Voice disorder discrimination using vowel acoustic measures in female speakers.

BACKGROUND: Sustained vowels are important vocal tasks that have been investigated in discriminating voice disorders using acoustic analysis. To date, no study has combined vowel acoustic measures only that evaluate major aspects of the pathological voice signals in voice disorder discrimination. AIMS: To investigate the value of vowel acoustic measures that quantify glottal noise, signal stability, signal periodicity, spectral slope and overall voice quality in discriminating female speakers with and without voice disorders. METHODS & PROCEDURES: Sustained vowel /ɑ/ samples were extracted from 133 voice-disordered female patients and 97 non-voice disordered female speakers and were signal typed prior to analysis. Praat software was used to measure harmonics-to-noise ratio (HNR), glottal-to-noise excitation ratio (GNE), the standard deviation of fundamental frequency (F0SD) and cepstral peak prominence (CPPp); and the Analysis of Dysphonia in Speech and Voice (ADSV) program was used to measure CPPadsv, low/high spectral ratio (LH) and the cepstral/spectral index of dysphonia (CSID). Outcome measures included sensitivity, specificity, and discrimination accuracy. OUTCOMES & RESULTS: As individual acoustic measures, only spectral-based measures showed good (CPPadsv) and acceptable (CSID) discrimination results. The HNR, GNE and CPPp measures had acceptable sensitivity but poor or non-acceptable specificity and discrimination accuracy. Logistic regression models with all Praat measures (F0SD, HNR, GNE, CPPp) plus ADSV measures (CPPadsv, LH or CSID) provided excellent sensitivity, good-to-excellent specificity and excellent discrimination accuracy. ROC analysis for all individual measures showed that CPPadsv, CSID, CPPp, GNE and F0SD had the highest area under the curve (AUC) values. CONCLUSIONS & IMPLICATIONS: A combination of acoustic measures that evaluate the major aspects of vocal dysfunction resulted in good to excellent voice discrimination outcomes. Individual acoustic measures had lower discrimination ability than combined measures. The findings implied that acoustic measures extracted from a prolonged vowel were useful in voice disorder discrimination. WHAT THIS PAPER ADDS: What is already known on this subject Acoustic measures hold great value in discriminating voice disorders from normal voices. However, no study has evaluated discrimination values of a combination of sustained vowel acoustic measures that quantify additive noise, signal stability, signal periodicity, spectral slope and overall voice quality in single-gender cohorts. Previous studies have not used signal typing (the classification of the acoustic signals) for time-based measures, impacting the reliability of discrimination. What this study adds to the existing knowledge This study was the first to implement signal typing to include sustained vowel samples of Types 1 and 2 signals for discrimination statistics. We showed that a combination of vocal acoustic measures using time- and spectral-based extraction from the sustained /ɑ/ vowel evaluating additive noise, signal stability, signal periodicity, spectral slope and overall voice quality resulted in good to excellent sensitivity, specificity and discrimination accuracy. As individual measures, traditional time-based measures such as HNR had rather limited discrimination values whilst spectral-based measures provided higher discrimination values. Measures that are sensitive to signal types have low discrimination ability. What are the potential or actual clinical implications of this work? The sustained vowel /ɑ/ is a relevant, universal vocal task for clinical application using acoustic measures to discriminate female speakers with and without voice disorders if signal typing is implemented. Clinical voice assessment using vowels may not be effective if relying solely on time-based measurements. Spectral-based measures perform better in voice disorder discrimination given their insensitivity to signal types. The most effective voice disorder discrimination could only be obtained using a combination of acoustic measures that quantify major phenomena in the signals of disordered voices. Using measures extracted from both programs, Praat and ADSV, is useful given that specific settings in a program may impact on discrimination accuracy.

Vowel onset measures and their reliability, sensitivity and specificity: A systematic literature review.

