Semioccluded Vocal Tract Exercises Improve Self-Perceived Voice Quality in Healthy Actors.

PURPOSE: Semi-occluded vocal tract exercises (SOVTE) have shown to lead to more effective and efficient vocal production for individuals with voice disorders and for singers. The aim of the present study is to investigate the effects of a 10-minute SOVTE warm-up protocol on the actors' voice. METHODS: Twenty-seven professional theater actors (16 females) without voice complaints were audio-recorded while reading aloud, with their acting voice, a short dramatic passage at four time points. Recordings were made: the day before the show, just before and soon after the warm-up protocol which was performed prior to the show and soon after the show. The voice quality was acoustically and auditory-perceptually evaluated and quantified at each time point by blinded raters. Self-assessment parameters anonymously collected pre and post exercising were also analyzed. RESULTS: No statistically significant differences on perceptual ratings and acoustic parameters were found between pre/post exercise sessions and males/females. A statistically significant improvement was detected in the self-assessment parameters concerning comfort of production, sonorousness, vocal clarity and power. CONCLUSIONS: Vocal warm-up with the described SOVTE protocol was effective in determining a self-perceived improvement in comfort of production, voice quality and power, although objective evidence was missing. This straightforward protocol could thus be beneficial if routinely utilized by professional actors to facilitate the voice performance.

In Vivo Quantification of the Intraglottal Pressure: Modal Phonation and Voice Onset.

Intraglottal pressure is the driving force of vocal fold vibration. Its time course during the open phase of the vibratory cycle is essential in the mechanics of phonation, but measuring it directly is difficult and may hinder spontaneous voicing. However, it can be computed from the in vivo measured transglottal flow and glottal area (hence the air particle velocity) on the basis of the Bernoulli energy law and the interaction with the inertance of the vocal tract. As to sustained modal phonation, calculations are presented for the two possible shapes of glottal duct: convergent and divergent, including absolute calibration in order to obtain quantitative physical values. Whatever the glottal duct configuration, the calculations based on measured values of glottal area and air flow show that the integrated intraglottal pressure during the opening phase systematically exceeds that during the closing phase, which is the basic condition for sustaining vocal fold oscillation. The key point is that the airflow curve is skewed to the right relative to the glottal area curve. The skewing results from air compressibility and vocal tract inertance. The intraglottal pressure becomes negative during the closing phase. As to the soft (or physiological) voice onset, a similar approach shows that the integrated pressure differences (opening phase - closing phase) actually increase as the onset progresses, and this applies to the results based on Bernoulli's energy law as well as to those based on the interaction with the inertance of the vocal tract. Furthermore and similarly, the phase lead of the pressure wave with respect to the glottal opening progressively increases. The underlying explanation lies in the progressively increasing skewing of the airflow curve to the right with respect to the glottal area curve.

Speech Therapy as Treatment for Supragastric Belching.

The purpose of this study was to describe a newly developed speech therapy program as an innovating therapeutic approach and to assess the results of this intervention in patients with supragastric belching. This is a retrospective analysis of prospectively gathered data from 73 patients with supragastric belching who were treated with speech therapy between 2007 and 2017. Of these, 48 were included for evaluation of therapy. Thirty patients had supragastric belching proven by 24-h impedance measurements. Eighteen patients were diagnosed by an experienced speech language pathologist as having supragastric belching according to precise criteria. Speech therapy consists of explanation, creating awareness of esophageal air influx and exercises to discontinue the supragastric belching mechanism. Therapy effect was measured by comparing visual analogue scale (VAS) scores on belching and related symptoms. The median symptom duration at the start of therapy was 2 years. Supragastric belching symptoms decreased significantly with a total median VAS score of 406 (291-463) prior to treatment and a median VAS score of 125 (17-197) following treatment. Forty patients (83%) had a sufficient to major result with a median therapy duration of 3 months and ten sessions. Speech therapy was an effective treatment in the majority of patients with supragastric belching.

Physiology and Acoustics of Inspiratory Phonation.

