Variability of Maximum Glottal Angle on Clinical Sniff Task Differs in Patients With Functional and Organic Laryngeal Pathologies Compared to Healthy Controls.

OBJECTIVES: Practitioners rely heavily on flexible endoscopic visualization of the true vocal folds during a repeated "sniff-ee" maneuver to assess vocal fold mobility. However, the human eye lacks the temporal and spatial precision required to accurately gauge fine differences in maximal glottal angle. This study compared differences in maximal glottal angle variables during "sniff-ee" maneuvers across patients with various voice and laryngeal breathing disorders. METHODS: We retrospectively measured glottal angle from flexible laryngoscopy examinations in six groups of patients with voice and upper airway disorders: laryngeal dystonia/essential tremor (LD/ET), vocal fold lesions, vocal fold atrophy, paradoxical vocal fold motion disorder (PVFMD), muscle tension dysphonia (MTD), and healthy controls. Maximum glottal angle (GAMAX) and average glottal angle (GAAVG) were calculated during three serial "sniff-ee" maneuvers for all participants. Individual disorder groups (MTD, PVFMD, LD/ET, atrophy, and lesion) and broader disorder types (functional and organic) were compared to healthy controls using simple linear regression analyses. RESULTS: No significant difference in either GAMAX or GAAVG was found between controls and the disorder subgroups or broader disorder type (function and organic). However, there were statistically significant differences in the variability of GAMAX in both PVFMD (6.2° more variability; P < 0.001) and LD/ET (5.8° more variability; P < 0.001) compared to healthy controls. CONCLUSION: Patients diagnosed with LD/ET and PVFMD both demonstrated significantly more variability in their GAMAX compared to healthy controls, suggesting that movement consistency or coordination may be relatively compromised in these patient groups. Further research is warranted to investigate the sensitivity and specificity of glottal angle variability in diagnosing PVFMD and LD in clinical or research settings. LEVEL OF EVIDENCE: 4 SHORT SUMMARY: Laryngeal examinations from five patient groups were compared to those from healthy controls. Patients with paradoxical vocal fold motion disorder and laryngeal movement disorders exhibited significantly greater variability of glottal angle during sniff maneuver compared to healthy controls.

Volitional inspiration is mediated by two independent output channels in the primary motor cortex.

The diaphragm is a multifunctional muscle that mediates both autonomic and volitional inspiration. It is critically involved in vocalization, postural stability, and expulsive core-trunk functions, such as coughing, hiccups, and vomiting. In macaque monkeys, we used retrograde transneuronal transport of rabies virus injected into the left hemidiaphragm to identify cortical neurons that have multisynaptic connections with phrenic motoneurons. Our research demonstrates that representation of the diaphragm in the primary motor cortex (M1) is split into two spatially separate and independent sites. No cortico-cortical connections are known to exist between these two sites. One site is located dorsal to the arm representation within the central sulcus and the second site is lateral to the arm. The dual representation of the diaphragm warrants a revision to the somatotopic map of M1. The dorsal diaphragm representation overlaps with trunk and axial musculature. It is ideally situated to coordinate with these muscles during volitional inspiration and in producing intra-abdominal pressure gradients. The lateral site overlaps the origin of M1 projections to a laryngeal muscle, the cricothyroid. This observation suggests that the coordinated control of laryngeal muscles and the diaphragm during vocalization may be achieved, in part, by co-localization of their representations in M1. The neural organization of the two diaphragm sites underlies a new perspective for interpreting functional imaging studies of respiration and/or vocalization. Furthermore, our results provide novel evidence supporting the concept that overlapping output channels within M1 are a prerequisite for the formation of muscle synergies underlying fine motor control.

Self-Reported Stress, Trauma, and Prevalence of Laryngoresponders in the General Population.

