Perceptual Measures of Boychoir Voices During the Phases of Pubertal Voice Mutation.

BACKGROUND/OBJECTIVES: Vocal changes in the male singing voice associated with puberty are variable and often unpredictable resulting in challenges for the singer and the choral director. Limited knowledge regarding the physiologic changes in the vocal mechanism as they correlate to perceptual variations observed in the male adolescent singer exists in the literature. The purpose of this study was to examine pitch breaks and perceptual characteristics of vocal quality during singing tasks for boys in various stages of the male changing voice. STUDY DESIGN: Prospective Study. METHODS: Twenty-eight boys were initially evaluated at Cooksey Stage 0 (Pubertal Unchanged; n = 15) or Cooksey Stage 1 (Mid-Voice; n = 13). Range of age was 8-13 years old. Participants performed vocal slide intervals (1-3-1, 1-5-1, 1-8-1) with discrete starting frequencies on G3, C4, F4, and A4 and sang the "Star-Spangled Banner" in the key of Ab. Pitch breaks and perceptual qualities were evaluated on the recorded tasks by expert raters. Seven boys were evaluated again when they progressed to Cooksey Stage 4 (Baritone) performing the same singing tasks. RESULTS: For the participants evaluated at Cooksey Stage 0/1, pitch breaks were observed more in the higher frequencies and increased interval spacing regardless of starting frequency. Participants at Cooksey Stage 0 had more pitch breaks than Stage 1. At Cooksey Stage 4, an increase in the number of pitch breaks was observed in comparison to their tasks performed at Stage 0/1 and the perceptual quality of breathiness was significantly greater. CONCLUSIONS: Pitch breaks are a characteristic perceptual change that indicates a young man may be transitioning through puberty. Findings from the present study demonstrate that in addition to perceived pitch breaks, breathiness was noted to significantly increase as the male progressed through puberty. Breathiness was noted to be more significant than vocal timbre and overall vocal quality. This research provides acoustic evidence to enhance the perceptual characteristics of voice change for those who teach and train male voices through puberty.

Influence of preoperative voice assessment on treatment plan prior to airway surgery.

OBJECTIVES/HYPOTHESIS: Voice quality has emerged as an additional long-term outcome measure for patients with a history of airway surgery. The goal of this study was to evaluate the impact of preoperative voice assessment on the surgical management of patients who required complex airway surgery. STUDY DESIGN: Retrospective case series. METHODS: We analyzed clinical data for all patients who underwent an airway reconstruction procedure from September 1, 2012 to September 1, 2017 and had a voice clinic evaluation prior to surgery at a tertiary-care pediatric hospital. Each participant underwent a full clinical voice evaluation that yielded acoustic, imaging, perceptual, and handicapping index data. RESULTS: Six hundred forty-three patients underwent 831 airway surgeries (laryngotracheoplasty, cricotracheal resection, slide tracheoplasty, laryngeal cleft repair). Ninety-one (14.2%) of the 643 patients underwent a formal voice clinic evaluation prior to airway surgery; 39/91 (42.9%) were female. The mean age was 10.4 years (95% confidence interval [CI]: 9.2-11.6) with 31/91 (32.9%) participants demonstrating vocal fold immobility and 33/91 (36.3%) vocal fold hypomobility. A voice clinic evaluation provided new information for 62/91 (68.1%) patients, mainly for laryngeal dynamic components (vocal fold motion, source of phonation, arytenoid prolapse) and confirmed suspected disorders for the remaining patients. The average baseline Pediatric Voice Handicap Index overall score was 38.9 (95% CI: 33.3-44.5), and the average overall severity rating of the Consensus Auditory-Perceptual Evaluation of Voice was 54 (95% CI: 45.2-62.8). A voice clinic evaluation influenced management of 56/91 (61.5%) patients either by modification of the surgical plan (26/56, 46%) and/or adjusting voice therapy (21/56, 37.5%). CONCLUSIONS: Voice evaluation prior to airway reconstruction provided key information that influenced the management for most of the patients. Formal voice evaluation should be considered prior to complex airway surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2858-2863, 2018.