INTRODUCTION: Inspiratory phonation (IP) means phonating with inspiratory airflow. Some vocalists remarkably master this technique, to such an extent that it offers new dramatic, aesthetic, and functional possibilities in singing specific contemporary music. The present study aims to a better understanding of the physiological backgrounds of IP. MATERIAL AND METHODS: A total of 51 inhaling utterances were compared with 61 exhaling utterances in a professional soprano highly skilled in inhaling singing, by means of high-speed single-line scanning and advanced acoustic analysis. Ranges of intensity and Fo were kept similar. RESULTS: The main differences are: (1) an inversion of the mucosal wave, (2) a smaller closed quotient in IP, (3) a larger opening/closing quotient in IP with the additional difference that in IP, the quotient is larger than 1 (opening slower than closing), whereas it is less than 1 in expiratory mode (opening faster than closing), (4) a larger vocal-fold excursion in IP, (5) higher values of adaptive normalized noise energy in IP, and (6) a steeper slope of harmonic peaks in IP. However, jitter values are similar (within normal range), as well as damping ratios and central formant frequencies. The two voicing modes cannot be differentiated by blind listening. CONCLUSION: The basic physiological mechanisms are comparable in both voicing modes, although with specific differences. IP is actually to be considered as an "extended vocal technique," a term applied to vocalization in art music, which falls outside of traditional classical singing styles, but with remarkable possibilities in skilled vocalists.

Voice dosimetry and monitoring, with emphasis on professional voice diseases: Critical review and framework for future research.

Professional voice has become an important issue in the field of occupational health. Similarly, voice diseases related to occupations gain interest in insurance medicine, particularly within the frame of specific insurance systems for occupational diseases. Technological developments have made possible dosimetry of voice loading in the work-place, as well as long-term monitoring of relevant voice parameters during professional activities. A critical review is given, with focus on the specificity of occupational voice use and on the point of view of insurance medicine. Remaining questions and suggestions for future research are proposed.

Automatic Assessment of Acoustic Parameters of the Singing Voice: Application to Professional Western Operatic and Jazz Singers.

INTRODUCTION: The obvious perceptual differences between various singing styles like Western operatic and jazz rely on specific dissimilarities in vocal technique. The present study focuses on differences in vibrato acoustics and in singer's formant as analyzed by a novel software tool, named BioVoice, based on robust high-resolution and adaptive techniques that have proven its validity on synthetic voice signals. MATERIAL AND METHODS: A total of 48 professional singers were investigated (29 females; 19 males; 29 Western operatic; and 19 jazz). They were asked to sing "a cappella," but with artistic expression, a well-known musical phrase from Gershwin's Porgy and Bess, in their own style: either operatic or jazz. A specific sustained note was extracted for detailed vibrato analysis. Beside rate (s(-1)) and extent (cents), duration (seconds) and regularity were computed. Two new concepts are introduced: vibrato jitter and vibrato shimmer, by analogy with the traditional jitter and shimmer of voice signals. For the singer's formant, on the same sustained tone, the ratio of the acoustic energy in formants 1-2 to the energy in formants 3, 4, and 5 was automatically computed, providing a quality ratio (QR). RESULTS: Vibrato rates did not differ among groups. Extent was significantly larger in operatic singers, particularly females. Vibrato jitter and vibrato shimmer were significantly smaller in operatic singers. Duration of vibrato was also significantly longer in operatic singers. QR was significantly lower in male operatic singers. CONCLUSIONS: Some vibrato characteristics (extent, regularity, and duration) very clearly differentiate the Western operatic singing style from the jazz singing style. The singer's formant is typical of male operatic singers. The new software tool is well suited to provide useful feedback in a pedagogical context.

Automated tracking of quantitative parameters from single line scanning of vocal folds: a case study of the 'messa di voce' exercise.

This article presents a novel application of the 'single line scanning' of the vocal fold vibrations (kymography) in singing pedagogy, particularly in a specific technical voice exercise: the 'messa di voce'. It aims at giving the singer relevant and valid short-term feedback. A user-friendly automatic analysis program makes possible a precise, immediate quantification of the essential physiological parameters characterizing the changes in glottal impedance, concomitant with the progressive increase and decrease of the lung pressure. The data provided by the program show a strong correlation with the hand-made measurements. Additional measurements such as subglottic pressure and flow glottography by inverse filtering can be meaningfully correlated with the data obtained from the kymographic images.

