COVID-19 and Speech-Language Pathology Clinical Practice of Voice and Upper Airway Disorders.

Purpose Evaluation and management of voice and upper airway disorders in adults and children, by speech-language pathologists worldwide, have been significantly altered by the COVID-19 pandemic. Secondary to the pathogenic nature of the virus in the respiratory tract and upper airway, it is essential that speech-language pathologists who specialize in these disorders are knowledgeable of current practices to provide evidence-based care while minimizing viral transmission. Understanding how and when SARS-CoV-2 spreads is critical to the development of effective infection prevention within clinical practices. Method We established an evidence-based clinical practice guide for clinicians working with voice and upper airway through a comprehensive evaluation of peer-reviewed journals, non-peer-reviewed manuscripts on preprint servers, national health guidelines, and published and online consensus statements and emerging data. Emphasis was placed on risk mitigation for viral transmission via safe clinical practices, including evaluative procedures, therapy including telehealth, personal protective equipment, room, staffing, and distancing considerations. Results/Conclusions While knowledge relevant to viral transmission of SARS-CoV-2 is rapidly evolving, there is a paucity of literature specific to the evaluation and treatment of voice and upper airway disorders. Within these confines and given the potentially significant high risk of infection secondary to the nature of COVID-19, we summarize current considerations and recommend best practices that maximize risk mitigation whereby ensuring patient and provider safety.

Comparing Quality of Life and Perceptual Speech Ratings in Children With Cleft Palate.

OBJECTIVE: To delineate the relationship between patient and parent-reported quality of life (QOL) ratings and perceptual characteristics of speech assigned by a speech-language pathologist (SLP) in children with repaired cleft palate. DESIGN: Prospective. SETTING: Academic Children's Hospital. PARTICIPANTS: This population-based sample included children, aged 3 to 18 with a history of repaired cleft palate, and their parents. INTERVENTION: Participants completed the Velopharyngeal Insufficiency Effects on Life Outcomes Questionnaire (VELO). Children's speech was judged perceptually by an expert SLP using the Pittsburgh Weighted Speech Scale (PWSS). MAIN OUTCOME MEASURE(S): Velopharyngeal Insufficiency Effects on Life Outcomes questionnaire assessed participant and parent perceptions of impact of velopharyngeal function on QOL. Pittsburgh Weighted Speech Scale assessed nasal emissions, facial grimacing, nasality, quality of phonation, and articulation. RESULTS: Enrollment included 48 participant parent dyads. Overall, participants reported high QOL scores within the 95% CI with children reporting slightly better yet not significantly different QOL (86.27 ± 8.96) compared to their parents (81.81 ± 15.2). Children received an average score of 1.38 ± 1.96 on the PWSS corresponding to borderline velopharyngeal competence. A significant moderate negative correlation was found between PWSS total score and parent VELO total score (r = -0.51103, P = .0002). Mild-moderate significant negative correlations were measured between PWSS total and the 5 subscales of the VELO. No significant correlations were measured between PWSS and child VELO total responses or between total scores and subscales. CONCLUSIONS: Results suggest that as perceptual analysis of speech improves, overall QOL improves moderately.

Measurement Reliability of Laryngeal Resistance and Mean Flow Rate in Pediatric Subjects.

OBJECTIVE: Mean flow rate (MFR) and laryngeal resistance (RL) are sensitive to changes in glottal configuration and biomechanics. There is little reported on aerodynamic parameters in children. We conducted a pilot study to evaluate MFR and RL measurement reliability in a pediatric population using labial and mechanical interruption methods. METHOD: Thirty-nine subjects aged 4-17 performed 10 trials per method. For labial interruptions, subjects produced five labial plosives at a comfortable amplitude. For mechanical interruptions, subjects maintained a steady /α/ while a balloon valve interrupted their airflow five times for 250 milliseconds each. MFR was measured as the flow through the interruption device between interruptions. RL was calculated by dividing subglottal pressure (Ps) by MFR. The primary outcome measures of this study were the coefficients of variation of MFR and RL. Paired t tests were used to compare each variable between the two methods. Pearson's correlation was used to analyze the relationship between each parameter and subject age. RESULTS: Mean PS (t(38) = 2.966, P < 0.01) and RL (t(38)=3.563, P < 0.01) were higher for labial interruptions while mean MFR (t(38) = -2.036, P < 0.05) was lower. Intrasubject coefficients of variation were higher for the labial technique for both MFR (t(38) = 4.939, P < 0.001) and RL (t(38) = 3.439, P < 0.01) while there was no difference in PS variability (P = 0.260). Mean MFR and RL were related to age for both the labial (MFR: r = 0.588, P < 0.001; RL: r = -0.468, p = 0.003) and mechanical trials (MFR: r = 0.534, P < 0.001; RL: r = -0.496, P = 0.001). The coefficients of variation for RL were negatively correlated with age for both labial (r = -0.415, P = 0.009) and mechanical trials (r = -0.471, P = 0.002). MFR was only correlated in the labial trials (r = -0.514, P = 0.001) and PS was only correlated in the mechanical trials (r = -0.519, P = 0.001). CONCLUSIONS: Differences in means and intrasubject variation are likely due to differences in task and measurement timing. Precision of MFR and RL measurement in pediatric subjects was higher for mechanical interruption; further exploration of this method and its clinical utility is warranted. Measurement of aerodynamic parameters may be a useful addition to pediatric voice assessment.

