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.

Analyzing Vocal Fold Frequency Dynamics Using High-Speed 3D Laser Video Endoscopy.

OBJECTIVE: To examine changes in lateral and vertical vibratory motion along the anterior, middle, and posterior sections of the vocal folds, as a function of vocal frequency variations. METHODS: Absolute measurements of vocal fold surface dynamics from high-speed videoendoscopy with custom laser endoscope were made on 23 vocally healthy adults during sustained /i:/ production at 10%, 20%, and 80% of pitch range. The 3D parameters of amplitude (mm), maximum velocity opening/closing (mm/s), and mean velocity opening/closing (mm/s) were computed for the lateral and vertical vibratory motion along the anterior, middle, and posterior sections of the vocal folds. Linear mixed model analysis was conducted to evaluate the differences in (a) vocal frequency levels (high vs. normal vs. low pitch), (b) axis level (vertical vs. lateral), (c) position level (anterior vs. middle vs. posterior), and (d) gender differences (male vs. female). RESULTS: Overall, the superior surface vertical motion of the vocal fold is greater compared with the lateral motion, especially in males. Along the superior surface, the mean and maximum closing velocities are greater posteriorly for low pitch. The location (anterior, middle, and posterior) along the superior surface is relevant only for vocal fold closing rather than opening, as the dynamics are different along the various locations. CONCLUSIONS: The study highlights the significance of assessing the vertical motion of the superior surface of the vocal fold to understand the complex dynamics of voice production. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3267-3276, 2024.

Machine Learning-assisted immunophenotyping of peripheral blood identifies innate immune cells as best predictor of response to induction chemo-immunotherapy in head and neck squamous cell carcinoma - knowledge obtained from the CheckRad-CD8 trial.

PURPOSE: Individual prediction of treatment response is crucial for personalized treatment in multimodal approaches against head-and-neck squamous cell carcinoma (HNSCC). So far, no reliable predictive parameters for treatment schemes containing immunotherapy have been identified. This study aims to predict treatment response to induction chemo-immunotherapy based on the peripheral blood immune status in patients with locally advanced HNSCC. METHODS: The peripheral blood immune phenotype was assessed in whole blood samples in patients treated in the phase II CheckRad-CD8 trial as part of the pre-planned translational research program. Blood samples were analyzed by multicolor flow cytometry before (T1) and after (T2) induction chemo-immunotherapy with cisplatin/docetaxel/durvalumab/tremelimumab. Machine Learning techniques were used to predict pathological complete response (pCR) after induction therapy. RESULTS: The tested classifier methods (LDA, SVM, LR, RF, DT, and XGBoost) allowed a distinct prediction of pCR. Highest accuracy was achieved with a low number of features represented as principal components. Immune parameters obtained from the absolute difference (lT2-T1l) allowed the best prediction of pCR. In general, less than 30 parameters and at most 10 principal components were needed for highly accurate predictions. Across several datasets, cells of the innate immune system such as polymorphonuclear cells, monocytes, and plasmacytoid dendritic cells are most prominent. CONCLUSIONS: Our analyses imply that alterations of the innate immune cell distribution in the peripheral blood following induction chemo-immuno-therapy is highly predictive for pCR in HNSCC.

Sources of Aerosol Dispersion During Singing and Potential Safety Procedures for Singers.

INTRODUCTION: With respect to the Covid-19 pandemic, singing is assumed to be associated with a high potential person-to-person transmission. However, it remains unclear how the impulse dispersion varies with different types of articulation, intensity levels of diction, or body position. Furthermore, it has not been understood in detail how to prevent aerosol dispersion during singing. MATERIAL AND METHODS: Single professional singers from the Bavarian Radio Chorus were asked to sing in different head positions, with different articulation patterns and different masks after inhaling the basic liquid of an e-cigarette. The vapor cloud was segmented and tracked over time. RESULTS: Consonants and exaggeration of diction enhanced the distance reached by the impulse dispersion. Furthermore, the greatest dispersion was reached for a neutral head position. All protection masks stopped the initial jet of the aerosols but the FFP2 masks were the most effective. CONCLUSION: Some protection equipment has been identified to be promising in reducing aerosol dispersion. However, systematic effects have to be evaluated in greater collectives.

Impulse dispersion of aerosols during playing the recorder and evaluation of safety measures.