Examining the Impact of Video Modeling Techniques on the Efficacy of Clinical Voice Assessment.

OBJECTIVES: The purpose of the current study was to determine whether or not presenting patients with a video model improves efficacy of the assessment as defined by efficiency and decreased variability in trials during the acoustic component of voice evaluations. METHODS: Twenty pediatric participants with a mean age of 7.6 years (SD = 1.50; range = 6-11 years), 32 college-age participants with a mean age of 21.32 years (SD = 1.61; range = 18-30 years), and 17 adult participants with a mean age of 54.29 years (SD = 2.78; range = 50-70 years) were included in the study and divided into experimental and control groups. The experimental group viewed a training video prior to receiving verbal instructions and performing acoustic assessment tasks, whereas the control group received verbal instruction only prior to completing the acoustic assessment. Primary measures included the number of clinician cues required and instructional time. Standard deviations of acoustic measurements (eg, minimum and maximum frequency) were also examined to determine effects on stability. RESULTS: Individuals in the experimental group required significantly less cues, P = 0.012, compared to the control group. Although some trends were observed in instructional time and stability of measurements, no significant differences were observed. CONCLUSIONS: The findings of this study may be useful for speech-language pathologists in regard to improving assessment of patients' voice disorders with the use of video modeling.

Feasibility of Clinical Endoscopy and Stroboscopy in Children With Bilateral Vocal Fold Lesions.

Purpose: The purpose of this study was to examine the utility of flexible and rigid endoscopy and stroboscopy for the identification of anatomical and physiological features in children with bilateral vocal fold lesions. The secondary purpose was to describe the age distribution of patients who could tolerate use of the different types of endoscopes. Method: This cross-sectional clinic-based study included 38 children (ages 5 to 12 years) diagnosed with bilateral vocal fold lesions via videoendoscopy. Vocal fold vibratory characteristics (e.g., mucosal wave) were rated by 4 clinicians by consensus. Results: Bilateral vocal fold lesions could be well described anatomically after visualization with both flexible and rigid endoscopes and were most commonly described as symmetrical and broad based. However, the clinicians' confidence in the accuracy of stroboscopy for rating vocal fold vibratory characteristics was limited for both flexible and rigid stroboscopes. Conclusions: Videoendoscopy was adequate for viewing and characterizing anatomical structures of bilateral vocal fold lesions in pediatric patients; however, vibratory characteristics were often not fully visualized with videostroboscopy. In view of the importance of visualizing vocal fold vibration in the differential diagnosis and treatment of vocal fold lesions, other imaging modalities, such as high-speed videoendoscopy, may provide more accurate descriptions of vocal fold vibratory characteristics in this population.

Assessment of Vibratory Characteristics in Children Following Airway Reconstruction Using Flexible and Rigid Endoscopy and Stroboscopy.

IMPORTANCE: Up to half of children have substantial dysphonia after airway reconstruction. Visual assessment of vocal function is valuable. Feasibility of flexible and rigid endoscopy has been reported; however, the clinical utility of stroboscopy has not been examined. Rating of vibratory characteristics, such as mucosal wave and amplitude of vibration, is essential for the development of interventions to improve voice outcomes. OBJECTIVE: To examine (1) clinicians' ratings of anatomical and physiological features in children following airway reconstruction on initial voice evaluation using videolaryngostroboscopy and (2) the relationship of age to the type of endoscopy used. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 32 patients aged 3 to 21 years evaluated for post­airway reconstruction dysphonia between July 2011 and July 2012 at a quaternary care children's hospital. INTERVENTIONS: Clinical voice evaluation protocol including rigid and/or flexible endoscopy with stroboscopy. MAIN OUTCOMES AND MEASURES: Demographic and voice quality characteristics were collected. The ability to complete endoscopy and ratings of anatomical and/or physiological features were assessed by a consensus of 4 clinicians. A t test was used to determine whether age was a significant factor in successful completion of videolaryngostroboscopy. RESULTS: Of 31 children who underwent flexible videolaryngostroboscopy, 22 (71%) examinations were completed with a distal chip endoscope and 9 (29%) with a fiberoptic. Significant differences were found in age between children who completed the distal chip vs. fiberoptic examination (mean [SD], 7.3 [2.7] vs. 5.5 [6.2] years; P = .05). Rigid endoscopy was attempted for 14 (44%) of 32 patients; 9 examinations (64%) were successful. Significant differences were found in age between patients for whom a rigid endoscopy could be successfully completed vs. those for whom it was not (mean [SD], 12.9 [3.4] vs. 6.2 [2.1] years; P < .001). Eighteen (56%) were glottic phonators, 8 (25%) supraglottic, and 6 (19%) aphonic. Vibratory characteristics were visible in 10 of 37 examinations (27%); 6 (16%) had ratable characteristics. CONCLUSIONS AND RELEVANCE: Endoscopy can be successfully completed in most children who have undergone airway reconstruction, most often using a distal chip endoscope.We found that vibratory characteristics were often not assessed adequately using videolaryngostroboscopy. Further work identifying imaging modalities that better display vibratory characteristics, such as high-speed videoendoscopy, may provide new insight into vocal function and lead to a more thorough evaluation.

