The Minimal Important Difference of Acoustic Voice Quality Index in the Treatment of Voice Disorders.

OBJECTIVES: The acoustic voice quality index (AVQI) is a reliable tool that objectively assesses dysphonia levels using six acoustic parameters. Despite its high criterion-related concurrent validity, diagnostic accuracy, and minimal detectable change derived from test-retest reliability, the minimal important difference (MID) of the AVQI has not been tested before. This study aimed to estimate the MIDs of AVQI for improvement audibly perceived by clinicians and self-reported improvement by patients. METHODS: A retrospective study was conducted on 110 patients who received treatment for voice disorders. Patients completed AVQI and Voice Handicap Index-10 (VHI-10) questionnaires before and after the therapy. The MIDs of the AVQI were estimated using the anchor of either auditory-perceptual judgment of total dysphonia levels by clinicians or the VHI-10 questionnaire by patients. A distribution-based approach was also used to complement the results. RESULTS: First, using the auditory-perceptual anchor, a decrease of 0.95 in the AVQI was estimated as the MID for clinicians' perception, as a result of the receiver operating curve. Then, using the patient-reported anchor, an improvement of 1.36 in the AVQI was estimated as the MID for patients' voice-related disability. The distribution-based approach also ensured the anchor-based results of both the MIDs. CONCLUSIONS: The AVQI is a reliable and valid tool for evaluating voice quality, and a 0.95 decrease in the AVQI represents a meaningful improvement for clinicians' perception, whereas a 1.36 decrease in the AVQI influences patients' self-reported disability. This study contributes to understanding the minimal change necessary for clinicians to make informed decisions and ensure patient satisfaction. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2805-2811, 2024.

Validation of Subharmonics Quantification Using Two-Stage Cepstral Analysis.

OBJECTIVES: Hoarseness is primarily perceived as breathiness or roughness. Despite the various tools that quantitatively assess hoarseness, roughness has been difficult to quantify because of its complex acoustic structure, such as subharmonics. The parameter obtained from the two-stage cepstral analysis is promising for evaluating roughness. Thus, this study aimed to improve the accuracy of the parameter using a customized pitch setting and investigate the relationship between roughness and subharmonics. STUDY DESIGN: The design is a retrospective study. METHODS: Two-stage cepstral analysis was used to analyze the voice recordings of 455 participants, speech impaired and normal controls, using the Analysis of Dysphonia in Speech and Voice and Praat software. For validation, the ground truth of subharmonics was visually quantified using a narrowband spectrogram. The reliability and validity of the two-stage cepstral analysis and subharmonics measures on spectrograms were evaluated. RESULTS: The two-stage cepstral analysis showed a very strong correlation (r = 0.963) between the two software programs. Intra- and inter-rater reliability of the subharmonics measures on spectrograms were also good. Two-stage cepstral analysis showed that even with customized pitch settings, the diagnostic systems and correlations for perceptual roughness and subharmonics were weak to moderate. The subharmonics measures on spectrograms showed a strong correlation with roughness and moderate diagnostic accuracy of subharmonics. CONCLUSIONS: The two-stage cepstral analysis showed some improvement in diagnostic accuracy and correlation with customized pitch settings, but it did not sufficiently detect subharmonics or roughness. The analysis using subharmonics measures on spectrograms proved the high correlation between subharmonics and roughness, indicating that developing acoustic analysis parameters that sufficiently detect subharmonics is necessary.

The Significant Influence of Hoarseness Levels in Connected Speech on the Voice-Related Disability Evaluated Using Voice Handicap Index-10.