OBJECTIVE: To systematically evaluate the evidence for the reliability, sensitivity and specificity of existing measures of vowel-initial voice onset. METHODS: A literature search was conducted across electronic databases for published studies (MEDLINE, EMBASE, Scopus, Web of Science, CINAHL, PubMed Central, IEEE Xplore) and grey literature (ProQuest for unpublished dissertations) measuring vowel onset. Eligibility criteria included research of any study design type or context focused on measuring human voice onset on an initial vowel. Two independent reviewers were involved at each stage of title and abstract screening, data extraction and analysis. Data extracted included measures used, their reliability, sensitivity and specificity. Risk of bias and certainty of evidence was assessed using GRADE as the data of interest was extracted. RESULTS: The search retrieved 6,983 records. Titles and abstracts were screened against the inclusion criteria by two independent reviewers, with a third reviewer responsible for conflict resolution. Thirty-five papers were included in the review, which identified five categories of voice onset measurement: auditory perceptual, acoustic, aerodynamic, physiological and visual imaging. Reliability was explored in 14 papers with varied reliability ratings, while sensitivity was rarely assessed, and no assessment of specificity was conducted across any of the included records. Certainty of evidence ranged from very low to moderate with high variability in methodology and voice onset measures used. CONCLUSIONS: A range of vowel-initial voice onset measurements have been applied throughout the literature, however, there is a lack of evidence regarding their sensitivity, specificity and reliability in the detection and discrimination of voice onset types. Heterogeneity in study populations and methods used preclude conclusions on the most valid measures. There is a clear need for standardisation of research methodology, and for future studies to examine the practicality of these measures in research and clinical settings.

Voice disorder recognition using machine learning: a scoping review protocol.

INTRODUCTION: Over the past decade, several machine learning (ML) algorithms have been investigated to assess their efficacy in detecting voice disorders. Literature indicates that ML algorithms can detect voice disorders with high accuracy. This suggests that ML has the potential to assist clinicians in the analysis and treatment outcome evaluation of voice disorders. However, despite numerous research studies, none of the algorithms have been sufficiently reliable to be used in clinical settings. Through this review, we aim to identify critical issues that have inhibited the use of ML algorithms in clinical settings by identifying standard audio tasks, acoustic features, processing algorithms and environmental factors that affect the efficacy of those algorithms. METHODS: We will search the following databases: Web of Science, Scopus, Compendex, CINAHL, Medline, IEEE Explore and Embase. Our search strategy has been developed with the assistance of the university library staff to accommodate the different syntactical requirements. The literature search will include the period between 2013 and 2023, and will be confined to articles published in English. We will exclude editorials, ongoing studies and working papers. The selection, extraction and analysis of the search data will be conducted using the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews' system. The same system will also be used for the synthesis of the results. ETHICS AND DISSEMINATION: This scoping review does not require ethics approval as the review solely consists of peer-reviewed publications. The findings will be presented in peer-reviewed publications related to voice pathology.

Comparison of Angiolytic Effects Between the 445-nm Blue Laser and 532-nm Pulsed KTP Laser.

OBJECTIVE: This study aimed to compare the selective absorption of the 445-nm Blue laser (BL) and the 532-nm pulsed potassium-titanyl-phosphate (KTP) laser by blood vessels. METHODS: Thirty-six chicken eggs at day 14 of incubation were dissected to expose the chick chorioallantoic membrane (CAM). Third-order vessels of the CAM were identified and irradiated using BL and KTP lasers using various settings at a laser-to-vessel distance of 3 mm using 0.4 mm fiber size. In total, 494 vessels segments were irradiated. Mean (standard deviation) number of irradiations for each setting was 26.0 (4.6), range from 15 to 39. Outcome measures included ablation rate (AR) and rupture rate (RR). RESULTS: The two lasers were compared for AR and RR at long and medium pulse width (PW) associated with different power levels. At long PW (above 100 ms), BL showed significantly higher AR than KTP at high energy (600 mJ/pulse) and low energy (400 mJ/pulse); they did not show different AR and RR at medium energy levels (500 mJ/pulse). Using medium PW settings plus high and medium energy levels, BL and KTP showed relatively high AR and did not significantly differ in performance. However, at medium PW plus low energy (400-450 mJ/pulse), KTP showed significantly higher AR compared to BL. CONCLUSION: At long PW, BL appeared to show higher AR than KTP at high or low energy levels, but they showed equivalent performance at medium energy. At medium PW, both performed similarly from high to medium energy, but KTP appeared to perform better than BL at lower energy settings. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3220-3225, 2024.

Vocal tasks for acoustic and/or auditory perceptual analysis for discriminating individuals with and without voice disorders: a systematic review protocol.