Measurement reliability of phonation threshold pressure in pediatric subjects.

OBJECTIVES/HYPOTHESIS: Phonation threshold pressure (PTP), the minimum subglottal pressure (Ps ) required for phonation, is sensitive to changes in laryngeal biomechanics and is often elevated with pathology. Little is reported on PTP in children; challenges with task performance and measurement reliability represent barriers to routine clinical assessment. STUDY DESIGN: Pilot study evaluating PTP and Ps measurement reliability in children using labial and mechanical interruption. METHODS: Twenty-two subjects aged 4 to 17 years (10.7 ± 3.9 years) participated. Ten trials were performed for each method; task order was randomized. For labial interruption, subjects produced /pα/ five times at softest (onset PTP) and comfortable amplitude. For mechanical interruption, subjects produced a sustained /α/ while a balloon valve interrupted phonation five times for 250 ms each; mechanical interruption was performed with a mouthpiece and mask. PTP was recorded as the difference between Ps and supraglottal pressure at phonation cessation (offset PTP). Mean PTP and Ps and intrasubject coefficients of variation were compared. Correlations with age were evaluated. RESULTS: Mean PTP (P < .001) and Ps (P = .005) were higher for labial interruption. Intrasubject coefficients of variation for PTP (P = .554) and Ps (P = .305) were similar across methods. Coefficient of variation was related to age for mechanical-mask trials only (r = -0.628, P = .00175). CONCLUSIONS: Differences in means are likely related to differences in task and PTP hysteresis effect. Reliability is comparable with all methods; using a mouthpiece may be preferable to a mask for mechanical interruption. Measurement of PTP is noninvasive, reliable, and may be a useful adjunct in pediatric voice assessment. LEVEL OF EVIDENCE: 3b Laryngoscope, 129:1520-1526, 2019.

Patient, Parent, and Speech-Language Pathologists' Perceptions of Pediatric Voice Therapy Through Interviews.

Purpose: Voice therapy is heavily reliant on patient adherence for success, and patient perceptions are an important piece of understanding adherence. Patient perceptions of voice therapy have not been studied in the pediatric population. The purpose of this study was to examine patient, parent, and speech-language pathologists' experiences and perceptions of voice therapy and how they reflect barriers to and facilitators of adherence to therapy. Method: Participants took part in semistructured interviews, which were transcribed, and content analysis was completed using established qualitative methods of content analysis to identify themes and subthemes related to voice therapy adherence. Participants: Thirty-four voice therapy patients (of ages 4-18) and their parents and 5 pediatric speech-language pathologists were included in the study. Results: Seven primary themes with multiple subthemes were identified. The primary themes identified were as follows: (a) voice therapy is fun, (b) voice therapy is easy, (c) voice therapy is worthwhile, (d) the clinician-patient match matters, (e) support systems are helpful, (f) fitting it in, and (g) changing behavior is hard. Conclusions: Adherence to voice therapy in pediatric populations is complex and depends on multiple intrinsic and extrinsic factors. Identification of themes related to adherence in voice therapy should serve to assist clinicians in planning therapy and in developing treatment programs.

Video Game Rehabilitation of Velopharyngeal Dysfunction: A Case Series.