INTRODUCTION: Group musical activities using wind instruments have been restricted during the CoVID19 pandemic due to suspected higher risk of virus transmission. It was presumed that the aerosols exhaled through the tubes while playing would be ejected over larger distances and spread into the room due to jet stream effects. In particular, the soprano recorder is widely used as an instrument in school classes, for beginners of all age groups in their musical education, in the context of leisure activities and in professional concert performances. Understanding the aerosol impulse dispersion characteristics of playing the soprano recorder could assist with the establishment of concepts for safe music-making. METHODS: Five adult professionally trained soprano recorder players (4 female, 1 male) played four bars of the main theme of L. van Beethoven's "Ode to Joy" in low and in high octaves, as well as with 3 different potential protection devices in the high octave. For comparison they spoke the corresponding text by F. Schiller. Before each task, they inhaled .5 L of vapor from an e-cigarette filled with base liquid. The vapor cloud escaping during speaking or playing was recorded by cameras and its spread was measured as a function of time in the three spatial dimensions. The potential safety devices were rated for practicability with a questionnaire, and their influence on the sound was compared, generating a long-term average spectrum from the audio data. RESULTS: When playing in the high octave, at the end of the task the clouds showed a median distance of 1.06 m to the front and .57 m diameter laterally (maxima: x: 1.35 m and y: .97 m). It was found that the clouds' expansion values in playing the recorder with and without safety measures are mostly lower when compared to the ordinary, raised speaking voice of the same subjects. The safety devices which covered the instrument did not show clear advantages and were rated as unpractical by the subjects. The most effective reduction of the cloud was reached when playing into a suction funnel. CONCLUSION: The aerosol dispersion characteristics of soprano recorders seem comparable to clarinets. The tested safety devices which covered holes of the instrument did not show clear benefits.

The Effect of Water Resistance Therapy on the Impulse Dispersion of Aerosols During Sustained Phonation.

INTRODUCTION: Group singing has been associated with higher transmission risks via exhaled and spread aerosols in the CoVID19 pandemic. For this reason, many musical activities, such as rehearsals and lessons, but also voice therapy sessions, have been restricted in many countries. Consequently, transmission risks and pathways have been studied, such as aerosol amounts generated by exhalation tasks, convectional flows in rooms, or the impulse dispersion of different kinds of phonation. The use of water resistance exercises such as those utilizing LAX VOX®, are common in voice lessons and as vocal warm-ups. With this context, this study investigates the impulse dispersion characteristics of aerosols during a voiced water resistance exercise in comparison to normal singing. METHODS: Twelve professional singers (six male, six female) were asked to phonate a stable pitch through a silicone tube into a bottle filled with water, holding the end of the tube 5 cm below the surface. Before performing the tasks, the singers inhaled the vapor consisting of 0.5 L base liquid from an e-cigarette. The exhaled gas cloud coming out of the bottle was recorded in all three spatial directions and the dispersion was measured as a function of time. RESULTS: At the end of the phonation task, the median distance to the front was 0.55 m and the median of the lateral expansion of the cloud was 0.89 m, the maximum to the front reached 0.88 m, and the maximum of lateral expansion 1.05 m. For the upwards direction of the clouds a median of 1.00 m and a maximum of 1.34 m from the mouth were measured. Three seconds after the end of the task, the medians were declining. CONCLUSION: The exhaled aerosol cloud can expand despite the obstacle of the water when using LAX VOX® during phonation.

Impulse dispersion of aerosols during playing wind instruments.

Musical activities, especially singing and playing wind instruments, have been singled out as potentially high-risk activities for the transmission of SARS CoV-2, due to a higher rate of aerosol production and emission. Playing wind instruments can produce condensation, droplets of saliva, and aerosol particles, which hover and spread in the environmental air's convectional flows and which can be potentially infectious. The aim of this study is to investigate the primary impulse dispersion of aerosols that takes place during the playing of different wind instruments as compared to breathing and to speaking. Nine professional musicians (3 trumpeters, 3 flautists and 3 clarinetists) from the Bavarian Symphony Orchestra performed the main theme from the 4th movement of Ludwig van Beethoven's 9th symphony in different pitches and loudness. The inhaled air volume was marked with small aerosol particles produced using a commercial e-cigarette. The expelled aerosol cloud was recorded by cameras from different perspectives. Afterwards, the dimensions and dynamics of the aerosol cloud were measured by segmenting the video footage at every time point. Overall, the flutes produced the largest dispersion at the end of the task, reaching maximum forward distances of 1.88 m. An expulsion of aerosol was observed in different directions: upwards and downwards at the mouthpiece, at the end of the instrument, and along the flute at the key plane. In comparison, the maximum impulse dispersions generated by the trumpets and clarinets were lower in frontal and lateral direction (1.2 m and 1.0 m towards the front, respectively). Also, the expulsion to the sides was lower.

