Stable Voice Clusters Identified When Using the Maximum versus Minimum Intensity Curve in the Phonetogram.

OBJECTIVE: To examine whether the minimum as well as the maximum voice intensity (i.e. sound pressure level, SPL) curves of a voice range profile (VRP) are required when discovering different voice groups based on a clustering analysis. In this approach, no a priori labeling of voice types is used. PATIENTS AND METHODS: VRPs of 194 (84 male and 110 female) professional singers were registered and processed. Cluster analysis was performed with the use of features related to (1) both the maximum and minimum SPL curves and (2) the maximum SPL curve only. RESULTS: Features related to the maximum as well as the minimum SPL curves showed three clusters in both male and female voices. These clusters, or voice groups, are based on voice types with similar VRP features. However, when using features related only to the maximum SPL curve, the clusters became less obvious. CONCLUSION: Features related to the maximum and minimum SPL curves of a VRP are both needed in order to identify the three voice clusters.

Laryngeal effects of nasal allergen provocation in singers with allergic rhinitis.

In spite of our recent insight into nasobronchial interaction mechanisms in allergic airway disease, the association between allergic rhinitis and voice complaints remains obscure. To evaluate the effects of nasal allergen provocation and seasonal grass pollen exposure on subjective and objective laryngeal parameters in singers with and without allergic rhinitis, an observational case control study was conducted. Prior to the pollen season, six grass pollen allergic and six non-allergic semiprofessional singers were exposed to nebulized sham solution and grass pollen extract (HAL°) in rising concentrations. After 3 min, 60 min and 24 h, nasal and laryngeal complaints were evaluated by the use of a visual analog scale (VAS). Laryngeal parameters like voice appearance (video stroboscopic images), voice range profile and subjective (GRBAS) and objective (jitter, shimmer, H/N, DSI) voice quality were evaluated before provocation, after 60 min and 24 h. During the pollen season, the allergic singers were re-evaluated. Results showed that in allergic singers both nasal (TNS of 4.0 ± 2.4 vs. 0.0 ± 0.0, p < 0.05) and laryngeal complaints (TLS of 1.4 ± 1.1 vs. 0.0 ± 0.2, p < 0.05) were induced at 3 min after the provocation. The induced laryngeal complaints were the feeling of laryngeal irritation, secretions and globus. No change in voice quality or stroboscopy score was measured. During the pollen season, laryngeal complaints were present (TLS of 2.4 ± 2.4) in allergic singers, without evidence for objective voice and laryngeal changes. In conclusion, we here demonstrate the rapid induction of laryngeal complaints in allergic singers by nasal allergen provocation and during the pollen season. There was no subject reported or investigator measured change in voice quality. No change in stroboscopy score was measured.

The background biopsychosocial status of teachers with voice problems.

OBJECTIVE: The aim of the study was to explore the background biopsychosocial status of teachers with a relative voice handicap. The study also intended to investigate this biopsychosocial status in relation to behavior of not always reporting voice complaints. METHODS: This research was a cross-sectional survey, performed using questionnaires: a general voice questionnaire, the Voice Handicap Index (VHI), and the Symptom Checklist-90 (SCL-90). The focus of the study is on those teachers who score the highest and the lowest on the SCL-90 as they report a higher or lower level of overall physical and psychosocial dysfunction. Fifty-five teachers score in the lowest quartile and 51 teachers score in the highest quartile of the total score of the SCL-90 (N=106 teachers). The upper quartiles of SCL-90 scores are mentioned as "high scores" and the lower quartile scores are mentioned as "low scores". VHI scores above the 75th percentile are referred to as "high voice handicap" and VHI scores below the 25th percentile are referred to as "low voice handicap". RESULTS: Subjects who had a high voice handicap have a greater relative risk for a high score on all the subscales (ORs between 2.1 and 20.2) and total score (OR=12.5) of the SCL-90. Teachers who had a high voice handicap and who did not report voice complaints have a greater relative risk for a high score for all the subscales (ORs between 1.8 and 24.5) and total score (OR=22.4) of the SCL-90. CONCLUSION: The voice handicap and the behaviour of nonreporting of voice complaints when having a voice handicap appear to be in relation to the biopsychosocial status of the teachers.

The voice handicap of student-teachers and risk factors perceived to have a negative influence on the voice.

A cross-sectional questionnaire survey was performed. The objectives of the study were to assess the psychosocial impact of current voice complaints as perceived by student-teachers with voice complaints in comparison with student-teachers without voice complaints, and to observe the pattern of risk factors in relation to their voice handicap. Subjects in the general population without a voice-demanding profession were selected as a reference group for limited comparison with the total group of student-teachers (future professional voice users). The respondents to the questionnaires were anonymous. Among the student-teachers, 17.2% reported current voice complaints in comparison with 9.7% of the reference group, and the odds ratio was 1.94, which showed the relative risk. Student-teachers had significantly greater total Voice Handicap Index (VHI) scores than the reference group (P = 0.034). The VHI subscale scores were not significantly different (P > 0.05). Student-teachers who reported current voice complaints had a significantly higher total VHI and subscale scores than student teachers without voice complaints (P < 0.001). Of the student-teachers without voice complaints, 17.0% had VHI scores greater than the 75th percentile. These persons may be neglecting their voice handicap and probably represent the false-negative cases in the estimation of voice complaints. Logistic regression analysis of each of the given risk factors with the VHI as the independent variable showed that the perceived negative influence of the given risk factors on their voices was significantly greater with increasing VHI scores across the VHI range. A significant correlation was observed between the number of perceived risk factors and increasing VHI scores across the VHI range. An increased awareness of risk factors in relation to their voice handicap would serve to motivate student-teachers to change factors that contributed to their voice problem. Attention to all risk factors, which the subjects perceive to be a risk, would aid in effective management of their voice handicap.

