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(MEDLINE, EMBASE, Scopus, Web of Science, CINAHL, PubMed Central, IEEE Xplore) and grey literature (ProQuest for unpublished dissertations) measuring vowel onset.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.

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.

BIDAR: Can Listeners Detect if a Man Is Bisexual from His Voice Alone?

Previous research has identified a range of perceptual voice and speech features that differ between gay and straight men, enabling listeners to determine if a man is gay or straight at a rate better than chance from his voice alone. To date, no published studies have examined if bisexual men's voices differ from gay and straight men's voices with regard to perceived masculinity-femininity - nor whether listeners can identify a bisexual man based only on his voice. In the present study, we examined if listeners could identify bisexual men's sexual identities from voice recordings. Seventy participants (N= 70) rated 60 voice recordings of a sample of 20 gay, 20 bisexual, and 20 straight Australian men on perceived sexual orientation and degree of masculinity-femininity. Participants could correctly categorize the sexual orientations of the gay and straight speakers at rates greater than chance, but bisexual men were only identified at chance. Bisexual voices were consistently misperceived as being the most exclusively female attracted, and, contrary to expectations, were perceived as the most masculine sounding of all the speakers. Together, these findings suggest that while the voices of bisexual men in our sample were perceived as more masculine and female attracted, listeners do not associate this impression with bisexuality, and thus cannot identify bisexual men from their voices. Consequently, while bisexual men appear to be at lower risk of facing voice-based identification and discrimination than gay men, they may be often misperceived as being straight.

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.

Effectiveness of Intensive Voice Therapy Versus Weekly Therapy for Muscle Tension Dysphonia: A Noninferiority Randomised Controlled Trial With Nested Focus Group.

OBJECTIVES: To investigate the noninferiority of intensive voice therapy and compare its effects with weekly voice therapy on multidimensional outcomes of voice and well-being, satisfaction, and attendance in people with muscle tension dysphonia (MTD). The study further aimed to explore clinician's perceptions of barriers and enablers to implementation of intensive therapy. STUDY DESIGN: Noninferiority randomised controlled trial with nested focus group. METHODS: Twenty adults with MTD were randomised to receive either weekly voice therapy (1 hour per week for 8 weeks) or intensive voice therapy (1 hour, 4 days per week for 2 weeks). Participants were assessed by a blinded assessor twice before treatment, once post treatment and once at 4 weeks follow up on the primary outcome measure VHI and a range of secondary auditory-perceptual, acoustic, and patient (i.e., VoiSS, satisfaction) and clinician reported outcome measures (i.e., AusTOMs, attendance rates). Five Speech Language Pathologists also participated in a focus group to explore barriers and enablers to implementing intensive therapy, with questions and analyses guided by the Theoretical Domains Framework. RESULTS: While noninferiority for the primary outcome measure VHI was not confirmed, secondary outcome measures revealed comparable within group clinically important improvements for VoiSS and the AusTOMs, as well as selected acoustic and auditory-perceptual measures for both groups. A trend of more improvements being maintained in the intensive group was identified. Comparably high satisfaction and attendance was also found between groups. Clinicians reported more enablers than barriers to providing intensive therapy which included beliefs that it led to greater progression and consolidation of patient learning, was supported by the local context and was associated with positive emotions. Barriers related to difficulties with booking and scheduling and the belief that intensive therapy was not for all patients. CONCLUSIONS: While the current study was likely underpowered to establish non-inferiority of intensive therapy, secondary outcomes suggested that intensive therapy may produce comparable benefits to voice, wellbeing, satisfaction and attendance compared to weekly therapy and may be a viable therapy option for individuals with MTD. When implementing intensive therapy, clinicians should consider patient's preferences and availability, as well as systems which allow for flexible booking and therapy provision for patients. Clear recommendations for future research including the use of a larger sample and telehealth are also provided.

Listening to Video Game Voices: A Call for Action for Research into the Vocal Health of Video Game Voice Actors.

Video game voice actors (VGVAs) are a professional voice user (PVU) population whose occupation relies on their ability to reliably deliver extremes in vocal performance. In their work VGVAs are required to perform solo for extended durations, producing highly complex character performances that not only include extremes of vocal parameters and qualities but also highly demanding vocal acts (ie, screaming, singing) within those voice archetypes. Based on the vocal demands of their work and current understandings of occupational voice disorder, it is reasonable to consider that VGVAs may be at increased risk of vocal fatigue, injury, and disorder, as manifestations of occupational disease. This risk is of primary concern to VGVAs who recently organized industrial action to highlight their concerns regarding vocal health within their industry. As a group that is not well represented within voice research, there is little literature currently available to inform clinical support of the population. Due to the unique nature of VGVA work and the highly specific nature of occupational voice use among PVUs, we cannot necessarily generalize research from other populations to VGVAs. As such, research utilising frameworks designed to capture the complexity of voice use, demands on the voice, and experiences of its use are required to support the concerns of the population. This paper introduces VGVAs as an emerging PVU population, describes the concerns of this population within the context of current understandings of vocal fatigue, occupational voice problems and PVU populations, and details the approaches required in the development of research into the population.