Effects of surgical masks on aerosol dispersion in professional singing.

BACKGROUND: In the CoVID-19 pandemic, singing came into focus as a high-risk activity for the infection with airborne viruses and was therefore forbidden by many governmental administrations. OBJECTIVE: The aim of this study is to investigate the effectiveness of surgical masks regarding the spatial and temporal dispersion of aerosol and droplets during professional singing. METHODS: Ten professional singers performed a passage of the Ludwig van Beethoven's "Ode of Joy" in two experimental setups-each with and without surgical masks. First, they sang with previously inhaled vapor of e-cigarettes. The emitted cloud was recorded by three cameras to measure its dispersion dynamics. Secondly, the naturally expelled larger droplets were illuminated by a laser light sheet and recorded by a high-speed camera. RESULTS: The exhaled vapor aerosols were decelerated and deflected by the mask and stayed in the singer's near-field around and above their heads. In contrast, without mask, the aerosols spread widely reaching distances up to 1.3 m. The larger droplets were reduced by up to 86% with a surgical mask worn. SIGNIFICANCE: The study shows that surgical masks display an effective tool to reduce the range of aerosol dispersion during singing. In combination with an appropriate aeration strategy for aerosol removal, choir singers could be positioned in a more compact assembly without contaminating neighboring singers all singers.

Aerosol Dispersion During Different Phonatory Tasks in Amateur Singers.

INTRODUCTION: Due to increased aerosol generation during singing, choir rehearsals were widely prohibited in the course of the CoVID-19 pandemic. Most studies on aerosol generation and dispersion focus on professional singers. However, it has not been clarified if these data are also representative for amateur singers. METHODS: Nine non-professional singers (four male, five female) were asked to perform five tasks; speaking (T+), singing a text softly (MT-) and loudly (MT+), singing on the vowel [ə] (M+) and singing with a N95 mask (MT+N95). Before performing the tasks, the singers were asked to inhale 0.5 L vapor produced by an e-cigarette consisting of the basic liquid. The spread of the exhaled vapor was recorded in all three dimensions by high-definition cameras and the impulse dispersion was detected as a function of time. RESULTS: Regarding the median dispersion to the front, all tasks showed comparable distances from 0.69 m to 0.82 m at the end of the tasks. However, the maximum aerosol dispersion showed a larger variety among different subjects or tasks, respectively. Especially in the M+ task a maximum distance of 1.96 m to the front was reached by a single subject. Although singing with a N95 mask resulted in a slightly increased median dispersion to the front, the maximum dispersion was decreased from 1.47 m (MT+) to 1.04 m (MT+N95). CONCLUSION: The maximum dispersion distance to the front of 1.96 m at the end of the M+ task and 1.47 m at the end of the MT+ task showed higher values in comparison to professional singers. Differences in phonation, articulation and mouth opening could lead to greater impulse dispersion. Singing in loud phonation with a N95 mask reduced the maximum impulse dispersion to the front to 1.04 m. Taking all results into consideration, a slightly larger safety distance should be necessary for non-professional singers.

The Effect of Singers' Masks on the Impulse Dispersion of Aerosols During Singing.

BACKGROUND: During the Covid-19 pandemic, singing activities were restricted due to several super-spreading events that have been observed during rehearsals and vocal performances. However, it has not been clarified how the aerosol dispersion, which has been assumed to be the leading transmission factor, could be reduced by masks which are specially designed for singers. MATERIAL AND METHODS: Twelve professional singers (10 of the Bavarian Radio-Chorus and two freelancers, seven females and five males) were asked to sing the melody of the ode of joy of Beethoven's 9th symphony "Freude schöner Götterfunken, Tochter aus Elisium" in D-major without masks and afterwards with five different singers' masks, all distinctive in their material and proportions. Every task was conducted after inhaling the basic liquid from an e-cigarette. The aerosol dispersion was recorded by three high-definition video cameras during and after the task. The cloud was segmented and the dispersion was analyzed for all three spatial dimensions. Further, the subjects were asked to rate the practicability of wearing the tested masks during singing activities using a questionnaire. RESULTS: Concerning the median distances of dispersion, all masks were able to decrease the impulse dispersion of the aerosols to the front. In contrast, the dispersion to the sides and to the top was increased. The evaluation revealed that most of the subjects would reject performing a concert with any of the masks. CONCLUSION: Although, the results exhibit that the tested masks could be able to reduce the radius of aerosol expulsion for virus-laden aerosol particles, there are more improvements necessary to enable the practical implementations for professional singing.