OBJECTIVES: This retrospective study examines the influence of voice quality in connected speech (CS) and sustained vowels (SV) on the voice-related disability in patients' daily living documented by Voice Handicap Index-10 (VHI-10). METHODS: A total of 500 voice recordings of CS and SV samples from 338 patients with voice disturbances were included, along with the patients' age, diagnoses, maximum phonation time, and VHI-10. Dataset-1 comprised of 338 untreated patients, whereas Dataset-2 included 162 patients before and after phonosurgeries. As a preliminary study, the concurrent and diagnostic validities based on auditory-perceptual judgments were examined for cepstral peak prominence (CPP) and CPP smoothed (CPPS) for CS and SV tasks. Next, simple correlations and multivariate regression analyses (MRA) were performed to identify which of the acoustic measures for the CS or SV tasks significantly influenced the total score or improvement of VHI-10. RESULTS: The preliminary study confirmed high correlations with hoarseness levels as well as the excellent diagnostic accuracy of CPP and CPPS for both CS and SV tasks. In Dataset-1, the simple correlations and MRA results showed that cepstral measures in both tasks demonstrated moderate correlations with, and significant contribution to the total score of VHI-10, respectively. However, in Dataset-2, the changes of cepstral measures, as well as the median pitch after phonosurgeries in the CS tasks only, showed significant contributions to the improvement of VHI-10. CONCLUSION: The study demonstrated that the hoarseness levels in both the CS and SV tasks equivalently influenced the VHI-10 scores, and that the post-surgical change of voice quality only in the CS tasks influenced the improvement of voice-related disability in daily living.

Intertext Variability of Smoothed Cepstral Peak Prominence, Methods to Control It, and Its Diagnostic Properties.

OBJECTIVES: This study aimed to estimate the intertext variability of smoothed cepstral peak prominence (CPPS), examine whether sound-processing techniques improved its variability and diagnostic capability, and evaluate the degree of intertext variability in detail with reference to the CPPS variabilities in sustained vowels. STUDY DESIGN: This was a retrospective study. METHODS: Text readings of 58 Japanese syllables were recorded from 210 speakers with different diagnoses and varying degrees of dysphonia, and were divided into six passages. Applying the sound-processing techniques to those passages, we prepared three sample types: (1) nonprocessed, (2) only-loud, and (3) only-voiced samples. The intertext CPPS variability and diagnostic properties were compared across the passages and sample types. For detailed analysis, we subsequently extracted 63 normophonic speakers who maintained constant quality in their vowel utterances to evaluate the degree of intertext CPPS variability in relation to the variabilities between repeated identical vowels and across different vowels. RESULTS: Although several combinations of passages showed moderate-to-large CPPS variabilities, those variabilities were decreased by either technique, especially the deletion of silent segments, which resulted in the best diagnostic accuracy. The degree of intertext CPPS variability for the only-voiced samples was comparable to that of the CPPS variabilities in sustained vowels. CONCLUSIONS: The sound-processing technique removing silent segments should be applied to enhance the diagnostic properties of CPPS. The additional technique of deleting unvoiced segments is worth adopting if clinicians and researchers seek to attenuate the influence of text differences in calculating CPPS values.

Acoustic Breathiness Index for the Japanese-Speaking Population: Validation Study and Exploration of Affecting Factors.

Objectives The purposes of this study were to validate the Acoustic Breathiness Index (ABI) for the Japanese-speaking population and to determine whether it is independent of factors such as sex, age, and perceptual ratings of roughness. Method First, the concurrent validity of the ABI for perceptual breathiness was evaluated on the concatenations of continuous speech and sustained vowels from 288 patients with varying degrees of dysphonia. The diagnostic accuracy was examined on 343 samples with 55 additional normophonic speakers. Second, the validity related to responsiveness-to-change was estimated on 222 samples obtained before and after interventions for 111 voice-disordered patients. Third, the relationships between the ABI and other variables (i.e., perceptual hoarseness/breathiness/roughness, sex, and age) were explored using bivariate and multivariate analyses for the 288 patients. Results First, the concurrent validity and the responsiveness-to-change validity were confirmed by strong correlation coefficients of .890 and .878, respectively. Second, the receiver operating characteristic analysis showed the area under the curve to be 0.939, indicating excellent accuracy. The ABI of 3.44 exhibited a sensitivity of 76.3% and a specificity of 94.1%. Third, although bivariate analyses revealed a weak relationship between ABI and roughness and an ABI difference by age, multiple regression analyses showed a strong relation between only ABI and breathiness, without a meaningful contribution from roughness, sex, and age factors. Conclusion The study confirmed that the ABI is an accurate and specific tool to estimate breathiness levels in the Japanese-speaking population and neither roughness, sex, nor age significantly affects the ABI.