Therapeutic consequences from changing voice ideals (clear to harsh, pleasant to jarring): summarizing report on a round-table discussion at the 5th World Voice Congress, Luxor, Egypt, 27-31 October 2012.

Starting out with an attempt to define an 'ideal voice', the discussion moved on to the hazards of pop singing, followed by the topics of harsh voices (from the desired effects in modern singing expression to devastating clinical cases), phoniatric targets (aesthetics and fitness), and, finally, the phoniatricians' attitudes comprising acceptance, neglect, and rejection. Therapy should aim at a resilient and effective voice regardless of the mere sound, unless the perfection of the vocal sound is the ultimate goal. In addition, the panellists agreed that voice specialists and all friends of healthy and efficient voices are obliged permanently to engage in voice care.

Long-term effects of previous oxandrolone treatment in adult women with Turner syndrome.

OBJECTIVE: Short stature is a prominent feature of Turner syndrome (TS), which is partially overcome by GH treatment. We have previously reported the results of a trial on the effect of oxandrolone (Ox) in girls with TS. Ox in a dose of 0.03 mg/kg per day (Ox 0.03) significantly increased adult height gain, whereas Ox mg/kg per day (0.06) did not, at the cost of deceleration of breast development and mild virilization. The aim of this follow-up study in adult participants of the pediatric trial was to investigate the long-term effects of previous Ox treatment. DESIGN AND METHODS: During the previous randomized controlled trial, 133 girls were treated with GH combined with placebo (Pl), Ox 0.03, or Ox 0.06 from 8 years of age and estrogen from 12 years. Sixty-eight women (Pl, n=23; Ox 0.03, n=27; and Ox 0.06, n=18) participated in the double-blind follow-up study (mean age, 24.0 years; mean time since stopping GH, 8.7 years; and mean time of Ox/Pl use, 4.9 years). We assessed height, body proportions, breast size, virilization, and body composition. RESULTS: Height gain (final minus predicted adult height) was maintained at follow-up (Ox 0.03 10.2±4.9 cm, Ox 0.06 9.7±4.4 cm vs Pl 8.0±4.6 cm). Breast size, Tanner breast stage, and body composition were not different between groups. Ox-treated women reported more subjective virilization and had a lower voice frequency. CONCLUSION: Ox 0.03 mg/kg per day has a beneficial effect on adult height gain in TS patients. Despite previously reported deceleration of breast development during Ox 0.03 treatment, adult breast size is not affected. Mild virilization persists in only a small minority of patients. The long-term evaluation indicates that Ox 0.03 treatment is effective and safe.

Children with specific language impairment show difficulties in sensory modulation.

The purpose of this study is to investigate whether a group of 116 Dutch children with specific language impairment (SLI) shows differences in sensory processing when compared to a control group of age-matched 4-7-year-old typical peers. The Sensory Profile-NL-a standardized questionnaire of 125 items-was completed by caregivers of children in both groups. Children with SLI differed significantly from the control group on all 14 section scores and 4 quadrant scores of the Sensory Profile-NL. The effect size of the difference in sensory modulation patterns of children with and without SLI on this measure was large (Cohen's d ≥ 0.80). Difficulties in sensory modulation can be characterized as frequent co-morbid problems in children with SLI.

The effect of oxandrolone on voice frequency in growth hormone-treated girls with Turner syndrome.