Reported vocal habits of first-year undergraduate musical theater majors in a preprofessional training program: a 10-year retrospective study.

OBJECTIVE: Collegiate-level musical theater performance students are a specialized group of vocal performers, who rely on frequent and optimal voice use for their academic advancement and ultimate livelihood. The purpose of this study was to gather information to develop a greater understanding of vocal health and practice patterns of incoming collegiate-level musical theater performers. STUDY DESIGN: Data obtained from questionnaires completed by freshman musical theater majors were retrospectively analyzed to gather information about baseline vocal habits of the participants. METHODS: Results of a questionnaire were obtained from incoming freshman musical theater students at the Cincinnati Conservatory of Music over a period of 10 years (2002-2011). One hundred eighty-eight participants (female = 90) (male = 98) with an average age of 18.28 years (standard deviation = 0.726) were included. RESULTS: Results specifying participants' self-reported vocal training and practice habits, vocal health and hygiene practices, and current vocal symptoms or contributing factors to potential voice problems are provided. CONCLUSIONS: Data obtained from the participants revealed that the potential for vocal problems exists in this group of performers, as over half of the subjects reported at least one current negative vocal symptom. The findings from this study provide information that may be useful for individuals who are involved in the training of vocal performers.

Pediatric normative data for the KayPENTAX phonatory aerodynamic system model 6600.

OBJECTIVES: The objectives of this study were to (1) establish a preliminary pediatric normative database for the KayPENTAX Phonatory Aerodynamic System (PAS) Model 6600 (KayPENTAX Corp, Montvale, NJ) and (2) identify whether the data obtained were age- and/or gender-dependent. STUDY DESIGN: Prospective data collection across groups. METHODS: A sample of 60 children (30 females and 30 males) with normal voices was divided into three age groups (6.0-9.11, 10.0-13.11, 14.0-17.11 years) with equal distribution of males and females within each group. Five PAS protocols (vital capacity, maximum sustained phonation, comfortable sustained phonation, variation in sound pressure level, voicing efficiency) were used to collect 45 phonatory aerodynamic measures. RESULTS: Measurements for the 45 PAS parameters examined revealed 13 parameters to have a difference that was statistically significant by age and/or gender. There was a significant age×gender interaction for mean pitch in the four protocols that reported this measure. Males in the oldest group had significantly lower mean pitch values than the middle and young groups. Statistically significant main effect differences were noted for seven parameters across three age groups (expiratory volume, expiratory airflow duration, phonation time, pitch range (in 2 protocols), aerodynamic resistance, acoustic ohms). Significant main effect differences for genders (males > females) were found for expiratory volume and peak expiratory airflow. CONCLUSIONS: The age- and gender-related differences found for some parameters within each of the five protocols are important for the interpretation of data obtained from PAS. These results could be explained by developmental changes that occur in the male and female respiratory and laryngeal systems.

An examination of elicitation method on fundamental frequency and repeatability of average airflow measures in children age 4:0-5:11 years.