Purpose: Video games provide a promising platform for rehabilitation of speech disorders. Although video games have been used to train speech perception in foreign language learners and have been proposed for aural rehabilitation, their use in speech therapy has been limited thus far. We present feasibility results from at-home use in a case series of children with velopharyngeal dysfunction (VPD) using an interactive video game that provided real-time biofeedback to facilitate appropriate nasalization. Method: Five participants were recruited across a range of ages, VPD severities, and VPD etiologies. Participants completed multiple weeks of individual game play with a video game that provides feedback on nasalization measured via nasal accelerometry. Nasalization was assessed before and after training by using nasometry, aerodynamic measures, and expert perceptual judgments. Results: Four participants used the game at home or school, with the remaining participant unwilling to have the nasal accelerometer secured to his nasal skin, perhaps due to his young age. The remaining participants showed a tendency toward decreased nasalization after training, particularly for the words explicitly trained in the video game. Conclusion: Results suggest that video game-based systems may provide a useful rehabilitation platform for providing real-time feedback of speech nasalization in VPD. Supplemental Material: https://doi.org/10.23641/asha.5116828.

Effect of MP4 Therapy Videos on Adherence to Voice Therapy Home Practice in Children With Dysphonia.

OBJECTIVES/HYPOTHESIS: Voice disorders in children are often treated with behavioral voice therapy, which requires home practice of exercises. Previous studies with adults demonstrated increased practice frequency when patients were given videos of a clinician and patient performing therapy tasks. The purpose of this study was to determine whether videos of practice exercises would increase adherence to therapy in children. STUDY DESIGN: The study used a randomized double crossover research design. METHODS: Twenty-eight patients, aged 6-18, referred for voice therapy were included in the study. Two conditions were alternated on a weekly basis: standard-of-care therapy and standard-of-care therapy with video models added. Participants recorded practice frequency and participated in semi-structured interviews, which were analyzed for themes. RESULTS: Participants practiced an average of 1.79 times per day without videos and 1.72 with videos (P = 0.743), indicating no significant difference between conditions. There was also no age group effect (P = 0.314). Qualitative analysis of interview responses established the following themes: (1) I knew how to do my exercises, (2) I didn't like seeing/hearing myself, (3) Videos helped me remember to practice, (4) I didn't like the video player itself, (5) The videos didn't make a difference with practice, and (6) Practicing was no fun. CONCLUSIONS: Video models of therapy tasks do not appear to influence adherence to home practice frequency in children with voice disorders, in contrast to findings in adults. Videos were found useful by several participants as reminders to practice.

Objective Measure of Nasal Air Emission Using Nasal Accelerometry.

Purpose: This article describes the development and initial validation of an objective measure of nasal air emission (NAE) using nasal accelerometry. Method: Nasal acceleration and nasal airflow signals were simultaneously recorded while an expert speech language pathologist modeled NAEs at a variety of severity levels. In addition, microphone and nasal accelerometer signals were collected during the production of /pɑpɑpɑpɑ/ speech utterances by 25 children with and without cleft palate. Fourteen inexperienced raters listened to the microphone signals from the pediatric speakers and rated the samples for the severity of NAE using direct magnitude estimation. Mean listener ratings were compared to a novel quantitative measurement of NAE derived from the nasal acceleration signals. Results: Correlation between the nasal acceleration energy measure and the measured nasal airflow was high (r = .87). Correlation between the measure and auditory-perceptual ratings was moderate (r = .49). Conclusion: The measure presented here is quantitative and noninvasive, and the required hardware is inexpensive ($150). Future studies will include speakers with a wider range of NAE severity and etiology, including cleft palate, hearing impairment, or dysarthria. Further development will also involve validation of the measure against airflow measures across subjects.

Effects of spectral content on Horii Oral-Nasal Coupling scores in children.

A miniature accelerometer and microphone can be used to obtain Horii Oral-Nasal Coupling (HONC) scores to objectively measure nasalization of speech. While this instrumentation compares favorably in terms of size and cost relative to other objective measures of nasality, the metric has not been well characterized in children. Furthermore, the measure is known to be affected by vowel loading, as speech loaded with "high" vowels is consistently scored as more nasal than speech loaded with "low" vowels. Filtering the signals used in computation of the HONC score to better isolate the correlates of nasalization has been shown to reduce vowel-related effects on the metric, but the efficacy of filtering has thus far only been explored in adults. Here, HONC scores for running speech and the vowel portions of consonant-vowel-consonant tokens were calculated for the speech of 26 children, aged 4-9 yrs. Scores were computed using the broadband accelerometer and speech signals, as well as using filtered, low-frequency versions of these signals. HONC scores obtained using both broadband and filtered signals resulted in well-separated scores for nasal and non-nasal speech. HONC scores computed using filtered signals were found to exhibit less within-participant variability.

Characteristics of phonatory function in singers and nonsingers with vocal fold nodules.