INTRODUCTION: It has been proposed that some individuals are "laryngoresponders" (LRs) in that their stress manifests in the laryngeal region and laryngeal functions (e.g., voice and breathing). Preliminary data support the notion that LRs might differ from nonlaryngoresponders (NLRs) in their self-reported past trauma and recent stress. The purpose of this study was to establish the point prevalence of self-identified LRs in the general population. METHOD: Using a web-based questionnaire, participants reported up to 13 stress-vulnerable bodily regions and described symptom nature and severity for each region. At the end of the questionnaire, they were explicitly prompted to report whether their laryngeal region or its functions were affected by stress. Participants were categorized a posteriori as Unprompted LRs, Prompted LRs, Inconsistent LRs, or NLRs. We compared LR and NLR groups on the Perceived Stress Scale (PSS-10) and the Childhood Trauma Questionnaire (CTQ-SF). We also redistributed the survey to a subset of participants to establish grouping reliability. RESULTS: A total of 1,217 adults responded to the survey, and 995 provided complete data sets. Of those, 15.7% were classified as Unprompted LRs, 26.7% as Prompted LRs, 3% as Inconsistent LRs, and 54.6% as NLRs. Unprompted LRs demonstrated significantly higher/worse PSS-10 and CTQ-SF scores than all other groups. Reliability of LR classification was moderate upon follow-up, κ = .62, 95% confidence interval [0.47, 0.77]. CONCLUSIONS: Unprompted LRs described their symptoms in ways that were indistinguishable from patients with functional voice disorders (e.g., throat clenches, voice gets tired easily, lose my voice, voice gets hoarse). The method of self-report solicitation impacted the resulting response. Specifically, the report of larynx-related symptoms differed substantially depending on whether or not the participants were directly prompted to consider the larynx and its related functions.

Intrinsic Laryngeal Muscle Activity During Subvocalization.

PURPOSE: Subvocalization, the low-grade activity of speech articulator muscles while thinking or reading, may mediate phonological representations of verbal material. However, no literature exists that directly measures whether intrinsic laryngeal muscles (ILMs) are active during subvocalization. The possibility of ILM activation during subvocalization has implications for establishing appropriate baselines when experimental conditions involve linguistic features. METHOD: In two separate studies, forty-five cisgender women completed one or two silentsil tasks (two in the first study, Experiments 1a and 1b, and one in the second, Experiment 2). Fine wire electromyography was used to directly measure ILM activity during an at-rest baseline and silent tasks used to determine whether subvocalization occurred (referred to hereafter as "subvocalization tasks"). Other muscles were measured via surface electromyography: submental muscle in Experiments 1a and 1b, anterior tibialis in Experiment 2, and upper trapezius in all experiments. RESULTS: Interrupted time-series analysis was used to directly measure changes in ILM activity from baseline to the subvocalization tasks. A paired two tailed t-test was used to measure mean differences in ILM activity across conditions for each participant. Some individuals displayed statistically significant increases from baseline during subvocalization tasks, whereas others displayed decreases. Cohen's d was used to calculate the effect size for each muscle across the three subvocalization conditions. Of the 21 muscles measured across three experiments, five yielded a small mean effect size, and the effect sizes for the remaining 16 muscles were negligible. At a group level, only the right cricothyroid showed statistically significant changes (Experiment 1b). CONCLUSION: The ILM responses during subvocalization vary in both magnitude and direction. Most but not all changes can be described as negligible. For future studies of ILM activity during conditions that involve linguistic processing, investigators should consider the idiosyncratic variation during subvocalization when determining the most appropriate baseline task.

Measuring Communicative Congruence and Communicative Dysphoria in a Sample of Individuals Without Voice Disorders.

PURPOSE: This study examines communicative congruence and communicative dysphoria in adults who deny having a voice disorder. Communicative congruence is the degree to which a person's communication is consistent with their sense of self/identity. Communicative dysphoria is the psychological entropy resulting from communicative incongruence. We propose that these experiences may influence patients' psychosocial well-being and are thus relevant to the field of speech-language pathology. We hypothesized that both constructs would be normally distributed with an inverse relationship. We also hypothesized that communicative congruence would predict scores on the Center for Epidemiological Studies-Depression (CES-D) scale, subscales of the Big Five Aspect Scales (BFAS; a personality measure), and achieve convergent validity with the Vocal Congruence Scale (VCS). METHOD: Participants (adults 18-70 years) completed the BFAS, CES-D, VCS, and the Voice Handicap Index-10 (VHI-10) before recording a series of speech tasks. Participants' recordings were played back while they responded to questions probing their communicative congruence and communicative dysphoria. RESULTS: The 196 participants were predominantly female (67.3%) and cisgender (96.4%). Communicative congruence was negatively skewed, and communicative dysphoria was normally distributed. Both variables significantly related to each other: More incongruence was associated with more dysphoria. Communicative congruence was inversely related to CES-D scores. The personality metatrait Plasticity related to communicative congruence, as did the domain of Extraversion and the aspects Withdrawal, Enthusiasm, and Assertiveness. Communicative congruence achieved high convergent validity with the VCS. CONCLUSIONS: Counter to our hypothesis, participants reported more congruence than incongruence, but all other hypotheses were supported. Participants who reported incongruence were more likely to report symptoms of depression. These findings suggest that even in a predominantly cisgender cohort, some individuals' mental well-being might relate to how well their communication aligns with their identity. This work may inform future investigations into these constructs and their effects on voice therapy outcomes. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.20739967.