OBJECTIVE: The purpose of this study was to determine the effect of task type on fundamental frequency (F(0)) and the short-term repeatability of average airflow values in preschool/kindergarten-age children. STUDY DESIGN: Prospective, experimental. METHODS: Thirty healthy children (age 4.0-5.11 years) were included in this study. Participants completed three tasks (sustained vowel, counting, and storytelling) used to elicit measurements of F(0). With a 10-minute interval, participants also completed two trials of sustained /a/ at a comfortable pitch and loudness level for the measurement of average airflow rate. F(0) and intensity of the vowel production were recorded for both trials. RESULTS: A repeated measures analysis of variance revealed a significant main effect for task type elicitation on F(0) values (P=0.0003). A significant difference between elicitation tasks for F(0) was observed in the comparison of the counting and storytelling task (P<0.0001). A paired t test revealed no significant difference in average airflow rate across two trials (P=0.872). The change in F(0) and intensity was measured across the trials, and separate analyses of covariance revealed that these changes did not significantly influence average airflow values, (P=0.809) and (P=0.365), respectively. CONCLUSIONS: The results of this study demonstrated that F(0) may be influenced by task type in young children. Average airflow values appear to be stable over a short time period. This information is important in determining methods of evaluation and the reliability of instrumental measures in young children with voice disorders.

Update on pediatric voice and airway disorders: assessment and care.

PURPOSE OF REVIEW: To investigate the status of the recent literature focused on studying the assessment and treatment of pediatric voice and airway disorders using both established and novel techniques. RECENT FINDINGS: Recent research regarding voice assessment and treatment reveals the use of systematic and innovative approaches when collecting instrumental and perceptual voice data. There are recent advancements in certain surgical interventions designed to minimize complications. Wider use of functional endoscopic imaging of the pediatric larynx is improving our understanding of childhood voice production and airway management. There is also an important emerging focus on quantifying the impact of having a childhood voice disorder through the use of new tools. Although there is an increase in pediatric voice and airway research, many studies tend to be entirely descriptive rather than quantitative. There continues to be little specific research that uses prospective, longer-term and formal voice outcomes before and after behavioral and surgical interventions. SUMMARY: Pediatric voice and airway disorders are an important childhood health problem. Voice assessment in children should include formal perceptual and instrumental evaluations, including sophisticated acoustic, aerodynamic and imaging modalities. The care of these children requires a collaborative approach that includes systematic and innovative treatment methods.

Comparison of the Pediatric Voice Handicap Index with perceptual voice analysis in pediatric patients with vocal fold lesions.

OBJECTIVE: To compare a subjective patient/family-derived voice handicap survey with an expert observer-derived method of evaluating voice disturbance in pediatric patients with vocal fold lesions (VFLs). DESIGN: Retrospective review. SETTING: Tertiary care referral center. PATIENTS: Thirty-eight children with VFLs referred for voice evaluation. MAIN OUTCOME MEASURES: Pediatric Voice Handicap Index (pVHI) scores and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores. Percentages for CAPE-V (100-point scale) and pVHI (92-point scale) were calculated for direct comparisons. Relationships between pVHI scores and CAPE-V scores were investigated using the Spearman rank correlation. RESULTS: Thirty-eight patients with VFLs (median age, 8.3 years; age range, 4.2-17.2 years; 63% males) were included from a database of more than 600 children and evaluated between November 15, 2005, and June 15, 2010. The median CAPE-V overall score was 30.3 (range, 1-67), and the normalized total pVHI score was 29.3 (range, 0-73) (P = .90). The Spearman rank correlation showed significant fair correlations between CAPE-V overall and functional pVHI and between CAPE-V strain and breathiness, and the pVHI total, functional, but none higher than ρ = 0.44 (P ≤ .03). The correlation was higher in males for CAPE-V loudness to total pVHI (ρ = 0.40, P = .04) and in females for CAPE-V breathiness (ρ = 0.58, P = .03) and strain (ρ = 0.55, P = .04) to total pVHI. CONCLUSIONS: The CAPE-V and the pVHI are useful tools in the measurement of voice outcomes in children with VFLs. There are fair correlations between the CAPE-V and the pVHI, and they likely evaluate important yet different aspects of voice disturbance. Significant gender differences in these correlations should be further evaluated in future studies.