PURPOSE: The goals of this study were to determine if there were significant differences between singers and nonsingers in the morphology of vocal nodules and the associated impact on vocal function. METHOD: Participants were 10 professionally trained singers with nodules, eight nonsingers with nodules, and 10 individuals with healthy normal voice (controls). Surface electromyography (sEMG) from three anterior neck locations and acoustic rise times for vowels /a/ and /i/ were measured in all the participants. In individuals with nodules, dB SPL/cm H(2)O, glottal airflow, and nodule location and size were also measured. RESULTS: There were no significant differences between singers and nonsingers with nodules in terms of airflow, dB SPL/cm H(2)O, nodule size, or nodule location. In nonsingers with nodules, airflow and nodule size were significantly correlated, but were not significantly correlated in singers. Vowel rise times and sEMG during vocal tasks did not differentiate among nodule and control groups. Sternocleidomastoid sEMG during initiation of the vowel /a/ was statistically significantly stronger in nonsingers with nodules relative to singers with nodules and controls. CONCLUSIONS: Nodule morphology did not differ between singers and nonsingers, although some behavioral aspects of phonation differed between the groups.

Comparison of neck tension palpation rating systems with surface electromyographic and acoustic measures in vocal hyperfunction.

The purpose of this study was to evaluate current neck tension palpation rating systems to determine interrater reliability and possible correlation with necksurface electromyography (sEMG, collected from three electrode recording locations) and to measure the third formant for /a/ during various vocal behaviors. This prospective study examined the neck muscle tension of 16 participants before and after a single session of voice therapy. Interrater reliability and relationships between palpation ratings and objective measures of sEMG (anterior neck) and the third formant for /a/ were assessed using Pearson's correlations (r). Interrater reliability was relatively low as measured by Pearson's correlations, although Wilcoxon signed-rank test results were similar as those in a previous study. Correlations between palpation ratings and sEMG and between ratings of laryngeal height and the third formant for /a/ were generally low. Correlations increased between anterior neck sEMG and ratings of suprahyoid muscle tension when examined in a reduced set of individuals with higher interrater reliability. Palpation rating scales do not reliably capture changes that may occur in neck muscle tension of typical voice therapy patients over one session. Consequently, little can be concluded from correlations between sEMG and palpation ratings.

Assessing the effectiveness of botulinum toxin injections for adductor spasmodic dysphonia: clinician and patient perception.

To determine the effectiveness of Botox treatment for adductor spasmodic dysphonia (ADSD), the clinician and patient judge changes in voice symptoms and the effect on quality of life. Currently, there is no standard protocol for determining the effectiveness of Botox injections in treating ADSD. Therefore, clinicians use a variety of perceptual scales and patient-based self-assessments to determine patients' impressions of severity and changes after treatments. The purpose of this study was to assess clinician-patient agreement of the effects of Botox on voice quality and quality of life in ADSD. Retrospective chart review of 199 randomly selected patients since 2004. Results indicated a weak correlation between the patient's assessment of voice impairment (EIS) and patient's quality of life impairment (Voice-Related Quality of Life [V-RQOL]) in the mild-moderate dysphonia severity group and the moderate-to-severe dysphonia group. There was a weak correlation between the patient's assessment of voice impairment EIS and the clinician's perceptual judgment of voice impairment (Consensus Auditory Perceptual Evaluation of Voice [CAPE-V]) only in the moderate to severe dysphonia group. There was a weak correlation between the patient's quality of life impairment (V-RQOL) and the clinician's perceptual judgment of voice impairment (CAPE-V) only in the severe to profound dysphonia group. The poor relationship among commonly used outcome measures leads us to question how best to assess the effectiveness of Botox in ADSD. Clinicians are required to document treatment outcomes, making it important to use scales that are valid, reliable, and sensitive to change. Future research directions include examining relationships between measures both before and after Botox injections, examining the specific factors that determine quality of life changes, and further research on specific parameters of the CAPE-V as well as comparing perceptual and quality of life scales with acoustic and aerodynamic measures in this population would be beneficial in the move toward more effective ways of measuring change.

Listening: the key to diagnosing spasmodic dysphonia.

Spasmodic dysphonia (SD) is a focal dystonia of the larynx. Adductor spasmodic dysphonia (ADSD) involves the laryngeal adductor muscles, and symptoms of vocal roughness, staccato-like sounds, and stops in phonation. Abductor spasmodic dysphonia (ABSD) affects the laryngeal abductor muscles, resulting in a breathy or whispered voice quality and voice breaks. SD has a significant impact on the quality of life. This article discusses symptoms of SD and the standard treatment of SD.