OpenHSV: an open platform for laryngeal high-speed videoendoscopy.

High-speed videoendoscopy is an important tool to study laryngeal dynamics, to quantify vocal fold oscillations, to diagnose voice impairments at laryngeal level and to monitor treatment progress. However, there is a significant lack of an open source, expandable research tool that features latest hardware and data analysis. In this work, we propose an open research platform termed OpenHSV that is based on state-of-the-art, commercially available equipment and features a fully automatic data analysis pipeline. A publicly available, user-friendly graphical user interface implemented in Python is used to interface the hardware. Video and audio data are recorded in synchrony and are subsequently fully automatically analyzed. Video segmentation of the glottal area is performed using efficient deep neural networks to derive glottal area waveform and glottal midline. Established quantitative, clinically relevant video and audio parameters were implemented and computed. In a preliminary clinical study, we recorded video and audio data from 28 healthy subjects. Analyzing these data in terms of image quality and derived quantitative parameters, we show the applicability, performance and usefulness of OpenHSV. Therefore, OpenHSV provides a valid, standardized access to high-speed videoendoscopy data acquisition and analysis for voice scientists, highlighting its use as a valuable research tool in understanding voice physiology. We envision that OpenHSV serves as basis for the next generation of clinical HSV systems.

A Deep Learning Enhanced Novel Software Tool for Laryngeal Dynamics Analysis.

Purpose High-speed videoendoscopy (HSV) is an emerging, but barely used, endoscopy technique in the clinic to assess and diagnose voice disorders because of the lack of dedicated software to analyze the data. HSV allows to quantify the vocal fold oscillations by segmenting the glottal area. This challenging task has been tackled by various studies; however, the proposed approaches are mostly limited and not suitable for daily clinical routine. Method We developed a user-friendly software in C# that allows the editing, motion correction, segmentation, and quantitative analysis of HSV data. We further provide pretrained deep neural networks for fully automatic glottis segmentation. Results We freely provide our software Glottis Analysis Tools (GAT). Using GAT, we provide a general threshold-based region growing platform that enables the user to analyze data from various sources, such as in vivo recordings, ex vivo recordings, and high-speed footage of artificial vocal folds. Additionally, especially for in vivo recordings, we provide three robust neural networks at various speed and quality settings to allow a fully automatic glottis segmentation needed for application by untrained personnel. GAT further evaluates video and audio data in parallel and is able to extract various features from the video data, among others the glottal area waveform, that is, the changing glottal area over time. In total, GAT provides 79 unique quantitative analysis parameters for video- and audio-based signals. Many of these parameters have already been shown to reflect voice disorders, highlighting the clinical importance and usefulness of the GAT software. Conclusion GAT is a unique tool to process HSV and audio data to determine quantitative, clinically relevant parameters for research, diagnosis, and treatment of laryngeal disorders. Supplemental Material https://doi.org/10.23641/asha.14575533.

Human Laryngeal Mucus from the Vocal Folds: Rheological Characterization by Particle Tracking Microrheology and Oscillatory Shear Rheology.

Mucus consistency affects voice physiology and is connected to voice disorders. Nevertheless, the rheological characteristics of human laryngeal mucus from the vocal folds remain unknown. Knowledge about mucus viscoelasticity enables fabrication of artificial mucus with natural properties, more realistic ex-vivo experiments and promotes a better understanding and improved treatment of dysphonia with regard to mucus consistency. We studied human laryngeal mucus samples from the vocal folds with two complementary approaches: 19 samples were successfully applied to particle tracking microrheology (PTM) and five additional samples to oscillatory shear rheology (OSR). Mucus was collected by experienced laryngologists from patients together with demographic data. The analysis of the viscoelasticity revealed diversity among the investigated mucus samples according to their rigidity (absolute G' and G″). Moreover some samples revealed throughout solid-like character (G' > G″), whereas some underwent a change from solid-like to liquid-like (G' < G″). This led to a subdivision into three groups. We assume that the reason for the differences is a variation in the hydration level of the mucus, which affects the mucin concentration and network formation factors of the mucin mesh. The demographic data could not be correlated to the differences, except for the smoking behavior. Mucus of predominant liquid-like character was associated with current smokers.