Consistency of the preoperative and intraoperative diagnosis of benign vocal fold lesions.

The purpose of this retrospective study was to compare the preoperative and intraoperative diagnosis of benign vocal fold lesions for consistency. The diagnosis was made in 221 consecutive patients with benign vocal fold lesions for which a microlaryngoscopy was carried out in a general ENT-clinic. The preoperative diagnosis was obtained by both white halogen and stroboscopic light. The intraoperative diagnosis was obtained by direct microscopic visualization and palpation of the vocal folds. In 36% of the patients, the preoperative diagnosis was changed intraoperatively. In 31% of the patients, a lesion was missed at the preoperative examination and a lesion was diagnosed only during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively, and in 82% of the patients intraoperatively. Specially intracordal lesions constituted a diagnostic pitfall. Because the preoperative and intraoperative diagnosis often differed, both the patients and the ENT-surgeon must keep an open mind about what may need to be done at surgery.

Some objective measures indicative of perceived voice robustness in student teachers.

One of the problems confronted in the teaching profession is the maintenance of a healthy voice. This basic pedagogical tool is subjected to extensive use, and frequently suffers from overload, with some teachers having to give up their profession altogether. In some teacher training schools, it is the current practice to examine the student's voice, and to refer any perceived susceptibility to strain to voice specialists. For this study, a group of vocally healthy students were examined first at the teacher training schools, and then at the ENT clinic at the University Hospital of Nijmegen. The aim was to predict whether the subject's voice might be at risk for occupational dysphonia as a result of the vocal load of the teaching profession. We tried to find objective measures of voice quality in student teachers, used in current clinical practice, which reflect the judgements of the therapists and phoniatricians. We tried to explain such measures physiologically in terms of robustness of, and control over voicing. Objective measures used included video-laryngostroboscopy, phonetography and spectrography. Maximum phonation time, melodic range in conjunction with maximum intensity range, and the production of soft voice are suggested as possible predictive parameters for the risk of occupational voice strain.

A lifetime of professional singing: Voice parameters and age in the Netherlands Radio Choir.

In professional choirs one would like to identify the incidence and severity of vocal problems due to ageing, and know how to influence them. The aim of the current study was to investigate to what extent easily obtainable voice parameters were age-related. From 47 singers of the Netherlands Radio Choir the Voice Range Profile parameters and the vibrato characteristics were measured. Dysphonia Severity Index (DSI) was calculated. We found that the age of male and female singers correlated negatively to the highest fundamental frequency and the Dysphonia Severity Index. No signs of slower and wider vibrato were found. These findings can lead to identifying adequate parameters e.g. for the ageing voice, useful in larger groups of professional singers.

The relation of vocal fold lesions and voice quality to voice handicap and psychosomatic well-being.

BACKGROUND: Voice disorders have a multifactorial genesis and may be present in various ways. They can cause a significant communication handicap and impaired quality of life. OBJECTIVE: To assess the effect of vocal fold lesions and voice quality on voice handicap and psychosomatic well-being. METHODS: Female patients, aged 18-65 years, who were referred to the outpatient clinic with voice problems were subsequently assessed. Laryngostroboscopic examination and acoustic voice analysis were carried out, and the patients were asked to fill in the Voice Handicap Index (VHI) and Symptom Check List-90 questionnaires. RESULTS: Eighty-two patients were included. In 43 patients (52.4%), a vocal fold lesion was observed. The VHI and psychosomatic well-being did not differ significantly between patients with and without a vocal fold lesion. The patients with a vocal fold lesion showed lower scores on the Dysphonia Severity Index (DSI) compared with those without a vocal fold lesion. However, the DSI was not correlated with voice handicap and psychosomatic well-being, except for the VHI physical subscale. CONCLUSION: Objective measurement does not necessarily correlate with the subjective appraisal of the patient's voice handicap and psychosomatic well-being. Furthermore, the criterion of the presence of a vocal fold lesion as the base of indemnity that is applied by health insurance institutions should be questioned.

Voice quality in relation to voice complaints and vocal fold condition during the screening of female student teachers.