OBJECTIVE: The primary objective of the present systematic review is to: (1) identify the current vocal tasks being used for acoustic and/or auditory perceptual analysis to differentiate between individuals with and without voice disorders. The secondary objectives are to: (2) evaluate the evidence of the sensitivity, specificity and accuracy of those vocal tasks for acoustic and/or auditory perceptual analysis in discriminating the individuals with voice disorders from those without; and (3) compare the values between the vocal tasks in discriminating individuals with voice disorders from those without. METHOD AND ANALYSIS: We search the following electronic databases: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science Core Collection, PubMed Central and Google Scholar. Grey literature searches will include ProQuest Dissertations and Theses, ClinicalTrials.gov and the Cochrane Register of Controlled Trials. Websites of professional organisations and textbooks will be hand searched for relevant information related to the research question. Study screening, selection and data extraction will be conducted independently by two reviewers. Any disagreements will be resolved by discussion or by involving a third reviewer.The methodological quality of the included studies will be appraised using the relevant Critical Appraisal Tools by JBI. The clinical guidelines and recommendations for voice assessment by professional bodies will be appraised using the Reporting Items for practice Guidelines in HealThcare (RIGHT) checklist. The findings will be presented in the form of an information matrix with the tasks identified tabulated against the nature of the task, dimensions being tested, and their accuracy, sensitivity, and specificity in identifying individuals with voice problems. ETHICS AND DISSEMINATION: Formal ethics approval is not required. The findings will be presented at national and international conferences and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42023431634.

Auditory-perceptual Parameters as Predictors of Voice Acoustic Measures.

BACKGROUND: Much research has examined the relationship between perceptual and acoustic measures. However, little is known about the prediction values of perceptual measures on an acoustic parameter. AIMS: This study utilized simulated and disordered voice samples to investigate the prediction values of breathiness, roughness, and strain ratings on the selection of some time-based and spectral-based measures of voice quality. METHOD: This study retrospectively analysed two sets of precollected data. The experimental data had been collected from nine trained speakers manipulating false vocal fold activity, true vocal fold mass, and larynx height. The voice-disordered data had been extracted from a clinical database for 68 patients with muscle tension voice disorders (MTVD). Both data sets had been perceptually rated for breathiness, roughness, and strain. Voice samples (prolonged vowel /ɑ/ and Rainbow Passage readings) had undergone acoustic analysis using Praat for harmonics-to-noise ratio (HNR) and the program "Analysis of Dysphonia in Speech and Voice" (ADSV) for cepstral peak prominence (CPP), Cepstral/Spectral Index of Dysphonia (CSID), and Low/High spectral ratio (L/H ratio). Perceptual parameters were regressed against these acoustic measures to test their prediction values. RESULTS: Reliability data showed satisfactory intra- and inter-reliability of perceptual ratings for both data sets. Breathiness significantly predicted CPP (both vocal tasks) and CSID (Rainbow Passage) in experimental data and predicted all the acoustic measures in MTVD data. Roughness significantly predicted HNR, CPP, and CSID in experimental data, and CPP (Rainbow Passage) and CSID (both vocal tasks) in MTVD data. Strain (both vocal tasks) significantly predicted L/H ratio in both data sets. CONCLUSIONS: Breathiness ratings predicted selection of HNR, CPP and CSID; roughness ratings predicted selection of CPP and CSID, and strain ratings predicted L/H ratio.

Impact of Instructed Laryngeal Manipulation on Acoustic Measures of Voice-Preliminary Results.

BACKGROUND: Control of laryngeal muscles is required to manipulate pitch, volume, and voice quality. False vocal fold activity (FVFA) refers to the constriction and release of constriction of the false vocal folds. True vocal fold mass (TVFM) represents the cross-sectional thickness of the vocal folds. Larynx height (LH) refers to the vertical position of the larynx in the neck. To date, studies of voice control have examined the effects of these parameters separately. No study has investigated the impact of instructed systematic manipulation of these parameters on acoustic voice measures in vocally healthy trained subjects. AIMS: This study examined the effects of systematically manipulating FVFA, TVFM, and LH on several acoustic voice measures. METHOD: Twelve vocally trained speakers were instructed to use specific techniques to achieve experimental conditions of constriction and release of constriction of FVFA, thicker and thinner TVFM, and normal and low LH. Each condition was implemented in combination with manipulating the other parameters. Voice recordings of sustained vowel /a/ and Rainbow Passage were obtained for all laryngeal manipulation conditions and underwent acoustic analyses for fundamental frequency (F0), signal typing, harmonics-to-noise ratio (HNR), cepstral peak prominence (CPP), and vocal relative intensity. RESULTS: Constricted FVFA caused more aperiodicity in the signals, lower CPP, and lower vocal relative intensity than release of constriction. Thicker TVFM resulted in significantly higher CPP and vocal relative intensity than thinner TVFM. Modifying TVFM did not affect F0 and HNR. Low LH had significantly lower F0 but did not impact on HNR, CPP, and intensity. CONCLUSIONS: The effects of systematic manipulation of each laryngeal parameter resulted in independent acoustic effects without measurable interaction. Release of constriction of FVFA, thicker TVFM, and low LH were configurations that resulted in more optimal acoustic signals.