Interdependencies between acoustic and high-speed videoendoscopy parameters.

In voice research, uncovering relations between the oscillating vocal folds, being the sound source of phonation, and the resulting perceived acoustic signal are of great interest. This is especially the case in the context of voice disorders, such as functional dysphonia (FD). We investigated 250 high-speed videoendoscopy (HSV) recordings with simultaneously recorded acoustic signals (124 healthy females, 60 FD females, 44 healthy males, 22 FD males). 35 glottal area waveform (GAW) parameters and 14 acoustic parameters were calculated for each recording. Linear and non-linear relations between GAW and acoustic parameters were investigated using Pearson correlation coefficients (PCC) and distance correlation coefficients (DCC). Further, norm values for parameters obtained from 250 ms long sustained phonation data (vowel /i/) were provided. 26 PCCs in females (5.3%) and 8 in males (1.6%) were found to be statistically significant (|corr.| ≥ 0.3). Only minor differences were found between PCCs and DCCs, indicating presence of weak non-linear dependencies between parameters. Fundamental frequency was involved in the majority of all relevant PCCs between GAW and acoustic parameters (19 in females and 7 in males). The most distinct difference between correlations in females and males was found for the parameter Period Variability Index. The study shows only weak relations between investigated acoustic and GAW-parameters. This indicates that the reduction of the complex 3D glottal dynamics to the 1D-GAW may erase laryngeal dynamic characteristics that are reflected within the acoustic signal. Hence, other GAW parameters, 2D-, 3D-laryngeal dynamics and vocal tract parameters should be further investigated towards potential correlations to the acoustic signal.

Vocal fold oscillation pattern changes related to loudness in patients with vocal fold mass lesions.

INTRODUCTION: Vocal fold mass lesions can affect vocal fold oscillation patterns and therefore voice production. It has been previously observed that perturbation values from audio signals were lower with increased loudness. However, how much the oscillation patterns change with gradual alteration of loudness is not yet fully understood. MATERIAL AND METHODS: Eight patients with vocal fold mass lesions were asked to perform a glide from minimum to maximum loudness on the vowel /i/, ƒo of 125 Hz for male or 250 Hz for female voices. During phonation the subjects were simultaneously recorded with transnasal high speed videoendoscopy (HSV, 20,000 fps), electroglottography (EGG), and an audio recording. Based on the HSV material the Glottal Area Waveform (GAW) was segmented and GAW parameters were computed. RESULTS: The greatest vocal fold irregularities were observed at different values between minimum and maximum sound pressure level. There was a relevant discrepancy between the HSV and EGG derived open quotients. Furthermore, the EGG derived sample entropy and GAW values also evidenced different behavior. CONCLUSIONS: The amount of vocal fold irregularity changes with varying loudness. Therefore, any evaluation of the voice should be performed under different loudness conditions. The discrepancy between EGG and GAW values appears to be much stronger in patients with vocal fold mass lesions than those with normal physiological conditions. LEVEL OF EVIDENCE: 4.

Machine learning based identification of relevant parameters for functional voice disorders derived from endoscopic high-speed recordings.

In voice research and clinical assessment, many objective parameters are in use. However, there is no commonly used set of parameters that reflect certain voice disorders, such as functional dysphonia (FD); i.e. disorders with no visible anatomical changes. Hence, 358 high-speed videoendoscopy (HSV) recordings (159 normal females (NF), 101 FD females (FDF), 66 normal males (NM), 32 FD males (FDM)) were analyzed. We investigated 91 quantitative HSV parameters towards their significance. First, 25 highly correlated parameters were discarded. Second, further 54 parameters were discarded by using a LogitBoost decision stumps approach. This yielded a subset of 12 parameters sufficient to reflect functional dysphonia. These parameters separated groups NF vs. FDF and NM vs. FDM with fair accuracy of 0.745 or 0.768, respectively. Parameters solely computed from the changing glottal area waveform (1D-function called GAW) between the vocal folds were less important than parameters describing the oscillation characteristics along the vocal folds (2D-function called Phonovibrogram). Regularity of GAW phases and peak shape, harmonic structure and Phonovibrogram-based vocal fold open and closing angles were mainly important. This study showed the high degree of redundancy of HSV-voice-parameters but also affirms the need of multidimensional based assessment of clinical data.

