Union of the European Phoniatricians' position statement on the exit strategy of phoniatric and laryngological services: staying safe and getting back to normal after the peak of coronavirus disease 2019 (issued on 25th May 2020).

BACKGROUND: The following position statement from the Union of the European Phoniatricians, updated on 25th May 2020 (superseding the previous statement issued on 21st April 2020), contains a series of recommendations for phoniatricians and ENT surgeons who provide and/or run voice, swallowing, speech and language, or paediatric audiology services. OBJECTIVES: This material specifically aims to inform clinical practices in countries where clinics and operating theatres are reopening for elective work. It endeavours to present a current European view in relation to common procedures, many of which fall under the aegis of aerosol generating procedures. CONCLUSION: As evidence continues to build, some of the recommended practices will undoubtedly evolve, but it is hoped that the updated position statement will offer clinicians precepts on safe clinical practice.

Efficacy of microsurgery in Reinke's oedema evaluated by traditional voice assessment integrated with the Vocal Extent Measure (VEM).

SUMMARY: There are few data analysing to what specific extent phonomicrosurgery improves vocal function in patients suffering from Reinke's oedema (RE). The recently introduced parameter vocal extent measure (VEM) seems to be suitable to objectively quantify vocal performance. The purpose of this clinical prospective study was to investigate the outcomes of phonomicrosurgery in 60 RE patients (6 male, 54 female; 56 ± 8 years ([mean ± SD]) by analysing its effect on subjective and objective vocal parameters with particular regard to VEM. Treatment efficacy was evaluated at three months after surgery by comparing pre- and postoperative videolaryngostroboscopy (VLS), auditory-perceptual assessment (RBH-status), voice range profile (VRP), acoustic-aerodynamic analysis and patient's self-assessment using the voice handicap index (VHI-9i). Phonomicrosurgically, all RE were carefully ablated. VLS revealed removal or substantial reduction of oedema with restored periodic vocal fold vibration. All subjective and most objective acoustic and aerodynamic parameters significantly improved. The VEM increased on average from 64 ± 37 to 88 ± 25 (p #x003C; 0.001) and the dysphonia severity index (DSI) from 0.5 ± 3.4 to 2.9 ± 1.9. Both parameters correlated significantly with each other (rs = 0.70). RBH-status revealed less roughness, breathiness and overall grade of hoarseness (2.0 ± 0.7 vs 1.3 ± 0.7). The VHI-9i-score decreased from 18 ± 8 to 12 ± 9 points. The average total vocal range enlarged by 4 ± 7 semitones, and the mean speaking pitch rose by 2 ± 4 semitones. These results confirm that: (1) the use of VEM in RE patients objectifies and quantifies their vocal capacity as documented in the VRP, and (2) phonomicrosurgery is an effective, objectively and subjectively satisfactory therapy to improve voice in RE patients.

[Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children and adults]. / Positionspapier der DGHNO und der DGPP - Stand der klinischen und endoskopischen Diagnostik, Evaluation und Therapie von Schluckstörungen bei Kindern und Erwachsenen.

Position Paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current State of Clinical and Endoscopic Diagnostics, Evaluation, and Therapy of Swallowing Disorders in Children and AdultsSwallowing disorders are frequent. The main concern is mortality due to aspiration induced pneumonia and malnutrition. On the other hand quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract and sequelae of tumor treatment in the head and neck region are the main pathologic entities.Predominantly ENT physicians and phoniatrists, are asked for diagnostics and therapy who will coordinate the interdisciplinary treatment according to the endoscopic findings.A differentiated approach in history, diagnostics, and symptom oriented treatment is necessary for the mostly complex disorders. The integration of non-medical personnel such as logopeds (speech language pathologists), physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over by them in close cooperation.In particular an interdisciplinary cooperation with the staff from intensive care medicine is indispensable.The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists.Endoscopy is a medical service that is basically not delegable. Consequently substitution of the physician is precluded.

[How to render an expert opinion on dysphonia]. / Begutachtung der Stimmfunktionsstörung.