The Acoustic Voice Quality Index Version 03.01 for the Japanese-speaking Population.

OBJECTIVES: We aimed to determine the most appropriate syllable number for analyzing the Acoustic Voice Quality Index for the Japanese-speaking population (AVQIv3-JP) and to validate AVQIv3-JP using the determined syllable number. METHODS: First, we counted how many syllables should be included in each continuous speech (CS) sample to achieve time-balanced analysis between CS and sustained vowel samples using our previous dataset including 336 CS samples with 58 syllables. From the descriptive statistics of the counted syllable numbers, the most appropriate syllable number was identified. Subsequently, we performed validation procedures of AVQIv3-JP using our latest dataset including 455 recordings. RESULTS: Thirty Japanese syllables were judged to be the most appropriate syllable number. The concurrent validity of the AVQIv3-JP using 30 syllables was confirmed by Spearman's rho of 0.873. Subsequently, the receiver operating characteristic analysis demonstrated the excellent discriminative capability of AVQIv3-JP, showing the area under the curve of 0.915. The AVQIv3's original threshold of 2.43 in the Dutch language corresponded to sensitivity and specificity of 64.6% and 97.3%, respectively. In the present study, a threshold of 1.41 achieved the best accuracy with balanced sensitivity and specificity of 84.4% and 85.6%, respectively. Furthermore, the 95th percentile of the control participants exhibited a threshold of 2.06, showing sensitivity and specificity of 72.1% and 93.8%, respectively, as well as reasonable positive and negative likelihood ratios of 11.7 and 0.298, respectively. CONCLUSION: The AVQIv3 using 30 Japanese syllables is a reliable measurement tool for estimating the severity of voice quality and detecting abnormal voices.

Immediate effects of humming on computed electroglottographic parameters in patients with muscle tension dysphonia.

OBJECTIVES: To investigate the immediate effects of humming and subsequent um-hum phonation on the computed parameters of electroglottographic (EGG) signals in muscle tension dysphonia (MTD) patients and nondysphonic speakers. METHODS: We included 21 MTD participants exhibiting both vocal roughness and supraglottic compression, who were able to produce successful humming and um-hum phonation. Twenty nondysphonic participants were selected as controls. Each participant was instructed to perform three phonatory tasks: natural phonation, humming phonation without pitch changes, and subsequent um-hum phonation, that is, humming with a pitch glide up as if agreeing with someone. Acoustic and EGG signals were recorded while the participants performed these tasks. Computed parameters reflecting the irregularities in vocal fold vibrations and the degree of glottal contact were calculated and compared between the tasks. RESULTS: The MTD group showed decreases in both perceptual vocal roughness and acoustic perturbation parameters while performing the tasks. The perturbation parameters of EGG signals and the standard deviation of the contact quotient (CQ) also exhibited significant decreases associated with either of humming or um-hum phonation in both groups. In addition, the CQ exhibited significant increases following humming alone in the MTD group and the combination of humming and um-hum phonation in both groups. CONCLUSIONS: These results suggest that the combination of humming without pitch changes and subsequent um-hum phonation have the immediate effect in adjusting the regularity of vocal fold vibration and augmenting the degree of glottal contact in MTD patients as well as nondysphonic speakers, whereas humming alone increases the degree of glottal contact in MTD patients.

Immediate effectiveness of humming on the supraglottic compression in subjects with muscle tension dysphonia.

AIMS: To verify whether humming corrects supraglottic compression in muscle tension dysphonia (MTD) patients. METHODS: We enrolled 23 MTD participants (13 male, 10 female) showing supraglottic compression. Each individual was instructed to perform 3 types of phonation under transnasal laryngofiberscopy: natural phonation, humming phonation without pitch change and subsequent um-hum phonation, i.e. humming with pitch glide up as if agreeing with someone. The degree of supraglottic compression was estimated with 2 parameters. The false vocal fold and anterior-posterior indices (the FVF and AP indices) were calculated by normalizing the lateral width and AP length of the visible vocal cords at phonation normalized to the mean vocal cord length at inspiration, respectively. These indices were compared among the tasks. RESULTS: All the MTD participants but 5 females accomplished decreases in the vocal roughness scores upon the phonatory tasks. The whole MTD group showed significant increases in the FVF and AP indices even after humming without pitch change with a dominance of the AP index. The humming-responsive MTD subgroup showed greater increases in both indices than the humming-resistant subgroup. CONCLUSION: These data demonstrate that humming corrects both the lateral and AP components of supraglottic compression in most MTD patients.