OBJECTIVES/HYPOTHESIS: Oxandrolone (Ox) increases height gain but may also cause voice deepening in growth hormone (GH)-treated girls with Turner syndrome (TS). We assessed the effect of Ox on objective and subjective speaking voice frequency in GH-treated girls with TS. STUDY DESIGN: A multicenter, randomized, placebo (Pl)-controlled, double-blind study was conducted. METHODS: One hundred thirty-three patients were included and treated with GH (1.33 mg/m2/d) from baseline, combined with Pl or Ox in a low (0.03 mg/kg/d) or conventional (0.06 mg/kg/d) dose from the age of 8 years and estrogens from the age of 12 years. Yearly from starting Ox/Pl until 6 months after discontinuing GH+Ox/Pl, voices were recorded and questionnaires were completed. RESULTS: At start, mean (±standard deviation [SD]) voice frequency SD score (SDS) was high for age (1.0±1.2, P<0.001) but normal for height. Compared with GH+Pl, voices tended to lower on GH+Ox 0.03 (P=0.09) and significantly lowered on GH+Ox 0.06 (P=0.007). At the last measurement, voice frequency SDS was still relatively high in GH+Pl group (0.6±0.7, P=0.002) but similar to healthy girls in both GH+Ox groups. Voice frequency became lower than -2 SDS in one patient (3%) on GH+Ox 0.03 and three patients (11%) on GH+Ox 0.06. The percentage of patients reporting subjective voice deepening was similar between the dosage groups. CONCLUSIONS: Untreated girls with TS have relatively high-pitched voices. The addition of Ox to GH decreases voice frequency in a dose-dependent way. Although most voice frequencies remain within the normal range, they may occasionally become lower than -2 SDS, especially on GH+Ox 0.06 mg/kg/d.

Efficacy and safety of oxandrolone in growth hormone-treated girls with turner syndrome.

CONTEXT AND OBJECTIVE: GH therapy increases growth and adult height in Turner syndrome (TS). The benefit to risk ratio of adding the weak androgen oxandrolone (Ox) to GH is unclear. DESIGN AND PARTICIPANTS: A randomized, placebo-controlled, double-blind, dose-response study was performed in 10 centers in The Netherlands. One hundred thirty-three patients with TS were included in age group 1 (2-7.99 yr), 2 (8-11.99 yr), or 3 (12-15.99 yr). Patients were treated with GH (1.33 mg/m(2) . d) from baseline, combined with placebo (Pl) or Ox in low (0.03 mg/kg . d) or conventional (0.06 mg/kg . d) dose from the age of 8 yr and estrogens from the age of 12 yr. Adult height gain (adult height minus predicted adult height) and safety parameters were systematically assessed. RESULTS: Compared with GH+Pl, GH+Ox 0.03 increased adult height gain in the intention-to-treat analysis (mean +/- sd, 9.5 +/- 4.7 vs. 7.2 +/- 4.0 cm, P = 0.02) and per-protocol analysis (9.8 +/- 4.9 vs. 6.8 +/- 4.4 cm, P = 0.02). Partly due to accelerated bone maturation (P < 0.001), adult height gain on GH+Ox 0.06 was not significantly different from that on GH+Pl (8.3 +/- 4.7 vs. 7.2 +/- 4.0 cm, P = 0.3). Breast development was slower on GH+Ox (GH+Ox 0.03, P = 0.02; GH+Ox 0.06, P = 0.05), and more girls reported virilization on GH+Ox 0.06 than on GH+Pl (P < 0.001). CONCLUSIONS: In GH-treated girls with TS, we discourage the use of the conventional Ox dosage (0.06 mg/kg . d) because of its low benefit to risk ratio. The addition of Ox 0.03 mg/kg . d modestly increases adult height gain and has a fairly good safety profile, except for some deceleration of breast development.

Language development before and after temporal surgery in children with intractable epilepsy.

PURPOSE: To obtain systematic knowledge of language development before and after epilepsy surgery in regions that, if damaged, are known to entail language impairment in adults. METHODS: Twenty-four children (mean age 11 years; range 5.8-15.7 years) with pharmacologically intractable epilepsy participated prior to (the majority) anterior temporal lobectomy and 6, 12, and 24 months thereafter. Reception and production of lexicon (vocabulary) and syntax (sentence structure including grammar) were examined using developmental language tests that provide normative data. RESULTS: Prior to surgery the mean language delay varied from 1.7 years (productive syntax) to 3.5 years (productive lexicon). For lexicon, language delay was larger, the older the children; for syntax it was smaller in children with mothers with higher education. Over the 2 years following surgery, the children developed in all four language components. Development was, however, slower than normal, that is, language delay increased, in three of the four components: in productive lexicon it continued to increase, and in receptive lexicon and productive syntax it appeared to stabilize during the second year. Receptive syntax developed at a normal pace. The development of productive lexicon was remarkably slow when surgery and language mediation were both in the left hemisphere. DISCUSSION: Pharmacologically intractable epilepsy of the temporal lobe, or the underlying condition, is a significant risk factor for delayed language development. Temporal epilepsy surgery does not result in acceleration of language development. If language is still mediated in the operated left hemisphere, development of particular language components may slow down after surgery.