Voice outcomes following adult cricotracheal resection.

OBJECTIVES: Cricotracheal resection (CTR) is an effective treatment for moderate-to-severe laryngotracheal stenosis (LTS) in adults. However, one of the potentially significant sequela of this procedure is postoperative dysphonia and permanent voice alteration. The objective of this study is to characterize voice changes in adult patients with subglottic stenosis who have undergone CTR. STUDY DESIGN: Retrospective case-series. METHODS: Acoustic, aerodynamic, and consensus auditory-perceptual evaluation of voice (CAPE-V) data were reviewed for consecutive adult patients undergoing CTR and perioperative voice evaluation from 2000 to 2010. RESULTS: Sixteen patients (median age 44 years, 94% female) underwent CTR and voice evaluation during the study period. Thirteen patients underwent postoperative evaluation and had a mean overall CAPE-V score of 47.5/100, mean fundamental frequency (F0) of 156.7 Hz, average estimated subglottic pressure of 10.0 cm H(2) O, and an average airflow of 224 mL/sec. Seven patients underwent pre- and postoperative evaluations and had a significant reduction in mean F0 (206.5 vs. 151.1 Hz, P = .002) and mean F0 for connected speech (194.9 vs. 152.7 Hz, P = .047), but not in median intensity, range, estimated subglottic pressure, or airflow. Median overall CAPE-V scores worsened, but did not reach statistical significance (12 vs. 61.5, P = .28). Seventy-one percent of patients underwent an increase in acoustic signal typing postoperatively. CONCLUSIONS: Although CTR is an effective treatment for adult LTS, it results in significant alteration of the adult voice. In particular, CTR decreases the fundamental frequency of connected speech and vowel phonation and changes the acoustic signal type. Patients should be counseled about these likely voice alterations prior to undergoing surgery.

Metabolic cost and speech quality while using an active workstation.

BACKGROUND: The effect of active workstation implementation on speech quality in a typical work setting remains unclear. PURPOSE: To assess differences between sitting, standing, and walking on energy expenditure and speech quality. METHODS: Twenty-two females and 9 males read silently, read aloud, and spoke spontaneously during 3 postural conditions: sitting, standing, and walking at 1.61 km/h. Oxygen consumption (VO2), blood pressure, and rating of perceived exertion (RPE) were obtained during each condition. Expert listeners, blinded to the purpose of the study and the protocol, assessed randomized samples of the participants' speech during reading and spontaneous speech tasks in 3 postural conditions. RESULTS: Standing elevated metabolic rate significantly over sitting (3.3 ± 0.7 vs. 3.6 ± 0.9 ml·kg-1·min-1). Walking at 1.6 km/h while performing the respective tasks resulted in VO2 values of 7.0 to 8.1 ml·kg-1·min-1. There was no significant difference in the average number of syllables included in each speech sample across the conditions. The occurrence of ungrammatical pauses was minimal and did not differ across the conditions. CONCLUSION: The significant elevation of metabolic rate in the absence of any deterioration in speech quality or RPE support the utility of using active work stations to increase physical activity (PA) in the work environment.

Characterization of supraglottic phonation in children after airway reconstruction.

OBJECTIVES: We examined select acoustic (signal type), aerodynamic, and perceptual measures and associated surgical data in a cohort of children who were endoscopically identified as using supraglottic phonation after undergoing airway reconstruction. METHODS: Twenty-one children (4 to 18 years of age) who were seen in the Cincinnati Children's Hospital Medical Center for Pediatric Voice Disorders and identified as using supraglottic phonation were included in this study. According to standard protocol, each of these children underwent acoustic, aerodynamic, and perceptual analyses and laryngeal imaging. Their medical records were reviewed for surgical history. RESULTS: Four primary supraglottic compression patterns and 3 distinct sound sources for voice were identified. Signal type classification revealed that 20 of 21 voice signals were either type II or type III. Signal type was moderately associated with compression pattern (p = 0.01). No statistically significant findings were found in testing the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) Overall Severity score against compression patterns and vibration source. The mean Strain scores for participants who used a combined source of vibration were significantly higher than for those who used their ventricular folds. CONCLUSIONS: The compensatory compression patterns and alternate sources of vibration used by these children resulted in moderate to severe dysphonias. How children compensate after undergoing airway reconstruction has important implications for behavioral and surgical interventions aimed at improving voice quality. Not all aspects of traditional voice evaluation are suitable for this population.