Identifying Clinical Behaviors Using the Motor Learning Classification Framework: A Pilot Study.

CONTEXT: Although differences in clinical interactions with patients between students and experienced clinicians are well described, differences in therapeutic training behaviors have not been explored, especially in relation to motor learning principles. AIMS: This pilot study compared clinical behaviors between speech language pathology (SLP) students and experienced SLPs in a voice therapy task, using prepractice variables in the Motor Learning Classification Framework (MLCF). METHODS: Using a quasi-experimental design, five final-year undergraduate SLP students and four experienced SLPs with a voice therapy caseload taught a standardized patient to produce a vocal siren. Two trained raters categorized the clinicians' behaviors using the MLCF. RESULTS: High intrarater reliability (91.9%, 92.3%) and interrater reliability (89.6%, 82.1%) were shown across both raters. Both clinician groups used the same percentage of behaviors classified as verbal information but differed in the subtypes of these behaviors. Experienced clinicians used behaviors categorized as problem-solving and only experienced clinicians used repeated behavior sequences that included perceptual training. Both groups used significantly more talking behaviors than doing behaviors. CONCLUSIONS: The MLCF can be reliably used to identify prepractice behaviors during client interactions in voice therapy. Students and experienced clinicians showed similarities in behaviors, but experienced clinicians used more problem solving and perceptual training behaviors than students. These differences have implications for student training. The greater use of talking behaviors than doing behaviors warrants further investigation into whether this impacts the subsequent quality of practice engaged by the client and ultimately treatment effectiveness.

Microlaryngeal Laser Surgery Using High-flow Nasal Ventilation at Two Oxygen Concentration Deliveries.

OBJECTIVES: Ventilation using 100% oxygenation creates a risk of fire during laser microlaryngeal surgery (MLS). The purpose of this study is to describe the technique of transnasal high-flow ventilation using laser safe (30%) oxygen conditions, measure the intraoperative real-time laryngeal oxygen concentration, and examine patient saturation status using this technique. METHODS: Prospective IRB approved study of patients undergoing tubeless laser MLS using high-flow nasal oxygenation. Delivered oxygen concentration was reduced from 100% to 30% before lasering using an oxygen-air blender then increased to 100% post-laser procedure. Outcome measures included time for laryngeal oxygen concentration to equalize to laser safe levels; time to, methods of and duration of rescue ventilation; and desaturation rates and apnoeic times at both 100% and 30% oxygen deliveries. RESULTS: Fifty patients were recruited (mean age = 47.4 years). Mean laryngeal oxygen concentration (%) at 100% and 30% deliveries was 98.46 and 31.45, respectively. Mean (SD) of laryngeal oxygen concentration equalization time to 30% (seconds) was 9.4 (3.69). At 30% oxygen delivery desaturation rate was faster and apneic time shorter compared with 100%. Eighteen patients required rescue (jet) ventilation and they had a faster apneic desaturation rate (%/minute) than patients not requiring rescue. Mean (SD) apneic time (minutes) at 30% delivery was 4.56 (2.25) and 4.41 (2.18) in rescue versus non-rescue groups respectively. BMI was the only significant predictor of desaturation rate at 30% oxygen delivery. CONCLUSION: It is possible to achieve a safe time window for use of laser during MLS using transnasal humidified high-flow ventilation by delivering 30% oxygen concentration. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:634-639, 2023.

Do the Nonlinear Dynamic Acoustic Measurements, Nonlinear Energy Difference Ratio and Spectrum Convergence Ratio, Correlate with Perceptual Evaluation of Esophageal Voice Speakers?