Investigating Past Trauma in Laryngoresponders Versus Non-Laryngoresponders: Piloting New Methods in an Exploratory Study.

OBJECTIVES/HYPOTHESIS: This exploratory pilot study aimed to probe the relationship between past experiences of trauma in people who self-identify as "laryngoresponders" compared to those who do not. It also explored the communicative context of past traumatic events in laryngoresponders versus non-laryngoresponders. STUDY DESIGN: Prospective, within-subjects experimental design. METHODS: 29 vocally healthy cisgender women (ages 19 to 56) completed a battery of validated self-report measures relating to their past traumatic experiences. Participants also completed two original self-report measures designed to provide insight about (1) where stress tends to manifest in their body and (2) communicative settings of participants' past trauma. RESULTS: Six participants (21%) self-identified a predictable laryngeal and/or vocal response to acute stress and thus comprise the laryngoresponders group. Laryngoresponders exhibited worse scores on 75% of all trauma-related variables compared to non-laryngoresponders, and Emotional Neglect was disproportionately represented in laryngoresponders. Participants with a reported history of childhood Emotional Neglect (83% of laryngoresponders, 35% of nonlaryngoresponders) reported quantitatively "less ideal" communication experiences in the context of past traumatic experiences. CONCLUSIONS: Other investigators identify the larynx as a "vulnerable body pathway" for some women. This pilot study of adult women without voice complaints revealed several commonalities amongst self-reported laryngoresponders, and compels further exploration of the voice-trauma relationship.

Listeners' Perceptions of Speaker Personality Traits Based on Speech.

PURPOSE: Voice and speech are rich with information about a speaker's personality and other features of identity. This study seeks to determine the extent to which listeners agree about speakers' social, physical, and personality attributes. METHOD: Two experiments were conducted. In the first experiment, listeners rated a group of speakers who were unbalanced for sex and personality traits. The second experiment elaborated on the first by ensuring the speaker set was balanced for sex and personality traits. Both experiments played standard speech samples from speakers who provided personality information via the Multidimensional Personality Questionnaire-Brief Form. Groups of listeners rated each speaker on the same personality traits and other features of identity. Responses were analyzed for listener agreement. RESULTS: For both experiments, listeners showed consistently high levels of agreement on the personality attributes of a speaker. For certain speakers, listener agreement on some personality traits was as high as 92% and 97% in Experiments 1 and 2, respectively. Furthermore, a range of agreement across personality subscales was observed across speakers such that some were agreed-upon across all personality ratings and others were agreed-upon only for a few personality traits. CONCLUSIONS: When it comes to judging personality traits and other features of identity, most listeners might not be "correct" about speakers' traits and attributes, but they broadly agree about how the listener sounds. Some speakers send more salient voice and speech cues that drive agreement about their personality, whereas others speak in a manner that precludes consensus. Supplemental Material https://doi.org/10.23641/asha.16906990.

Mapping Meta-Therapy in Voice Interventions onto the Rehabilitation Treatment Specification System.

Meta-therapy refers to the clinical dialogue via which direct and indirect voice treatments are introduced and discussed, and which helps build a useful conceptual framework for voice therapy. Meta-therapy was idiosyncratically defined in previous work. However, the current colloquial narrative of meta-therapy is not standardized or specific enough to be reliably taught, rigorously studied, or clinically delivered with high fidelity. Therefore, this article uses a standard framework (the Rehabilitation Treatment Specification System or RTSS) to further articulate and operationalize meta-therapy in vocal rehabilitation. Meta-therapy's conceptual framework generally aligns with the RTSS's treatment theory and associated concepts; e.g., the treatment component and its underlying ingredients, mechanisms of action, and target. Because the treatment theories in meta-therapy most frequently involve mechanisms of action related to information processing, they primarily map onto the RTSS's Representations treatment components. The treatment targets in meta-therapy are often focused on changes in the patient's cognitions, knowledge, beliefs, attitudes, intentions, and/or awareness regarding voice-related modifications. The ingredients in meta-therapy are frequently clinician actions conveying information with the goal of appropriately shaping the patient's mental representations, and are delivered with verbal cues, stories, analogies, etc. This manuscript provides specific examples of how meta-therapy is applied in clinical voice practice. Considerations for future investigation of meta-therapy are proposed.