[Present and future state of cancer screening for esophageal cancer and gastric cancer].

Recently, endoscopic examinations have played a major role in the diagnosis and treatment in the field of gastroenterology. It is considered that endoscopy would be an important examination for cancer screening of the esophagus and the stomach. However, endoscopic services for cancer screening are in short supply. Furthermore, we have to take the complications and poor economic benefits of endoscopy in to consideration when we apply it as a practical cancer screening system. Thus, an effective primary screening system must be provided for the endoscopic screening of cancer of the esophagus and the stomach. People with a defect in aldehyde dehydrogenase-2(ALDH2)should be distinguished by their facial flushing in drinking and for their high risks of esophageal cancer. In cases with gastric cancer screening by endoscopy, an x-ray study is expected to be a primary screening because of its efficacy. It already has been recommended for population-based screening in Japanese guidelines for gastric cancer screening. In cases with opportunistic screening of gastric cancer, patients should be allowed to choose from several studies such as the x-ray study, direct endoscopy, and the so-called high risk screening of gastric cancer for estimating risks and planning of screening for gastric cancer.

Endoscopic resection for T1a-MM and T1b-SM1 squamous cell carcinoma of the esophagus.

In Japan, the first paper on endoscopic resection (ER) for squamous cell carcinoma (SCC) of the esophagus confined to the mucosa was reported as endoscopic mucosal resection (EMR) in 1988. Since publication of that article, ER has been recommended as the standard treatment for squamous and mucosal cancer of the esophagus. T1a-EP and T1a-LPM esophageal cancer seldom involves lymph node metastasis. However, in cases of T1a-MM and T1b-SM1 esophageal cancer with lymph node metastasis (10% to 30%), the indication of ER is limited. The risk factors for lymph node metastasis in T1a-MM and T1b-SM1 esophageal cancer were cleared by clinical and pathological studies. Endoscopic findings such as type 0-I or type 0-III, size of 50 mm or more, and pathological findings such as lymphatic permeation, venous permeation, poorly differentiated SCC and INFb or INFc were suggestive of high risk for lymph node metastasis. In addition, histopathological findings of small cancer nests, defined as "budding" or "droplet infiltration," suggest frequent lymph node metastasis. In cases of T1a-MM and T1b-SM1 esophageal cancer with high risk of lymph node metastasis, adjuvant therapy including chemoradiotherapy and radical esophagectomy are recommended after ER. A recent advance in ER for esophageal cancer is the establishment of endoscopic submucosal dissection (ESD). It has allowed us to perform an en-block resection of a large mucosal lesion of the esophagus and detailed histopathological examination. However, ESD requires more difficult manipulation than EMR. The indication of EMR or ESD is sought.

[Association between laryngeal findings and vocal qualities in muscle tension dysphonia with supraglottic contraction].

Muscle tension dysphonia (MTD) is a voice disorder associated with abnormal laryngeal posture or glottic configuration induced by excessive contraction of the laryngeal muscles, and supraglottic contraction is one of the characteristic findings in MTD. In recent study we investigated the changes in laryngeal findings and voice quality and the association between them in the course of voice therapy for MTD with supraglottic contraction. The effects of voice therapy on the laryngeal and the vocal findings were assessed by two rating methods: the MTD score and the conventional GRBAS scores and both scores were gradually improved. Of the two components of supraglottic contraction, false vocal cord compression was more curable than anterior-posterior compression at the aryepiglottic level. Little correlation was found between the scores at the first examination, but significant associations (p < 0.05) were found between the differences of MTD score and G/R/S scores but not B/A scores before and after the series of voice therapy. These results suggest that supraglottic contraction is a crucial factor worsening voice quality and that MTD score is useful to assess the efficacy of voice therapy for MTD.