Pathogenesis of vocal fold nodules: new insights from a modelling approach.

OBJECTIVE: To give new insights into the pathogenesis of vocal fold nodules: (a) why the female/male ratio is so extreme, (b) how an hourglass-shaped vibration pattern - eliciting a localized microtrauma - originates, and (c) what the roles of muscular tension imbalance and of behavioral aspects are. MATERIALS AND METHODS: Simulations with a 3-dimensional computer model of the vibrating vocal folds. RESULTS AND CONCLUSION: (1) A slightly incomplete dorsal vocal fold adduction is a first condition for inducing an hourglass vibration pattern. (2) A limited collision zone is only possible with a small degree of curving of the rest position of the vocal fold edges in their ventral portion. This is an anatomical characteristic of the adult female larynx. Muscular fatigue and resulting hypotonia seem to enhance this curving. (3) If both these conditions are fulfilled, a sufficient vibration amplitude is required to achieve a localized impact. (4) This third condition can be obtained by an increased subglottal pressure and/or by a decrease in active stress of the tension forces between the neighboring vocalis masses. These last aspects incorporate muscular tension imbalance (dyskinesia) and behavioral aspects in the modelling process. Decrease in active stress is a possible effect of fatigue, and increase in subglottal pressure a result of effort compensation.

Experience with a medicolegal decision-making system for occupational hearing loss-related tinnitus.

Owing to an increasing number of requests for compensation, a medicolegal decision-making system for tinnitus related to noise-induced hearing loss (NIHL) has been elaborated at the Federal Belgian Institute of Occupational Diseases. Experience with 113 patients, all of them claiming compensation for NIHL and tinnitus, is now available. The patients underwent an exhaustive audiological investigation, and their professional career and noise exposure were carefully and objectively documented. We reviewed the group of 35 "accepted" cases (i.e., with chronic tinnitus recognized as related to NIHL and financially compensated as an occupational disease) and analyzed the medicolegal arguments for acceptance or rejection. In these patients, tinnitus was mostly bilateral, was perceived on average at a frequency of 4 KHz and with a supraliminal intensity of 7.2 dB, and lasted on average for 7.3 years. To gain better insight into the relationship between cochlear damage and chronic tinnitus, we compared our group to a control group of 35 patients with similar hearing thresholds at 3 and 4 KHz but free of tinnitus. The main difference is a significantly steeper slope of the audiometric curve between 2 and 3 KHz in the tinnitus group. Furthermore, a notch in the distortion product-gram is noticed in 60% of the ears affected by tinnitus versus 9% of the ears in the control group. This abrupt discontinuity in the activity along the tonotopic axis of the auditory system-the main characteristic of NIHL-could be a factor eliciting tinnitus, as a correspondence between the audiometric notch and tinnitus frequency appears to exist.

Comparación de los trastornos de la voz con el Voice Handicap Inventory Index / Comparing voice pathologies with the Voice Handicap Inventory: is a weighting factor required?

El Voice Handicap Inventory/Index (VHI) es un instrumento difundido para medir la calidad de vida relacionada con los trastornos de la voz. Sin embargo, la literatura muestra que el VHI no es apropiado para comparar distintas enfermedades. Nosotros intentamos entender el punto de vista personal del paciente que respondía agregando a cada ítem del VHI una medida de su importancia. Por ende, proponemos un factor de ponderación/corrección que parece facilitar la comparación de las enfermedades. Dado que el apoyo financiero gubernamental o de los terceros pagadores a menudo se basa en tablas y figuras, puede ser de interés disponer de una herramienta que compare la gravedad de estos trastornos, es decir, las diferentes categorías de las enfermedades de la voz.