Intrinsic Laryngeal Muscle Response to a Public Speech Preparation Stressor: Personality and Autonomic Predictors.

Purpose Laboratory stressors have been shown to impact the activity of the intrinsic laryngeal muscles (ILMs), which may be part of the final causal pathway in some stress-induced voice disorders. Previous research suggests that personality traits such as stress reaction might increase one's susceptibility to these problems. Also, the autonomic nervous system response is implicated in the pathogenesis of voice disorders putatively involving ILM hyperfunction. The purpose of this study was to investigate personality and autonomic nervous system predictors of ILM responses to stressor exposure. Method Thirty-seven physically and vocally healthy female adults completed a personality questionnaire and were subjected to a speech preparation task intended to induce stress. Fine wire electromyography of the ILMs was performed so that the activity of these muscles could be measured prior to and during the stressor. Participants' trait stress reaction was measured as a personality-based predictive variable, as was respiratory-corrected respiratory sinus arrhythmia, a putative measure of vagal outflow to the heart. Results The personality measure trait stress reaction uniquely predicted thyroarytenoid, trapezius, and tibialis activity, whereas respiratory sinus arrhythmia uniquely predicted the activity of all muscles studied. Differences were observed in the autonomic predictor variable as a function of whether or not effects of respiration were accounted for in the variable's calculation. Conclusions This study explores the potential mediating roles of personality and autonomic function in ILM activity during a stressor. Both variables have value in predicting ILM activity during stressor exposure.

Intrinsic Laryngeal Muscle Response to a Public Speech Preparation Stressor.

Purpose: Research suggests that abnormal levels of intrinsic laryngeal muscle (ILM) contraction is a potential causal factor in stress-induced voice disorders. This study seeks to characterize the ILM stress response in a cohort of vocally healthy women. Method: The authors used an unblinded, nonrandomized, repeated-measures design. Forty vocally healthy female adults were subjected to a stressful speech preparation task. Measurements of heart rate, blood pressure, trapezius muscle (positive control) activation, and tibialis muscle (negative control) activation were obtained from 37 participants before and during stressor exposure, in a nonvoice and nonspeaking task paradigm, to confirm physiological stress response compared to baseline. Fine wire electromyography of the ILMs (posterior cricoarytenoid, thyroarytenoid/lateral cricoarytenoid muscle complex, and cricothyroid) was performed simultaneously so that the activity of these muscles could be measured prior to and during stressor exposure. Results: The protocol successfully elicited the typical and expected physiological stress responses. Findings supported the hypothesis that, in some individuals, the ILMs significantly increase in activity during stress reactions compared to baseline, as do the control muscles. Conclusions: This study characterizes ILM responses to psychological stress in vocally healthy participants. Some of the female adults in this study appeared to be "laryngeal stress responders," as evidenced by increased activity of the ILMs during a silent (i.e., nonvocal, nonspeech) speech preparation task that they considered to be stressful.

Subthalamic Nucleus Neurons Differentially Encode Early and Late Aspects of Speech Production.

Basal ganglia-thalamocortical loops mediate all motor behavior, yet little detail is known about the role of basal ganglia nuclei in speech production. Using intracranial recording during deep brain stimulation surgery in humans with Parkinson's disease, we tested the hypothesis that the firing rate of subthalamic nucleus neurons is modulated in sync with motor execution aspects of speech. Nearly half of 79 unit recordings exhibited firing-rate modulation during a syllable reading task across 12 subjects (male and female). Trial-to-trial timing of changes in subthalamic neuronal activity, relative to cue onset versus production onset, revealed that locking to cue presentation was associated more with units that decreased firing rate, whereas locking to speech onset was associated more with units that increased firing rate. These unique data indicate that subthalamic activity is dynamic during the production of speech, reflecting temporally-dependent inhibition and excitation of separate populations of subthalamic neurons.SIGNIFICANCE STATEMENT The basal ganglia are widely assumed to participate in speech production, yet no prior studies have reported detailed examination of speech-related activity in basal ganglia nuclei. Using microelectrode recordings from the subthalamic nucleus during a single-syllable reading task, in awake humans undergoing deep brain stimulation implantation surgery, we show that the firing rate of subthalamic nucleus neurons is modulated in response to motor execution aspects of speech. These results are the first to establish a role for subthalamic nucleus neurons in encoding of aspects of speech production, and they lay the groundwork for launching a modern subfield to explore basal ganglia function in human speech.