[Endoscopic mucosal resection for esophageal cancer].

Lymph node metastasis or microvascular permeation is rare among esophageal cancer which remains within the epithelium or the lamina propria mucosae. Endoscopic mucosal resection (EMR) is recommended for them as a radical treatment. Radical esophagectomy had been indicated for esophageal cancer reaching to the muscularis mucosae for their incidence of lymph node metastasis (10%). Recently, number of m3 or sm1 cancer cases treated by EMR has been increased, for some clinical trial succeeded to show that there is no significant difference between the prognosis of patient treated by EMR and by surgery. Thirty one patients (14%) have been lost among 219 patients who underwent EMR (mucosal cancer: 196 and submucosal cancer: 23). Four cases (13% of all patients lost after EMR) died of esophageal cancer, (one case with m3 cancer was lost by lymph node metastasis, one with sm2 cancer by liver metastasis, and two patients who refused surgical treatment by local recurrence after EMR), nineteen by other diseases than esophageal cancer and eight by cancer at other organs (lung: 3, hypoharynx: 2, mesopharynx: 1, stomach: 1, ureter: 1). Three of them were found concomitantly and 5 metachronously. Local recurrence was found in 8.3% of all patients treated by EMR. All patients with recurrence had received piecemeal resection. Sixty seven percents of all lesion of local recurrence was detected by endoscopic surveillance within one year after EMR. All recurred lesions were treated by EMR and pathological studies on resected specimens revealed that all recurred lesions were mucosal cancer. Metachronous esophageal cancer was found in 11% of all EMR cases. Sixty five percent of all metachronous cancer were detected in one to three years after EMR. Metachronous esophageal cancer after EMR was frequently found among cases with esophageal mucosa which has many small unstained areas. Malignant lesions were found in 33 cases (15%) of all patients treated by EMR synchronously and 37 (17%) metachronously. The stomach and the head and neck are most frequent site of associated cancers.

Superficial basaloid squamous carcinoma of the esophagus. A clinicopathological and immunohistochemical study of 12 cases.

Basaloid squamous carcinoma (BSC) is a rare variant of squamous cell carcinoma (SCC). In this study, clinicopathological and immunohistochemical characteristics of 12 superficial esophageal BSCs were examined and compared with those of typical superficial SCCs. Eight cases were classified into an elevated type, and the other four into a depressed type. High-grade intraepithelial neoplasia was not observed around the invasive lesions in five cases, and only BSC components were apparent. High-grade intraepithelial neoplasia was demonstrated in seven cases, five of which had both BSC and SCC components in the invasive lesion. A cribriform growth pattern, comedo-type necrosis, and hyaline deposits were conspicuous histological findings. CK14 was positively stained in 90% of the series, but the proportion of positive cells was small in most cases. Type IV collagen was increased or well preserved in the basement membrane in 70% of cases, but heparan sulfate was decreased in the majority. In comparison with SCCs, lymphatic permeation was observed less frequently. However, regarding the frequencies of venous permeation, nodal metastasis, p53 protein expression, and Ki-67 labeling index, no significant differences were noted. Thus, esophageal BSCs demonstrate the pathological features characteristic of an early stage, but pathological parameters related to biological behavior do not significantly vary from those typical of SCCs.

Vertical and horizontal growth features of superficial esophageal squamous cell carcinomas: histopathological evaluation of endoscopically resected specimens.