BACKGROUND: The acoustic assessment of phonation after total laryngectomy is challenged by signal aperiodicity which makes frequency-based acoustic measures less reliable. This is important for patients who use esophageal voice since voice samples mostly include type III (highly aperiodic) and 4 (chaotic) signals. As such, using non-linear measures, which are better suited for aperiodic phonation, may be useful to investigate the relationship between acoustic signal characteristics and perception of esophageal voice quality. OBJECTIVES: This study aimed to investigate whether nonlinear dynamic acoustic methods, nonlinear energy difference Ratio (NEDR) and spectrum convergence ratio (SCR), were correlated with perceptual measures in subjects who used esophageal phonation. METHODS: Thirty-one subjects who had undergone total laryngectomy and use esophageal voice as a rehabilitation method were included in this study. Expert and non-expert raters listened to the esophageal voice samples from the subjects and rated vowels and connected speech samples on a scale from 1 to 7 on dysphonia severity and intelligibility. In addition, non-linear acoustic analysis was performed to calculate NEDR and SCR. Analysis from the raters was compared to the non-linear acoustic analysis to find the correlation between the variables. RESULTS: There were no significant correlations between any of the non-linear acoustic measures NEDR and SCR and the perceptual ratings at the significance level of 0.05. Correlations were calculated for each acoustic measure among the expert raters and among the non-expert raters in both connected speech samples and sustained vowel fragments. CONCLUSIONS: In conclusion, the nonlinear dynamic acoustic analyses of spectrum convergence ratio and nonlinear energy difference ratio do not have a significant correlation with perceptual measures of esophageal voice.

The Relationship Between Pitch Discrimination and Acoustic Voice Measures in a Cohort of Female Speakers.

BACKGROUND: Evidence across a range of musically trained, hearing disordered and voice disordered populations present conflicting results regarding the relationship between pitch discrimination (PD) and voice quality. PD characteristics of female speakers with and without a musical training background and no self-reported voice disorder, and the relationship between PD and voice quality in this particular population, have not been investigated. AIMS: To evaluate PD characteristics in a cohort of female participants without a self-reported voice disorder and the relationship between PD and acoustic voice measures. METHOD: One hundred fourteen female participants were studied, all of whom self-reported as being non-voice disordered. All completed the Newcastle Assessment of Pitch Discrimination which involved a two-tone PD task. Their voices were recorded producing standardized vocal tasks. Voice samples were acoustically analyzed for frequency-domain measures (fundamental frequency and its standard deviation, and harmonics-to-noise ratio) and spectral-domain measures (cepstral peak prominence and the Cepstral/Spectral Index of Dysphonia). Data were analyzed for the whole cohort and for musical and non-musical training backgrounds. RESULTS: In the whole cohort, there were no significant correlations between PD and acoustic voice measures. PD accuracy in musically trained speakers was better than in non-trained speakers and correlated with fundamental frequency standard deviation in prolonged vowel tasks. Vocalists demonstrated superior PD accuracy and fundamental frequency standard deviation in prolonged vowels compared to instrumentalists but did not show significant correlations between PD and acoustic measures. The Newcastle Assessment of Pitch Discrimination was a reliable tool, showing moderate-good prediction value in differentiating musical background. CONCLUSIONS: There was little evidence of a relationship between PD and acoustic measures of voice quality, regardless of musical training background and superior PD accuracy among the musically trained. These data do not support ideas concerning the co-development of perception and action among individuals identified as having voice quality measures within normal ranges. Numerous measures of voice quality, including measures sensitive to pitch, did not distinguish across musically and non-musically trained individuals, despite individual differences in pitch discrimination.

Acoustic characteristics of fricatives, amplitude of formants and clarity of speech produced without and with a medical mask.