Neurogenic Orofacial Weakness and Speech in Adults With Dysarthria.

PURPOSE: This study compared orofacial strength between adults with dysarthria and neurologically normal (NN) matched controls. In addition, orofacial muscle weakness was examined for potential relationships to speech impairments in adults with dysarthria. METHOD: Matched groups of 55 adults with dysarthria and 55 NN adults generated maximum pressure (Pmax) against an air-filled bulb during lingual elevation, protrusion and lateralization, and buccodental and labial compressions. These orofacial strength measures were compared with speech intelligibility, perceptual ratings of speech, articulation rate, and fast syllable-repetition rate. RESULTS: The dysarthria group demonstrated significantly lower orofacial strength than the NN group on all tasks. Lingual strength correlated moderately and buccal strength correlated weakly with most ratings of speech deficits. Speech intelligibility was not sensitive to dysarthria severity. Individuals with severely reduced anterior lingual elevation Pmax (< 18 kPa) had normal to profoundly impaired sentence intelligibility (99%-6%) and moderately to severely impaired speech (26%-94% articulatory imprecision; 33%-94% overall severity). CONCLUSIONS: Results support the presence of orofacial muscle weakness in adults with dysarthrias of varying etiologies but reinforce tenuous links between orofacial strength and speech production disorders. By examining individual data, preliminary evidence emerges to suggest that speech, but not necessarily intelligibility, is likely to be impaired when lingual weakness is severe.

Voice outcomes after total thyroidectomy, partial thyroidectomy, or non-neck surgery using a prospective multifactorial assessment.

BACKGROUND: Voice alteration remains a significant complication of thyroid surgery. We present a comparison of voice outcomes between total thyroidectomy (TT), partial thyroidectomy (PT), and non-neck (NN) surgery using a multifactorial voice-outcomes classification tool. STUDY DESIGN: Patients with normal voice (n = 112) were enrolled between July 2004 and March 2009. The patients underwent TT (n = 54), PT (n = 35), or NN (n = 23) surgery under general endotracheal anesthesia as part of a prospective observational study involving serial multimodality voice evaluation preoperatively, and at 2 weeks, 3 months, and 6 months postoperatively. Patients with adverse voice outcomes were grouped into the negative voice outcomes (NegVO) category, including patients with objective (abnormality on videolaryngostroboscopy and substantial voice dysfunction) and subjective (normal videolaryngostroboscopy but with notable voice impairment) NegVO. Voice outcomes were compared among study groups. RESULTS: Negative voice outcomes occurred in 46% (95% CI, 34-59%) and 14% (95% CI, 6-30%) of TT and PT groups, respectively. No NegVOs were observed after NN surgery. Early NegVOs were more common in the TT group than in the NN or PT groups (p < 0.001). Most voice disturbances resolved by 6 months (TT 84%; PT 92%) with no difference in NegVO among all groups (p = 0.23). Black race and significant changes in certain voice outcomes measures at the 2-week follow-up visit were identified as predictors of late (3 to 6 months) NegVO. CONCLUSIONS: This comprehensive voice outcomes study revealed that the extent of thyroidectomy impacts voice outcomes in the early postoperative period, and identified risk factors for late NegVO in post-thyroidectomy patients who should be considered for early voice rehabilitation referral.

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

OBJECTIVE: To determine the effect of presence and location of severity labels for different types of visual analog scales (VAS) on overall severity (OS) ratings in dysphonic speech. STUDY DESIGN: Experimental, between group comparisons. METHODS: Dysphonic and normal voice samples from male and female speakers were presented to inexperienced listeners for judgments of OS. To rate samples, listeners used an undifferentiated 100-mm VAS labeled at the extremes, a VAS with nonlinearly distributed labels as in the "beta" version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), or a VAS with symmetrically distributed labels as in the "official" version of the CAPE-V. RESULTS: Overall, mean OS ratings did not differ significantly across scale types, although ratings using the nonlinearly marked VAS were generally lower than those from other scales. This effect was significant for female speakers whose samples tended toward moderate OS. The ratings distribution, when compiled into 10-mm bins, differed significantly by scale type, with users of the nonlinearly marked scales skewing their ratings toward normal. CONCLUSIONS: The presence and placement of labels on VAS did not significantly affect OS ratings overall, but values were significantly lower when rating female voices with the nonlinearly labeled VAS. Results indicate that professionals should specify the scale type used for rating OS and use scales consistently when comparing voices.