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.

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.

Secondary Tracheoesophageal Puncture After Laryngectomy Increases Complications With Shunt and Voice Prosthesis.

OBJECTIVES/HYPOTHESIS: To evaluate the demographics, clinical features, management, and prognostic indicators of tracheoesophageal puncture complications in patients undergoing placement of voice prosthesis following cancer treatment. STUDY DESIGN: Retrospective analysis. METHODS: A retrospective analysis was conducted of cases from a tertiary referral center diagnosed between 1996 and 2015. Multivariate logistic regression was used to determine factors associated with tracheoesophageal puncture (TEP) and voice prostheses-complication-free survival (TEP/VP-CFS). RESULTS: One hundred fourteen cases were identified. Most patients were males (92.9%) with pT3 (26.8%) or pT4 (58.1%) N+ (53.6%) tumors. All patients received laryngectomy as the primary treatment, with 75% of patients receiving adjuvant radiation therapy or chemoradiotherapy. Complications with TEP were common (65.2%). The most frequent problem was salivary leakage (50.0%), which at the same time was the most common reason for changing the prosthesis. On univariate regression analysis, prosthesis placement time after adjuvant radiotherapy (hazard ratio [HR]: 4.17, 95% confidence interval [CI]: 2-8.69), secondary prosthesis placement after primary surgery (HR: 3.97, 95% CI: 1.99-7.9), and laryngectomy with flap reconstruction (HR: 1.96, 95% CI: 0.99-3.89) were significant prognosticators for complications. Multivariate regression analysis revealed secondary prosthesis placement after adjuvant radiotherapy (HR: 3.66, 95% CI: 1.39-9.68) or after primary surgery (HR: 2.57, 95% CI: 0.92-7.2) to be the strongest predictors of reduced TEP/VP-CFS. CONCLUSIONS: Secondary prosthesis placement after primary surgery, placement after previous irradiation, and laryngectomy with flap reconstruction are predictors of poor TEP/VP-CFS. Planned adjuvant radiotherapy is not a contraindication for TEP with prosthetic placement, but it is very important to place the prosthesis during the primary surgery or at least before scheduled radiotherapy. LEVEL OF EVIDENCE: 4 Laryngoscope, 2020.

Intersegmenter Variability in High-Speed Laryngoscopy-Based Glottal Area Waveform Measures.

OBJECTIVES/HYPOTHESIS: High-speed videoendoscopy (HSV) has potential to objectively quantify vibratory vocal fold characteristics during phonation. Glottal Analysis Tools (GAT) version 2018, developed in Erlangen, Germany, is software for determining various glottal area waveform (GAW) quantities. Before having GAT analyze HSV videos, segmenters have to define glottis manually across videos in a semiautomatic segmentation protocol. Such interventions are hypothesized to induce variability of subsequent GAW measure computation across segmenters and may attenuate GAT measures' reliability to a certain point. This study explored intersegmenter variability in GAT's GAW measures based on semiautomatic image processing. STUDY DESIGN: Cohort study of rater reliability. METHODS: In total, 20 HSV videos from normophonic and dysphonic subjects with various laryngeal disorders were selected for this study and segmented by three trained segmenters. They separately segmented glottis areas in the same frame sets of the videos. Upon analysis of GAW, GAT offers 46 measures related to topologic GAW dynamic characteristics, GAW periodicity and perturbation characteristics, and GAW harmonic components. To address GAT's reliability, intersegmenter-based variability in these measures was examined with intraclass correlation coefficient (ICC). RESULTS: In general, ICC behavior of the 46 GAW measures across three raters was highly acceptable. ICC of one parameter was moderate (0.5 < ICC < 0.75), good for seven parameters (0.75 < ICC < 0.9), and excellent for 38 parameters (0.9 < ICC). CONCLUSIONS: Overall, high ICC values confirm clinical applicability of GAT for objective and quantitative assessment of HSV. Small intersegmenter differences with actual small parameter differences suggest that manual or semiautomatic segmentation in GAT does not noticeably influence clinical assessment outcome. To guarantee the software's performance, we suggest segmentation training before clinical application. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:E654-E661, 2020.