In Germany, parameters for medicolegal evaluation of dysphonia have to be revised against the background of communication disorders getting more important in a modern communication society. In this work, up-to-date diagnostic tools are reviewed and evaluated for medicolegal purposes. Parametrization is -performed according to the International Classification of Functioning, Disability and Health ICF. Following this schema, -dysphonia is graded as follows: 1) No dysphonia (no problem, percentile 0-4) impairment of the whole person 0%, 2) Slight, strain-induced dysphonia (slight problem, percentile 5-24) -impairment of the whole person 0-10%, 3) Moderate dysphonia (moderate problem, percentile 25-49) impairment of the whole person 20-30%, 4) Severe dysphonia (severe problem, percentile 50-95) impairment of the whole person 40-50%, 5) Complete loss of voice (extreme problem, percentile 96-100%) impairment of the whole person 50%.

[Validation of the German version of the Singing Voice Handicap Index]. / Validierung des Singing Voice Handicap Index in der deutschen Fassung.

The Singing Voice Handicap Index (SVHI) was developed in the United States for the self-assessment of patients with singing problems. It has been translated into German and its reliability and validity have been assessed. In total, 54 (35 female, 19 male) dysphonic singers and 130 (74 female, 56 male) non-dysphonic professional singers were included in the study. Reliability rested on high test-retest reliability (r = 0.960, p ≤ 0.001, Pearson correlation) and a Cronbach's α of 0.975. A principal component analysis using the Varimax method and the results of the screeplot suggest the SVHI scored as a single scale. Validity rested on a highly significant correlation between the severity of the self-rated voice impairment by the patient and the total SVHI score. Dysphonic singers have significantly higher SVHI scores than healthy singers. The SVHI is thus suited to implementation as a diagnostic tool in German-speaking countries.

[Microlaryngoscopy and phonomicrosurgery]. / Mikrolaryngoskopie und Phonomikrochirurgie.

Microlaryngoscopy is a reliable technique and the most frequently applied method in laryngeal surgery. The design of new laryngoscopes and the application of video endoscopes may permit further improvements in laryngeal exposure, whilst minimizing the damage caused by their insertion. In contrast to this, the principle microsurgical procedures for improvement, restoration and preservation of the vocal function have remained almost unchanged. These techniques are oriented towards minimal excision of pathological tissue with maximal conservation of normal tissue, in particular the epithelium of the vocal folds and the lamina propria-the basic structures for vocal fold vibration. Phonomicrosurgy can only be justified on the basis of a proven improvement as evidenced by vocal function analysis.

Item reduction of the voice handicap index based on the original version and on European translations.

OBJECTIVE: Constructing an internationally applicable short-scale of the Voice Handicap Index (VHI). METHODS: Subjects were 1,052 patients with 5 different types of voice disorder groups from Belgium, France, Sweden, Germany, Italy, The Netherlands, Portugal, and the USA. Different 9- and 12-item subsets were selected from the 30 VHI items using (1) the first factor of an unrotated factor analysis (narrow range subsets) and (2) the first three factors after promax rotation (broad range subsets). Country-specific subsets were selected to test deviations from the international subsets. For all subsets, reliability was investigated using Cronbach's alphas and correlations with the total VHI. Validity was investigated using regression on voice disorder groups. All analyses were performed for the total and for all country-specific subject samples. RESULTS: Reliability was high for all item subsets. It was lower for the international compared to the country-specific subsets and for the broad range compared to the narrow range subsets. Validity was best for the broad range subsets. Validity was better for the international than for the country-specific subsets. For all statistics the 12-item subsets were not essentially better than the 9-item subsets. CONCLUSION: The international broad range 9-item subset forms a scale which approximates well the total VHI.

[Quality assurance of a universal newborn hearing screening. Recommendations of the German Society of Phoniatrics and Pediatric Audiology]. / Qualitätssicherung eines universellen Neugeborenen-Hörscreenings. Empfehlungen der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie.