Role of steroids in acute phonotrauma: A basic science investigation.

OBJECTIVES/HYPOTHESIS: Steroids are used for the treatment of laryngitis in vocal performers and other individuals despite the absence of evidence demonstrating their impact on vocal fold inflammation. Our objective was to examine laryngeal secretion cytokine inflammatory profile changes associated with corticosteroid treatment in a human phonotrauma model. STUDY DESIGN: Prospective, individual, randomized, double-blinded, controlled trial. METHODS: Participants included 10 healthy females who were randomized to either treatment with oral hydrocortisone or placebo, each given in three doses over 20 hours after the experimental induction of acute phonotrauma. Cytokines associated with inflammation and healing (interleukin [IL]-1ß, IL-6, IL-10) were measured in laryngeal secretions before and after vocal loading and at 4 and 20 hours after treatment. RESULTS: Proinflammatory mediators IL-1ß and IL-6 were doubled in the controls versus the steroid treatment group at 21 hours following induction of acute vocal fold inflammation. Anti-inflammatory cytokine IL-10 showed a 6.3-fold increase in the steroid treatment group versus the controls, indicating anti-inflammatory modulation by steroid treatment. CONCLUSIONS: This study provides biologic evidence supporting the use of steroids for acute vocal fold inflammation associated with phonotrauma. LEVEL OF EVIDENCE: 1b.

The role of voice therapy in the treatment of dyspnea and dysphonia in a patient with a vagal nerve stimulation device.

Vagal nerve stimulators (VNS) are implanted to treat medically refractory epilepsy and depression. The VNS stimulates the vagus nerve in the left neck. Laryngeal side effects are common and include dysphagia, dysphonia, and dyspnea. The current case study represents a patient with severe dyspnea and dysphonia, persisting even with VNS deactivation. The case demonstrates the use of voice and respiratory retraining therapy for the treatment of VNS-induced dysphonia and dyspnea. It also highlights the importance of a multidisciplinary approach, including laryngology, neurology, and speech-language pathology, in the treatment of these challenging patients.

Intrinsic laryngeal muscle activity in response to autonomic nervous system activation.

OBJECTIVES/HYPOTHESIS: To determine whether the intrinsic laryngeal muscles exhibit a response to induced autonomic nervous system (ANS) activation, and to characterize responses that may occur. STUDY DESIGN: Prospective within-subjects study. METHODS: A cold pressor (CP) task was used to trigger a whole-body ANS response in eight vocally normal adult females. Surface electromyography of the trapezius muscle and bipolar hook-wire electromyography of intrinsic laryngeal muscles, as well as cardiovascular measures of heart rate (HR) and blood pressure (systolic [SBP] and diastolic [DBP]), were used to characterize participants' response to CP exposure compared to at-rest baseline. RESULTS: Cardiovascular response to the CP task was confirmed for subjects via HR or blood pressure measures. Post hoc Bonferroni analysis confirmed statistically significant increases in HR (P = .027), SBP (P < .001), and DBP (P < .001) during the CP task as compared to baseline. Concurrent increases in muscle activity were generally observed in trapezius, posterior cricoarytenoid, bilateral thyroarytenoid/lateral cricoarytenoid muscle complex, and bilateral cricothyroid muscles for each subject. Three individuals elected to repeat the CP task and displayed the same pattern of laryngeal response as observed in their first exposure. Results for repeated baseline measures obtained after the cessation of the CP task were compared to pre-CP baseline. Overall laryngeal activation remained even after the cardiovascular response was attenuated. CONCLUSIONS: Results are consistent with the suggestion that human laryngeal muscles exhibit an elevated level of activation concurrent with ANS activation, and endorse the putative link between laryngeal muscle tension and acute stress. Findings are replicable within a subset of three individuals.

Spectral-cepstral estimation of dysphonia severity: external validation.