BACKGROUND: Previous research has found that high-frequency energy of speech signals decreased while wearing face masks. However, no study has examined the specific spectral characteristics of fricative consonants and vowels and the perception of clarity of speech in mask wearing. AIMS: To investigate acoustic-phonetic characteristics of fricative consonants and vowels and auditory perceptual rating of clarity of speech produced with and without wearing a face mask. METHODS & PROCEDURES: A total of 16 healthcare workers read the Rainbow Passage using modal phonation in three conditions: without a face mask, with a standard surgical mask and with a KN95 mask (China GB2626-2006, a medical respirator with higher barrier level than the standard surgical mask). Speech samples were acoustically analysed for root mean square (RMS) amplitude (ARMS ) and spectral moments of four fricatives /f/, /s/, /ʃ/ and /z/; and amplitude of the first three formants (A1, A2 and A3) measured from the reading passage and extracted vowels. Auditory perception of speech clarity was performed. Data were compared across mask and non-mask conditions using linear mixed models. OUTCOMES & RESULTS: The ARMS of all included fricatives was significantly lower in surgical mask and KN95 mask compared with non-mask condition. Centre of gravity of /f/ decreased in both surgical and KN95 mask while other spectral moments did not show systematic significant linear trends across mask conditions. None of the formant amplitude measures was statistically different across conditions. Speech clarity was significantly poorer in both surgical and KN95 mask conditions. CONCLUSIONS & IMPLICATIONS: Speech produced while wearing either a surgical mask or KN95 mask was associated with decreased fricative amplitude and poorer speech clarity. WHAT THIS PAPER ADDS: What is already known on the subject Previous studies have shown that the overall spectral levels in high frequency ranges and intelligibility are decreased for speech produced with a face mask. It is unclear how different types of the speech signals that is, fricatives and vowels are presented in speech produced with wearing either a medical surgical or KN95 mask. It is also unclear whether ratings of speech clarity are similar for speech produced with these face masks. What this paper adds to existing knowledge Speech data collected using a real-world, clinical and non-laboratory-controlled settings showed differences in the amplitude of fricatives and speech clarity ratings between non-mask and mask-wearing conditions. Formant amplitude did not show significant differences in mask-wearing conditions compared with non-mask. What are the potential or actual clinical implications of this work? Wearing a surgical mask or a KN95 mask had different effects on consonants and vowels. It appeared from the findings in this study that these masks only affected fricative consonants and did not affect vowel production. The poorer speech clarity in these mask-wearing conditions has important implications for speech perception in communication between clinical staff and between medical officers and patients in clinics, and between people in everyday situations. The impact of these masks on speech perception may be more pronounced in people with hearing impairment and communication disorders. In voice evaluation and/or therapy sessions, the effects of wearing a medical mask can occur bidirectionally for both the clinician and the patient. The patient may find it more challenging to understand the speech conveyed by the clinician while the clinician may not perceptually assess patient's speech and voice accurately. Given the significant correlation between clarity ratings and fricative amplitude, improving fricative signals would be useful to improve speech clarity while wearing these medical face masks.

Pitch Discrimination Testing in Patients with a Voice Disorder.

Auditory perception plays an important role in voice control. Pitch discrimination (PD) is a key index of auditory perception and is influenced by a variety of factors. Little is known about the potential effects of voice disorders on PD and whether PD testing can differentiate people with and without a voice disorder. We thus evaluated PD in a voice-disordered group (n = 71) and a non-voice-disordered control group (n = 80). The voice disorders included muscle tension dysphonia and neurological voice disorders and all participants underwent PD testing as part of a comprehensive voice assessment. Percentage of accurate responses and PD threshold were compared across groups. The PD percentage accuracy was significantly lower in the voice-disordered group than the control group, irrespective of musical background. Participants with voice disorders also required a larger PD threshold to correctly discriminate pitch differences. The mean PD threshold significantly discriminated the voice-disordered groups from the control group. These results have implications for the voice control and pathogenesis of voice disorders. They support the inclusion of PD testing during comprehensive voice assessment and throughout the treatment process for patients with voice disorders.

Telehealth voice assessment by speech language pathologists during a global pandemic using principles of a primary contact model: an observational cohort study protocol.

INTRODUCTION: SARS-CoV-2, a highly contagious severe acute respiratory syndrome, has spread to most countries in the world and resulted in a change to practice patterns for the assessment and diagnosis of people with voice disorders. Many services are transitioning to telehealth models to maintain physical distancing measures and conserve personal protective equipment used by healthcare workers during laryngoscopy examinations. The speech-language pathology primary contact (SLPPC) assessment for patients referred to ear, nose and throat (ENT) services in Australia has been shown to reduce waiting times for assessment while streamlining access to ENT assessment and allied health practitioner treatment pathways. METHODS AND ANALYSIS: A prospective observational cohort study will see patients in a newly developed telehealth model which uses the principles from a usual care SLPPC assessment protocol. Participants will be offered an initial telehealth assessment (speech-language pathology primary contact telehealth (SLPPC-T)) prior to being prioritised for a face-to-face laryngoscopy assessment to complete the diagnostic process. The telehealth assessment will collect sociodemographic information, personal and family medical history, key symptoms, onset and variability of symptoms, red-flag signs or symptoms for laryngeal malignancy, and clinical voice assessment data for auditory-perceptual and acoustic analysis. The study outcomes include (1) association of signs, symptoms and specific voice measures collected during SLPPC-T with voice disorder classification provided after laryngoscopy; (2) degree of concordance between voice disorder classification after SLPPC-T and after laryngoscopy; (3) health service and patient-related costs and health outcomes of the SLPPC-T; (4) patient and stakeholder views and beliefs about the SLPPC-T process. ETHICS AND DISSEMINATION: Ethical approval has been granted prior to commencement of the study enrolment by the Gold Coast Hospital and Health Service Human Research Ethics Committee (reference number HREC/2020/QGC/62832). Results will be shared through the publication of articles in peer-reviewed medical journals and presentation at national and international scientific meetings. TRIAL REGISTRATION NUMBER: ACTRN12621000427875.