Statutory implementation of a universal newborn hearing screening requires a continuous quality assurance monitoring. Therefore, at the Annual Meeting in 2007, the members of the German Society of Phoniatrics and Pediatric Audiology passed a recommendation on measures of quality assurance applied to newborn hearing screening. This recommendation describes the procedures, performance, location, time frame, and technical prerequisites of the screening and of potentially necessary follow-ups, the definition of hearing loss to be detected, the performing and responsible professional groups and their qualifications for the screening, the regulation of repeat and control screenings, the confirmation diagnostics and initiation of therapy, the information of parents, the documentation of screening results, the aims and organization of a tracking system, the tasks of regional screening centers and of a supraregional institution for the quality assurance of the hearing screening, the central collection of person and screening-related quality relevant data, and the accessibility of defined data sets as predisposition for cost analyses and quality reports.

[Postoperative care in operative laryngology]. / Postoperative Betreuung in der operativen Laryngologie.

The postoperative care after phonosurgery and laryngologic procedures from the physician's view comprises control of wound healing and confirmation of restitution of the vocal folds or the larynx. The physician manages the patient's behaviour, prescribes medication if necessary and provides advice on measures to promote healing, such as voice rest and work incapacity. Basic knowledge on wound healing is an aid for deciding at which point in time voice rest and work incapacity can be ended. Professional voice users need a specifically tailored line of conduct during the period of voice rehabilitation. The documentation includes the organic findings and the vocal function.

Validation of the voice handicap index by assessing equivalence of European translations.

OBJECTIVE: We aimed to assess the equivalence of translations of the Voice Handicap Index (VHI). PATIENTS AND METHODS: Confirmatory factor analysis was used to assess equivalence of the US version and several translations including (1) Dutch, (2) Flemish Dutch (Belgium), (3) UK English, (4) French, (5) German, (6) Italian, (7) Portuguese and (8) Swedish. VHI questionnaires were gathered from 1,281 subjects. Patients were classified into 11 voice lesion categories. Patients with incomplete response (4%) and patients within voice lesion categories with small numbers were excluded from further analyses, leaving a cohort of 1,052 patients from 8 countries. RESULTS: The internal consistency of the VHI proved to be good. Confirmatory factor analysis across countries revealed that a 3-factor fixed measurement model best fitted the data; the 3 subscales appeared to highly intercorrelated, especially in the US data. The underlying structure of the VHI was also equivalent regarding various voice lesions, but distinct groups were recognized with respect to the height of the VHI scores, indicating that various voice lesions lead to a diversity of voice problems in daily life. CONCLUSION: The US VHI and the translations appeared to be equivalent, which means that the results from studies from the various included countries can be compared.

[Are there auditory processing and perception disorders in children with dyslexia?]. / Lassen sich auditive Verarbeitungs- und Wahrnehmungsstörungen (AVWS) bei Kindern mit Lese-Rechtschreib-Störungen nachweisen?

BACKGROUND: In this paper the dichotic tests and the CERA (Cortical Evoked Response Audiometry) of children with dyslexia had been examined, in order to find out if there are auditory processing and perception disorders. PATIENTS AND METHODS: 33 children with dyslexia had been compared with 28 children without problems of writing and reading. The mean age of the children was 9 years. All of the children had been examined by the following audiometric measurements: tympanometry, pure-tone-audiometry, speech-audiometry, dichotic Tests by Uttenweiler and Feldmann and the Cortical Evoked Response Audiometry (CERA) rated according to Esser. RESULTS: The intelligence quotients were in the group of dyslexic children significantly lower. The Uttenweiler and Feldmann tests were in dyslexic children significantly lower in the control group as well. The late cortical responses ware normal or near normal in both groups. CONCLUSION: Dichotic speech tests indicate central auditory processing and perception deficits in dyslexia. These tests are confounded, however, by attention and memory deficits. The CERA rated according to Esser does not point out to these auditory disorders in dyslexia.

[On the auditory evaluation of voice quality]. / Zur auditiven Bewertung der Stimmqualität.