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.

Similarities and differences across patient completed voice case history questionnaires - A scoping review.

BACKGROUND: Case history assessments are ubiquitously performed across various health professions for diagnostic purposes. Questionnaires are considered a valuable tool within this process. There is currently no standardized tool available to collect such information in the assessment of voice disorders. Conflicting advice from peak bodies and research evidence makes the process heterogenous, haphazard and difficult to compare findings. OBJECTIVE: To systematically identify existing case history questionnaires available for general clinical practice and provide synthesis and analysis of the questions within. METHODS: A scoping review was conducted across published and unpublished literature using the PRISMA Extension for Scoping Reviews framework. The broad search included research papers within six electronic databases, textbooks, online publishing sites, voice clinic websites and peak body websites. Search criteria were uniformly applied. Descriptive analysis and content analysis was conducted. At each stage, transparency and replicability was achieved through an independent review process. RESULTS: Identified voice case history questionnaires were few (n = 23) with 80% from unpublished sources. A total of 581 unique questions were identified. No single question was common across all 23 questionnaires. The most frequently asked questions, excluding demographics, included medicines taken (n = 21), smoking (n = 20) and alcohol (n = 19). These questions were not reflected in the highest frequency categories: Health Status/Medical Conditions/Reports (n = 200), Vocal Symptoms (n = 88), Voice Use (n = 51) despite these categories representing 58% of all questions asked. Within the highest frequency category, the subcategory of Systemic Diseases was the highest, representing 19% of all questions within the category. CONCLUSIONS: This study illuminates the similarities yet many differences that exist across identified voice case history questionnaires in terms of number of questions, number of categories, preference for question-type and structure. It demonstrates the need for standardization of a voice case history questionnaire which would potentially enable more accurate diagnosis and data comparison between voice clinics to aid future research.

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.

Frameworks, Terminology and Definitions Used for the Classification of Voice Disorders: A Scoping Review.

BACKGROUND: A challenge for clinicians and researchers in laryngology is a lack of international consensus for an agreed framework to classify homogenous groups of voice disorders. Consistency in terminology and agreement in how conditions are classified will provide greater clarity for clinicians and researchers. OBJECTIVE: This scoping review aimed to examine the published literature on frameworks, terminology, and criteria for the classification of voice disorders. DESIGN: Seven online databases (MEDLINE, Embase, CINAHL, PsycInfo, Scopus, Cochrane Collaboration, Web of Science) and grey literature sources were searched. Studies published from 1940 to 2021 were included if they provided a descriptive detail of a classification framework structure and described the methodological approaches to determine classification. A narrative synthesis of the main concepts including terminology, classification criteria, grouping of conditions, critical appraisal items and gaps in research was undertaken. RESULTS: A total of 2,675 publications were screened. Twenty sources met inclusion criteria, including published articles and grey literature. Thirty-five classification groups and over 150 sub-groups were described. The classification group labels, and criteria for inclusion of conditions varied across the frameworks. Several key themes in terminology and criteria useful for classification are discussed, and a core set of suggested terms and definitions are presented. CONCLUSIONS: The quality of research on classification frameworks for voice disorders is low and not one system encompasses all voice disorders across the whole spectrum. Continued high quality research using consensus methodology and inter-rater reliability scores is recommended to develop and test an internationally agreed classification framework for voice disorders.

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.

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.

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.

Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis.

Despite continued surgical advancements in the field of cardiothoracic transplantation, post-operative complications remain a burden for the patient and the multidisciplinary team. Lesser-known complications including swallowing disorders (dysphagia), and voice disorders (dysphonia), are now being reported. Such disorders are known to be associated with increased morbidity and mortality in other medical populations, however their etiology amongst the heart and lung transplant populations has received little attention in the literature. This paper explores the potential mechanisms of oropharyngeal dysphagia and dysphonia following transplantation and discusses optimal modalities of diagnostic evaluation and management. A greater understanding of the implications of swallowing and laryngeal dysfunction in the heart and lung transplant populations is important to expedite early diagnosis and management in order to optimize patient outcomes, minimize allograft injury and improve quality of life.

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.