Supraglottic Botulinum Toxin Improves Symptoms in Patients with Laryngeal Sensory Dysfunction Manifesting as Abnormal Throat Sensation and/or Chronic Refractory Cough.

Laryngeal sensory dysfunction (LSD) encompasses disorders of the vagal sensory pathways. Common manifestations include chronic refractory cough (CRC) and abnormal throat sensation (ATS). This study examined clinical characteristics and treatment outcomes of LSD using a novel approach of laryngeal supraglottic Onabotulinum toxin Type A injection (BTX). This was a retrospective review of clinical data and treatment outcomes of supraglottic BTX in patients with LSD. Between November 2019 and May 2021, 14 patients underwent 25 injection cycles of supraglottic BTX for treatment of symptoms related to LSD, including ATS and CRC. Primary outcome measures included the Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ), Cough Severity Index (CSI), Reflux Symptom Index (RSI), and Voice Handicap Index-10 (VHI-10) at baseline and within three months of treatment. Pre- and post-treatment data were compared using a linear mixed model. After supraglottic BTX, LHQ scores improved by 2.6. RSI and CSI improved by 8.0 and 5.0, respectively. VHI-10 did not change as a result of treatment. Short-term response to SLN block was significantly associated with longer term response to BTX treatment. These findings suggest that LSD presents clinically as ATS and CRC along with other upper airway symptoms. Supraglottic BTX injection is a safe and effective technique in the treatment of symptoms of LSD.

Active Ingredients of Voice Therapy for Muscle Tension Voice Disorders: A Retrospective Data Audit.

BACKGROUND: Although voice therapy is the first line treatment for muscle-tension voice disorders (MTVD), no clinical research has investigated the role of specific active ingredients. This study aimed to evaluate the efficacy of active ingredients in the treatment of MTVD. A retrospective review of a clinical voice database was conducted on 68 MTVD patients who were treated using the optimal phonation task (OPT) and sob voice quality (SVQ), as well as two different processes: task variation and negative practice (NP). Mixed-model analysis was performed on auditory-perceptual and acoustic data from voice recordings at baseline and after each technique. Active ingredients were evaluated using effect sizes. Significant overall treatment effects were observed for the treatment program. Effect sizes ranged from 0.34 (post-NP) to 0.387 (post-SVQ) for overall severity ratings. Effect sizes ranged from 0.237 (post-SVQ) to 0.445 (post-NP) for a smoothed cepstral peak prominence measure. The treatment effects did not depend upon the MTVD type (primary or secondary), treating clinicians, nor the number of sessions and days between sessions. Implementation of individual techniques that promote improved voice quality and processes that support learning resulted in improved habitual voice quality. Both voice techniques and processes can be considered as active ingredients in voice therapy.

Aerosol-generating behaviours in speech pathology clinical practice: A systematic literature review.