BACKGROUND: For routine clinical purposes, dysphonic voices are assessed perceptually using the GRBAS scale or analogues. For clinical application, the crucial question is the interrater reliability (IRR) of the auditory perceptual assessment of voice quality. Therefore, the IRR of the four point RBH (roughness, breathiness, hoarseness vs overall grade) scale was studied. Other parameters, e.g. validity and intrarater reliability were not considered. METHODS: A total of 78 patients read a standard text "Der Nordwind und die Sonne". These samples were evaluated by 19 speech and voice therapy students according to the degree of roughness, breathiness and hoarseness. Data were subjected to reliability analysis. RESULTS: Our data indicate a high IRR with a Cronbach's alpha of 0.94. No single rating of the 19 raters could be omitted without decreasing the IRR. DISCUSSION: The data indicate that the perceptual assessment of hoarseness for running speech is highly reliable. The application of the RBH scale is suitable for clinical purposes. It should be considered as an outcome measure.

[Validation of the German version of the Voice Handicap Index]. / Validierung des Voice Handicap Index (VHI) in der deutschen Fassung.

The voice handicap index (VHI) was developed in the United States for subjective evaluation of a voice disturbance by the patient. The translation into German has been applied for a German population of patients. It was validated by the examination of 316 adult patients, 221 female and 95 male. The reliability of the VHI rests on a high Cronbach's alpha (0.96). A factor analysis in order to structure the items yields four factors that can be interpreted as negative voice experience (factor 1-explaining 20.83% of the variance after rotation), lack of assertiveness (factor 2-18.82%), lack of vocal power (factor 3-12.84%), and negative emotionality (factor 4-11.01%). The mean VHI scores differ significantly from each other in different degrees of voice disturbance as estimated by the patients themselves. The voice handicap index is qualified as a diagnostic tool for German-speaking countries.

The speaker's formant in male voices.

Spectral analysis of vowels during connected speech can be performed using the spectral intensity distribution within critical bands corresponding to a natural scale on the basilar membrane. Normalization of the spectra provides the opportunity to make objective comparisons independent from the recording level. An increasing envelope peak between 3,150 and 3,700 Hz has been confirmed statistically for a combination of seven vowels in three groups of male speakers with hoarse, normal, and professional voices. Each vowel is also analyzed individually. The local energy maximum is called "the speaker's formant" and can be found in the region of the fourth formant. The steepness of the spectral slope (i.e. the rate of decline) becomes less pronounced when the sonority or the intensity of the voice increases. The speaker's formant is connected with the sonorous quality of the voice. It increases gradually and is approximately 10 dB higher in professional male voices than in normal male voices at neutral loudness (60 dB at 0.3 min). The peak intensity becomes stronger (30 dB above normal voices) when the overall speaking loudness is increased to 80 dB. Shouting increases the spectral energy of the adjacent critical bands but not the speaker's formant itself.

[Practical significance of measuring high formant spectra in phoniatric voice assessment]. / Zur praktischen Bedeutung der Messung hoher Formantpegel bei der phoniatrischen Stimmbeurteilung.

The measurement of sound energy in the spectral region between 2 and 5 kHz provides additional information to the auditive assessment of voice quality. It can be applied to healthy an sick voices, e. g. in tracing the therapeutic course. Devices for measuring voice range profiles with the possibility of evaluating the high formant region are especially useful and valuable. But, nonetheless, simultaneous auditive assessment is crucial to avoid misinterpretation. Calculation of the quotient of the sound pressure level in the region between 2 and 5 kHz by the total sound pressure level allows to determine vocal sound characteristics and changes of the sound. Pre- and postoperative sound spectra obtained from the voices of patients with diseases of the vocal folds illustrate the improvement of the harmonic structure and the decrease of noise components. The measurement of the high formant intensity has proven to be appropriate for the registration of the voice quality before and after therapy in 130 cases. Although the value of these measurements is highly validated in the phoniatric practice, extensive studies and, especially, expert discussions are still needed. The authors come to terms with opinions that question the validity of the described methods.