OBJECTIVES: The current study applied an acoustic algorithm incorporating measures from cepstral and spectral analyses, the Cepstral Spectral Index of Dysphonia (CSID), in an attempt to externally validate the CSID as an acoustic estimate of dysphonia severity. METHODS: Correlation (Pearson's r) between the CSID and trained listener-perceived severities as rated on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was calculated from sentence and sustained vowel samples from 56 patients before or after they underwent thyroid surgery. RESULTS: A strong correlation was identified between the mean CSID values calculated across CAPE-V sentences and vowels and the median rating of perceived overall severity (r = 0.82; p < 0.001). The CSID values did not differ significantly from their corresponding auditory-perceptual ratings of dysphonia severity for these samples (CSID: mean, 15.54, SD, 16.63; CAPE-V Severity: mean, 17.33, SD, 13.61; p = 0.16). CONCLUSIONS: Independent testing of an acoustic algorithm incorporating measures from cepstral and spectral analyses (the CSID) confirmed a strong correlation of the CSID to perceptual ratings of overall voice quality. This study provides external validation of the CSID as a robust correlate of dysphonia severity as rated by trained listeners.

Utility of the voice handicap index as an indicator of postthyroidectomy voice dysfunction.

OBJECTIVES/HYPOTHESES: The Voice Handicap Index (VHI) is a simple, reliable, self-administered questionnaire that has been used to identify negative voice outcomes after thyroidectomy. This study provides an updated report of a multiyear study examining the predictive ability of the VHI to classify normal versus negative voice outcomes (VOs). STUDY DESIGN: Prospective observational, longitudinal study of the patient reported impact of voice changes after thyroidectomy using the VHI. Since the preliminary report, the sample size doubled and methods for classifying voice outcomes (VOs) were refined. METHODS: Ninety-one adults provided voice assessment data preoperatively (baseline) and at approximately 2 weeks postthyroidectomy. VO was defined according to endoscopic laryngeal examination, acoustic, auditory perceptual, and patient report parameters. The VHI was tested for its sensitivity and specificity for identifying VO. RESULTS: Twenty-two participants (24.2%) qualified as having adverse VOs during the early postoperative period. A change from baseline in VHI of 13-16 points had a diagnostic accuracy of 86% sensitivity and 88% specificity for classifying early VO and had 70% and 95% positive and negative predictive values, respectively. The Functional and Physical subscales of the VHI had higher predictive value than the Emotional subscale. Adjunctive analyses of a two-subscale version of the VHI and of the 10 items that comprises the VHI-10 also revealed high predictive value for differentiating groups by VO. CONCLUSIONS: Balanced sensitivity and specificity are achieved at a change in the total VHI score of 13-16. These results are generally consistent with several other studies examining voice problems over time. The VHI, as well as its alternate versions, appear to be useful and should be incorporated into the diagnostic process for identifying patients with voice problems after thyroidectomy.

Racial disparities in voice outcomes after thyroid and parathyroid surgery.

BACKGROUND: There is evidence that the outcomes of head and neck surgery may differ across racial and ethnic groups. Vocal changes related to the operation are an anticipated risk of thyroidectomy and parathyroidectomy. Race-specific voice outcomes after thyroid and parathyroid operations have not been reported. Therefore, our aim was to examine the potential disparity in voice outcomes between white and black patients after thyroid or parathyroid operations. PATIENTS AND METHODS: Eighty-seven patients (59 white and 28 black) were included in a prospective observational trial. Subjects were evaluated before operation, and 2 weeks, 3 months, and 6 months postoperatively using a comprehensive battery of functional voice assessments of voice characteristics. The association of race with voice outcomes over time was evaluated with generalized linear models. RESULTS: Aside from volume of pathologic specimen (black, 117.5 cm3 vs. white, 43.2 cm3; P = .004), presence of multinodular goiter (black, 32.1% vs. white, 6.8%; P = .004) or Hashimoto's thyroiditis (black, 3.6% vs. white, 28.8%; P = .009), there were no differences between racial groups. Blacks were more likely than whites to have negative voice outcomes (odds ratio, 2.6; 95% confidence interval, 1.1-6.2; P = .034] throughout the postoperative period, especially at 6 months (black, 25% vs. white, 4%; P = .018). This finding was related principally to divergent scores on the voice-related quality-of-life scale, the voice handicap index. CONCLUSION: We observed greater rates of self-reported, negative voice outcomes among blacks than whites after thyroid or parathyroid operations. The precise mechanism for this disparity has not been described. The observed racial disparity in self-perceived voice impairment in this study merits further investigation.