pathologists agreed to compare phonation onset hardness according to this paradigm. The single-measures intraclass correlation coefficient (ICC) for absolute agreement was applied to determine the degree of reliability within as well as between raters. RESULTS: Intrarater ICC's showed acceptable reliability for two raters, yet poor reliability for the other two raters. Interrater ICC's demonstrated low reliability in general. Zooming in on the ratings shows that three of four evaluators agreed on which sample had the softest phonation onset, and that only two raters agreed on which recording had the hardest phonation onset. DISCUSSION: It can be concluded that there is considerable variability within and across raters when asked to indicate the word with the hardest phonation onset. This is the first study to approach auditory interpretation of phonation onset hardness with the paired comparison task. Questions are raised about the clinical utility of phonation onset hardness perception, the potential role of training, and the importance of a more objective yet clinically feasible measurement tool.

Exploration of the Influences of Temporary Velum Paralysis on Auditory-Perceptual, Acoustic, and Tomographical Markers.

Purpose To better understand hypernasality (HN), we explored the relations between velopharyngeal orifice, auditory perception of HN, and acoustic-spectral measures in an in vivo within-subject design: (a) with a normally functioning velum as the control condition and (b) with a temporarily paralyzed velum as the experimental condition. Method The velum of eight volunteers was injected with ropivacaine hydrochloride (Naropin) in the area of the levator veli palatini and tensor veli palatini muscles to induce temporary velopharyngeal inadequacy (VPI) and HN. Sustained [a] and [i] and oronasal text readings were recorded, and 3D cone-beam computed tomography images of the vocal tract were built before and during velar anesthesia. Differences between conditions and correlations in normal-to-numb differences between velopharyngeal cross-sectional area (VParea), mean ratings of HN severity, and nine acoustic-spectral measures were determined. Results Three subjects already had some incomplete velopharyngeal closure in the control condition. Temporary motor nerve blockage of the velum (increased VParea) was accomplished in seven subjects, leading to increased HN and changes in three acoustic-spectral measures. Furthermore, significant correlations only emerged between VParea, HN, and ModelKataoka. Conclusions In most of the participants, it was possible to temporarily increase the velopharyngeal orifice to investigate HN while controlling other speech variables and cephalic morphology. Although this study was exploratory and its are findings preliminary, it provided additional evidence for the possible clinical value of ModelKataoka, A 3-P 0, and B F1 for the objective measurement of VPI or HN.

Need for velopharyngeal surgery after primary palatoplasty in cleft patients. A retrospective cohort study and review of literature.

BACKGROUND: Enabling intelligible speech plays an important role in achieving social inclusion and a good quality of life of cleft patients. A crude measure of primary palatal repair quality is the incidence of operations to correct velopharyngeal insufficiency (VPI) after speech-language therapy has proven inadequate. This study assessed the necessity for surgery to correct velopharyngeal insufficiency following our standardized two-staged protocol, compared the results with the literature, and identified factors that may influence velopharyngeal competence. METHODS: A review of the literature was performed. The outcome measure in our series was the necessity for a secondary procedure to correct velopharyngeal insufficiency. The results of literature review were compared with the results of our case series, which we treated using a standardized protocol. RESULTS: In our retrospective study, 5 patients (2.5%) required secondary pharyngoplasty. In literature, the frequency of surgery to correct velopharyngeal insufficiency after one- and two-stage protocols were 13.6% and 24.5%, respectively. No statistical difference was found between bilateral and unilateral clefts. The frequencies of velopharyngeal surgery were 7.2% after Furlow palatoplasty, 17.5% after a 2-flap palatoplasty, 18.6% after a Wardill-Killner palatoplasty, and 35.6% after a Von Langenbeck palatoplasty. CONCLUSION: The literature reported that one-stage palatoplasty is correlated with a lower incidence of secondary pharyngeal surgery. Our standardized two-stage protocol proved successful in avoiding secondary velopharyngeal surgery but due to the reduced number of patients included in our study, more research is needed.

Validation of the Acoustic Voice Quality Index, Version 03.01, to the Brazilian Portuguese Language.

INTRODUCTION: Multiparametric indexes provide a more robust acoustic analysis of voice quality considering more than one acoustic parameter in the evaluation of sustained phonation and continuous speech. However, once the continuous speech is considered, differences among languages must be addressed. OBJECTIVE: To assess the concurrent validity and the diagnostic accuracy of the Acoustic Voice Quality Index version 03.01 (AVQI 03.01) in the Brazilian Portuguese. METHOD: The counting numbers 1-20 and the vowel /a/ of 150 subjects were used (37 nondysphonic; 113 with dysphonia). To reach higher precision of the AVQI, the length of the voiced parts of the continuous speech and the sustained vowel were equalized. Nine voice specialists performed the perceptual auditory judgment of the samples. However, only five listeners were chosen for further analysis based on their moderate to substantial intrarater reliability (Cohen's Kappa: 0.605-0.773) and their reasonable inter-rater reliability (Fleiss Kappa: 0.429). The index concurrent validity and diagnosis accuracy were analyzed with the Spearman correlation and the receiver-operating characteristic curve. RESULTS: The AVQI 03.01 concurrent validity was high (r = 0.716). The coefficient of determination demonstrated that 51% of the vocal deviation can be explained by the acoustic analysis (r2 = 0.512). The diagnostic accuracy was excellent (90.4%). At a threshold of 1.33, the AVQI sensitivity and specificity were 78.8% and 90.6%, respectively. CONCLUSION: The AVQI is a valid tool in the Brazilian Portuguese language. It can be used as a screening tool, for clinical follow-up and evaluation pre- and post-treatment/procedures. Voice specialist should be aware of false-negative and false-positive results of the AVQI, especially for screening purposes.

The Acoustic Voice Quality Index, Version 03.01, in French and the Voice Handicap Index.

OBJECTIVES: The Acoustic Voice Quality Index (AVQI), version 03.01, is a tool for quantitative assessment of the overall severity of dysphonia. Its computation includes six acoustic parameters, which are all analyzed with Praat freeware. It is based on recordings of a sustained vowel and part of a text read aloud. The psychometric qualities of this tool in various languages, including French, have been confirmed by numerous publications. However, studies investigating the correlation between tools for objective vocal assessment and voice-related quality of life show inconsistent results. Hence, the aim of this study was to contribute to the debate on measuring the correlations between the AVQI 03.01 score computed on French samples and the Voice Handicap Index (VHI). METHODS: Data from 78 patients were used; they were collected during initial vocal assessment and stored in the ear, nose, and throat caseload database of the University Hospital of Liège. The Spearman rank-order correlations (rs) between the VHI total score and subscores and the AVQI 03.01 scores for French samples were measured. The correlation between the diagnostic decisions ("normophonia" versus "dysphonia") of both tools was assessed using Cramer's phi. RESULTS: The Spearman correlation between AVQI 03.01 score and total VHI score, controlling for age, was moderate (rs = 0.62, P < 0.0001). The correlations between the AVQI 03.01 score and the functional, emotional, and physical subscores of the VHI were also moderate (rs = 0.643, 0.543, and 0.514, respectively, P < 0.0001). The correlation between the two instruments' diagnostic decisions ("normophonia" versus "dysphonia") was also moderate (φ = 0.52, P = 0.000). CONCLUSIONS: Although AVQI 03.01 scores were moderately correlated with the VHI total score and subscores, they measure two different things. The AVQI 03.01 assesses overall voice quality in terms of acoustic parameters, whereas the VHI assesses the multidetermined impact on the patient's everyday life. Both results should thus be taken into account, as part of a comprehensive vocal assessment.