Comparison of pediatric voice handicap index scores with perceptual voice analysis in patients following airway reconstruction.

OBJECTIVES: We performed a retrospective review to compare a subjective parental proxy-derived voice handicap survey to an observer-derived method of measuring voice perturbation in children who have undergone airway reconstruction. The main outcome measures were the Pediatric Voice Handicap Index (pVHI) total score and the Overall Severity score on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). METHODS: The percent Overall Severity CAPE-V score (score divided by 100) and the percent pVHI score (score divided by 92) were calculated. A Wilcoxon signed rank test was used to compare CAPE-V scores with the pVHI total scores. The relationship between the pVHI scores and the CAPE-V scores was investigated with a Spearman correlation. Subgroup analysis was performed to determine the relationship of surgery type to CAPE-V and pVHI scores. RESULTS: Fifty subjects with a history of airway surgery who were evaluated between 2005 and 2008 were identified. Forty-two of the 50 subjects had complete data for review. Their median age was 7.1 years (range, 3.3 to 17.9 years). Their pVHI total scores had a median of 30 (range, 1 to 80). Their Overall Severity CAPE-V scores had a median of 50.5 (range, 0 to 98). Their median CAPE-V percent was higher than their median pVHI percent (50.5% versus 32.6%; p = 0.0003). A weak correlation was found between the Overall Severity CAPE-V score and the pVHI total score (rho = 0.41; p = 0.0003). There was a trend toward higher Overall Severity CAPE-V scores in patients who underwent cricotracheal resection. The total number of airway surgeries was significantly correlated with the Overall Severity CAPE-V score (rho = 0.6; p <0.0001) but not with the pVHI score. CONCLUSIONS: Children who undergo airway reconstruction often have a resulting voice disturbance that can affect their lives in multiple dimensions. The results of this study revealed a weak-to-fair correlation between the parent-reported pVHI total score and expert ratings of voice quality using the CAPE-V. In this patient population, both of these tools provided important information regarding the relationship of the severity of voice disturbance to its handicapping effects.

Aerodynamic and acoustic assessment in children following airway reconstruction: an assessment of feasibility.

OBJECTIVE: The purpose of this study was to examine the feasibility of conducting aerodynamic and acoustic assessment in children following airway reconstruction. Underlying etiologies, co-morbidities and age related factors can present challenges for meaningful instrumental data collection in this population. METHODS: A chart review of 100 children who were seen for a complete voice evaluation at the Center for Pediatric Voice Disorders at the Cincinnati Children's Hospital Medical Center was conducted. Children who completed full or partial aerodynamic and acoustic protocols were identified. Data regarding the ability to participate in the assessment was tabulated, and vowel samples taken from the acoustic data were subjected to signal type classifications (e.g., Type I, II, III). RESULTS: Fifty-three children met the inclusion/exclusion criteria of the chart review. Of those children, 58% (n=31/53) were able to complete the full acoustic and aerodynamic protocols without any modification. In regards to the aerodynamic protocol alone, 64% (n=34/53) could complete protocol. In regards to the acoustic protocol alone, 75% (n=40/53) could complete the entire acoustic protocol without any modification. There were 32% (n=17) who provided a Type I acoustic signal which was appropriate for measurement of F(0). There was a significant correlation between age and ability to complete the protocol for both the aerodynamic (p=.007) and acoustic (p=.004) protocols. CONCLUSIONS: This study demonstrated that a majority of children were capable of completing aerodynamic and acoustic protocols. A significant proportion of children in this study had severe dysphonia, precluding the ability to extract fundamental frequency. Although aerodynamic and acoustic measures are feasible for many patients in this population, the severity of dysphonias observed in these patients causes the use of these measures to be limited in some cases for documenting behavioral and surgical outcomes measures.