Endoscopic mucosal resection (EMR) has been performed for intramucosal carcinomas with excellent results. To evaluate invasion depth of superficial esophageal squamous cell carcinomas (SESCCs) accurately, it is important to elucidate vertical and horizontal growth features. Using 179 specimens of SESCC taken by EMR, various factors associated with vertical and horizontal growth were examined pathologically to determine which were correlated with invasion depth, classified for this purpose into four levels, m1, m2, m3, and sm. Maximum tumor diameter, including high-grade intraepithelial neoplasia, differed between m1 and m2 cases and for invasive lesions between m2 and m3. Maximum tumor thickness varied between m1 and m2, m2 and m3, and m3 and sm. Multivariate analysis showed tumor thickness and diameter of invasion to be correlated with submucosal invasion. Tumor thickness and depth of the depressed lesions were correlated in depressed/flat type cases. In elevated type cases the thickness of the tumor did not differentiate between m3 and sm. Shape of the elevated lesion also influenced the invasion depth. Frequency of infiltrating type tumors, composed of irregular and small invading nests, was higher with sm than m3. To differentiate m3 and sm tumor the classification of gross type, thickness, depth of depressed lesions, shape of elevated lesions, and invasion patterns should all be evaluated.

Detection and treatment of an asymptomatic case of early esophageal cancer using chromoendoscopy and endoscopic mucosal resection.

Recent trends in the management of superficial esophageal cancer consist of improved detection and curative endoscopic therapy. However, successful endoscopic therapy has not been reported in Taiwanese patients with this disease. We describe the case of a male, 38-year-old habitual drinker admitted for a general health check-up, whose endoscopic examination revealed a slightly depressed discolored lesion in the middle esophagus. Chromoendoscopy with 3% Lugol's iodine solution showed a mesh-like unstained pattern occupying approximately two-thirds of the circumferential esophageal mucosa. Spraying with 2% toluidine blue solution stained a 3 x 6 cm suspect area pale blue. Endoscopic biopsy confirmed squamous cell carcinoma. Histopathologic examination revealed the lesion was a type IIc superficial esophageal cancer. Endoscopic ultrasonography showed the lesion was limited to the epithelial layer with no evidence of lymph node involvement. The lesion was removed en bloc using endoscopic mucosectomy. Microscopic examination of the resected specimen demonstrated that the depth of invasion was confined to the epithelial layer except for some areas with small nests of tumor cells within the lamina propria. Balloon dilatation to prevent post mucosectomy stricture was performed and the patient recovered uneventfully. At 1 year of follow-up, the patient was alive without any endoscopic signs of local recurrence. This case suggests that chromoendoscopy in combination with endoscopic resection is likely to benefit patients with early-stage esophageal cancer.

[Endoscopic evaluation of the depth of invasion in cases of superficial esophageal cancer in determining indications for endoscopic mucosal resection].

Endoscopic mucosal resection (EMR) should be performed for the treatment of squamous cell carcinoma of the esophagus limited to the lamina propria mucosae (m1 and m2 cancers), because lymph node metastasis is rare in these cases. The lymph node metastasis rate is 6% when cancers reach the muscularis mucosa(m3) or slightly invade the submucosa (sm1). Lymph node metastasis is noted in 47% of esophageal cancers moderately or severely invading the submucosa(sm2 and sm3). Radical esophagectomy is recommended for sm2 and sm3 disease. Type 0-II cancers are candidates for EMR, because 86% remain within the mucosa, while 90% of type 0-I lesions and 96% of type 0-III lesions are submucosal cancers. Among type 0-II cancers, most type 0-IIb lesions are m1 cancer. Among type 0-IIa cancers, 96% are mucosal. Type 0-IIc lesions are frequent among superficial esophageal cancers and 19% reach the submucosa. Endoscopic diffrentiation of m1 and m2 cancers is reliable, since 96% of all m1 and m2 cancers were correctly diagnosed before treatment. In cases with type O-IIc lesions which is most frequent among superficial esophageal cancers, m1 cancer showed very slight depressions with a smooth surface and reddening. Sometimes fine granular changes are seen. They are also delineated as an unstained area by endoscopic toluidine blue-iodine double staining. They showed very slight depressions with a smooth surface and reddening. Sometimes fine granular changes are seen. They are also delineated as an unstained area by endoscopic toluidine blue-iodine double staining. Dark blue dots, spots, or reticular staining are frequently identified in m2 cancers. In cases with m3 or sm1 cancer, coarse granular changes, small nodular elevations, or slightly deeper depressed areas in the m1 and m2 lesions suggest sites of deeper invasion.