OBJECTIVE: To evaluate the evidence of aerosol generation across tasks involved in voice and speech assessment and intervention, to inform better management and to reduce transmission risk of such diseases as COVID-19 in healthcare settings and the wider community. DESIGN: Systematic literature review. DATA SOURCES AND ELIGIBILITY: Medline, Embase, Scopus, Web of Science, CINAHL, PubMed Central and grey literature through ProQuest, The Centre for Evidence-Based Medicine, COVID-Evidence and speech pathology national bodies were searched up until August 13th, 2020 for articles examining the aerosol-generating activities in clinical voice and speech assessment and intervention within speech pathology. RESULTS: Of the 8288 results found, 39 studies were included for data extraction and analysis. Included articles were classified into one of three categories: research studies, review articles or clinical guidelines. Data extraction followed appropriate protocols depending on the classification of each article (e.g. PRISMA for review articles). Articles were assessed for risk of bias and certainty of evidence using the GRADE system. Six behaviours were identified as aerosol generating. These were classified into three categories: vegetative acts (coughing, breathing), verbal communication activities of daily living (speaking, loud voicing), and performance-based tasks (singing, sustained phonation). Certainty of evidence ranged from very low to moderate with variation in research design and variables. CONCLUSIONS: This body of literature helped to both identify and categorise the aerosol-generating behaviours involved in speech pathology clinical practice and confirm the low level of evidence throughout the speech pathology literature pertaining to aerosol generation. As many aerosol-generating behaviours are common human behaviours, these findings can be applied across healthcare and community settings. SYSTEMATIC REVIEW REGISTRATION: Registration number CRD42020186902 with PROSPERO International Prospective Register for Systematic Reviews.

Acoustic voice characteristics with and without wearing a facemask.

Facemasks are essential for healthcare workers but characteristics of the voice whilst wearing this personal protective equipment are not well understood. In the present study, we compared acoustic voice measures in recordings of sixteen adults producing standardised vocal tasks with and without wearing either a surgical mask or a KN95 mask. Data were analysed for mean spectral levels at 0-1 kHz and 1-8 kHz regions, an energy ratio between 0-1 and 1-8 kHz (LH1000), harmonics-to-noise ratio (HNR), smoothed cepstral peak prominence (CPPS), and vocal intensity. In connected speech there was significant attenuation of mean spectral level at 1-8 kHz region and there was no significant change in this measure at 0-1 kHz. Mean spectral levels of vowel did not change significantly in mask-wearing conditions. LH1000 for connected speech significantly increased whilst wearing either a surgical mask or KN95 mask but no significant change in this measure was found for vowel. HNR was higher in the mask-wearing conditions than the no-mask condition. CPPS and vocal intensity did not change in mask-wearing conditions. These findings implied an attenuation effects of wearing these types of masks on the voice spectra with surgical mask showing less impact than the KN95.

Effects of 445-nm Laser on Vessels of Chick Chorioallantoic Membrane with Implications to Microlaryngeal Laser Surgery.

OBJECTIVE: Previous research has shown that effective application of angiolytic lasers in microlaryngeal surgery is determined by wavelength, pulse width (PW), and fluence. Recently, a 445-nm (blue) laser (BL) has been developed with a potentially greater hemoglobin absorption than previous lasers. The chick chorioallantoic membrane (CAM) represents a suitable model for testing various settings to find out the most optimal settings of this laser. This study used the CAM model to examine whether successful photoangiolytic effects could be obtained using BL. METHODS: Seven hundred and ninety three third-order vascular segments of viable CAM were irradiated using BL via 400-µm diameter fiber, 1 pulse/second, with PW and power varied systematically at standardized fiber-to-vessel distances of 1 and 3 mm. Outcome measures including vessel ablation rate (AR), rupture rate (RR), and visible tissue effects were analyzed using Chi-square test. RESULTS: Energy levels of 400, 540, and 600 mJ (per pulse) were most effective for vessel ablation. A working distance of 3 mm resulted in higher ablation and less vessel rupture compared with 1 mm at these optimal energy levels. At 3 mm, a longer PW resulted in higher AR. At 1 mm, AR increased with shorter PW and higher power. The 1-mm working distance resulted in lower tissue effects than 3 mm. CONCLUSION: Findings in this study showed that BL was effective in vessel ablation using relevant combination of working distance, PW, and energy levels. To obtain high AR, longer working distance plus longer PW was required and if working distance was reduced, shorter PW should be set. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E1950-E1956, 2021.

A laryngographic and laryngoscopic study of Northern Vietnamese tones.

A laryngographic and laryngoscopic study of tone production in Northern Vietnamese, a language whose tones combine both fundamental frequency (f0) modulations and voice qualities (phonation types), was conducted with 5 male and 5 female speakers. Results show that the f0 contours of Northern Vietnamese tones are not only attributable to changes in vocal fold length and tension (partly through changes in larynx height), but that f0 drops are also largely caused by the glottal configurations responsible for the contrastive voice qualities associated with some of the tones. We also find that voice quality contrasts are mostly due to glottal constriction: they occasionally involve additional ventricular fold incursion and epiglottal constriction, but these articulations are usually absent.