The Voice Handicap Inventory/Index (VHI) is a widespread instrument for measuring the disease specific quality oflife related to voice disorders. Literature has shown, however, that the VHI is not suitable for comparing various pathologies. We tried to gain insight in theresponder’s personal view by adding a measure ofimportance to each VHI item. Hence we propose aweighting/correction factor which seems to facilitate comparing pathologies. As financial support by the government or third party payers often is based on tablesand figures, a tool for comparing the seriousness of diseases, i.e. different categories of voice pathologies, can be interesting.

Laryngeal electroglottography as a predictor of laryngeal electromyography.

We evaluate a group of patients who have mobile vocal folds, but have flexible laryngeal examinations suspicious for mild vocal fold paresis. The purpose of this retrospective study is to evaluate if electroglottography (EGG) can predict the probability of having an abnormal laryngeal electromyography (LEMG). Charts of patients evaluated and suspected of having mild vocal fold paresis between August 1, 2004 and March 30, 2006 were reviewed. We compared average EGG contact quotients (CQs), average absolute difference of recorded CQ from normal (|CQ-50%|), and EGG waveforms between patients with normal and abnormal LEMG. Waveforms were evaluated in blinded fashion. Statistical analysis was performed using chi square and t test analyses. One hundred and sixteen patients received both flexible laryngoscopy and LEMG as part of their evaluation. Forty-eight patients (41%) had confirmed paresis by LEMG and 68 patients (59%) had normal LEMGs. Only 9.1% of patients with a normal EGG waveform had an abnormal LEMG. In contrast, 40.4% of patients with an abnormal EGG waveform had abnormal LEMGs. The negative predictive value of a normal EGG waveform for an abnormal LEMG was 90.9%. No significant differences were identified between patients with normal versus abnormal LEMG in terms of average CQ (47.8% vs 46.4%) or |CQ-50%| (6.2 vs 5.6). Patients with a normal EGG waveform are unlikely to have an abnormal LEMG.

The effect of visible speech in the perceptual rating of pathological voices.

OBJECTIVE: To test a simple method for improving consistency among raters for the perceptual evaluation of pathological voice quality by providing visible speech (spectrogram) as additional information because, to date, the interrater variability still limits the widespread clinical use of the best available rating system. DESIGN: Experimental comparison between 2 different ways (with and without the addition of visible speech) of perceptual rating by trained professionals of recorded pathological voices. Furthermore, the correlation between acoustical (jitter, shimmer, and noise-harmonic ratio) and perceptual parameters was investigated in both rating conditions. SUBJECTS: Six experts evaluated 70 recorded pathological voices using the GIRBAS (grade, instability, roughness, breathiness, asthenicity, and strain) scale in 2 separate sessions: first, conventionally, without visible speech as additional information, and several months later, with visible speech as additional information. MAIN OUTCOME MEASURES: The kappa interrater agreement and the correlation coefficient between GIRBAS scores and acoustic measures. RESULTS: We found a significant effect of visible speech on the agreement between the raters. The interrater agreement according to kappa statistics was significantly stronger with the addition of visible speech than without for rating grade, roughness, and breathiness. The correlation between acoustical and perceptual parameters showed no significant effect of visible speech. CONCLUSIONS: The addition of visible speech to the perceptual evaluation of pathological voices is an interesting clinical asset to enhance its reliability. The addition of visible speech to the clinical setting is feasible, since affordable computer programs are currently available that can provide the spectrogram in quasi-real time while conversing with the patient. The acoustical analysis might be applied in addition to perceptual rating in a multidimensional approach to assess voice quality.

Accuracy of measurements on digital videostroboscopic images of the vocal folds.

OBJECTIVES: The reliability of objective measurements on digital laryngeal images was investigated. METHODS: The magnitude of the error of measurement of surface areas by visually tracing the outline was determined for three different areas: the area of the lesion and, during vibration, the glottal area on maximal opening of the vocal folds and the glottal area on maximal closing of the vocal folds. RESULTS: The errors in these areas were 10% to 30%. The results suggest that the error is mainly due to the uncertainty of the real outline of areas with a vague boundary. Correction for differences in magnification between two images (posttherapy and pretherapy) is of importance in about 25% to 65% of cases, depending on the area measured. CONCLUSIONS: Only when the magnification ratio is small (less than about +/- 10% from 1.0) may a correction not be necessary.