OBJECTIVES: The purpose of this study was to compare the perceptual examination of voice quality with the condition of the vocal folds and voice complaints during voice screening in female student teachers. METHODS: This research was a cross-sectional study in 214 starting student teachers using the four-point grade scale of the GRBAS and laryngostroboscopic assessment of the vocal folds. The voice quality was assessed by speech pathologists using the ordinal 4-point G-scale (overall dysphonia) of the GRBAS method in a running speech sample. Glottal closure and vocal fold lesions were recorded. A questionnaire was used for assessing voice complaints. RESULTS: More students with an insufficient glottal closure (89%) were rated dysphonic compared with students with sufficient glottal closure (80%). Students with sufficient glottal closure had a significantly lower mean G-score (1.21) compared with the group with insufficient glottal closure (1.52) (P = 0.038). This study showed a larger percentage of students with vocal fold lesions (96%) labeled a dysphonic voice compared to students with no vocal fold problems (81%). Students with no vocal fold lesions had a significantly lower mean G-score (1.20) compared with the group with vocal fold lesions (2.05) (P=0.002). A dysphonic voice (G≥1) was rated in 76% of the students without voice complaints compared with 86% of the students with voice complaints. Students with no voice complaints had a lower mean G-score (1.07) compared with the group with voice complaints (1.41) (P=0.090). CONCLUSION: The present study showed that perceptual assessment of the voice and voice complaints is not sufficient to check if the future professional is at risk. Therefore, preventive measures are needed to detect students at risk early in their education and this depends on broader assessment: on the one hand, assessing voice quality and voice complaints and on the other hand, examination of the vocal folds of all starting students.

Biopsychosocial impact of the voice in relation to the psychological features in female student teachers.

OBJECTIVE: The aim of the study was to assess biopsychosocial impact of the voice in relation to the psychological features in female student teachers. METHODS: This research was a cross-sectional study in 755 student teachers using general questionnaires, the Voice Handicap Inventory (VHI), Type D Scale-16, Symptom Check List (SCL-90), and Utrecht Coping List (UCL). Student teachers with a relative high score on the VHI (>75th percentile) and students with a relative low score (<25th percentile) were compared. RESULTS: Type D student teachers had a 4x greater risk of a high VHI-score (OR 4.23) than the non-type-D group. The student teachers with relative high VHI scores scored significantly higher (P<.001) on the SCL-90 total and all subscales, compared to the student teachers with relative low VHI scores. Furthermore, the students with a relative high VHI score had significant high scores on the subscales passive attitude (P<.001), palliative reactions (P<.001), avoidance and a waiting attitude (P<.001), and expression of emotions (P=.003) of the UCL. CONCLUSION: This study showed that a relative high biopsychosocial impact of the voice is related to the personality trait Type D, psychosomatic well-being and coping strategies in female student teachers. These features should be implemented in screening and training programs for students for a voice demanding profession. The students have to be prepared to cope with psychological, physical and vocal demands of the teaching profession. The speech therapist (of the vocational university) has to be aware of an important role in coaching the students into a more active coping attitude.

Prevalence of voice complaints, risk factors and impact of voice problems in female student teachers.

A cross-sectional questionnaire survey was done among 457 female student teachers and 144 females in the general population. The conclusions are based on the opinions of student teachers and the general population. The results of this study show that 39.6% of the student teachers and 32.6% of the general population reported voice complaints at the moment and/or over the past year (p=0.198). The association between various risk factors (vocal loading factors, physical factors, environmental factors and psycho-emotional factors) and voice complaints were examined. Vocal load was reported in both the student teachers and the general population (p=0.322). Among the subjects with voice complaints, the student teachers were significantly more of the opinion than the general population that environmental irritants in the classroom (p=0.001) and the composition of the group they communicate with (p=0.033) have a negative influence on their voice. In the groups with voice complaints, the student teachers reported significantly less than the general population that stress (p=0.004) and the deterioration of their general physical condition (p=0.003) have a negative influence on their voice. Remarkably, over a third of the student teachers and one fifth of the general population with voice complaints were of the opinion that decrease of hearing has a negative influence on their voices (p=0.113). There was no significant difference in Voice Handicap Index (VHI) scores (p=0.284) and impact of voice complaints among student teachers and the general population. Over 15% of the student teachers and the general population with voice complaints reported being or having been disabled due to the voice problem, probably reflecting the severity of the voice problem (p=0.838). The groups reporting voice complaints and disability in relation to their voice complaints have significantly higher VHI scores than those without voice complaints and disability, which indicates a higher psychosocial impact of voice complaints. Only around a third of the student teachers and the general population with voice complaints sought paramedical care (p=0.656)/treatment (p=0.361) for their voice complaint. Only a minority of student teachers (18.6%) and the general population (29.5%) with voice complaints were of the opinion that the number of people they communicate with has a negative influence on their voice (p=0.120). Only around a third of the student teachers and less than a tenth of the general population with voice complaints were of the view that they would develop a voice complaint due to their profession (p=0.003). Less than half of the student teachers and less than one fifth of the general population with voice complaints were aware of the potential risks of their profession on their voice (p=0.002). Voice complaints appear to have a multifactorial genesis. The student teachers are not sufficiently aware of the impact of the various risk factors on their voice. Furthermore, they are not aware of the potential risk that future teaching may have on their voice. This apparent lack of awareness in student teachers may be considered a risk factor for voice complaints.