Interventions That Target or Affect Voice or Speech Production During Public Speaking: A Scoping Review.

OBJECTIVES: Public speaking (PS) is frequently necessary in many professional, educational, and personal settings. Mastering this communication skill is particularly important in today's society. Training techniques for PS have been described in the literature. Given that PS anxiety affects performance, especially voice characteristics and speech fluency, the purpose of this scoping review is to examine, map, and narratively summarize the available evidence on PS interventions that target or affect voice or speech. METHODS: An extensive literature search was conducted in three bibliographic databases: Medline ALL/Ovid, PsycINFO/Ovid, and Eric/Ovid. Of the 850 studies identified, 22 met the eligibility criteria, and one was added from the reference lists of the included studies. RESULTS: A total of 23 studies were included. The interventions identified aim to improve speaking skills either by explicitly targeting the voice or speech (direct intervention, n = 15) or by targeting the cognitive, behavioral, psychological, or physical environment impacting the speaker's production (indirect intervention, n = 8). CONCLUSIONS: This scoping review provides the first published methodological summary of the characteristics of existing PS interventions that target or affect voice and speech. Heterogeneous characteristics were observed. Further studies are needed to determine which interventions are most effective.

Effects of Noise and a Speaker's Impaired Voice Quality on Spoken Language Processing in School-Aged Children: A Systematic Review and Meta-Analysis.

PURPOSE: Background noise and voice problems among teachers can degrade listening conditions in classrooms. The aim of this literature review is to understand how these acoustic degradations affect spoken language processing in 6- to 18-year-old children. METHOD: In a narrative report and meta-analysis, we systematically review studies that examined the effects of noise and/or impaired voice on children's response accuracy and response time (RT) in listening tasks. We propose the Speech Processing under Acoustic DEgradations (SPADE) framework to classify relevant findings according to three processing dimensions-speech perception, listening comprehension, and auditory working memory-and highlight potential moderators. RESULTS: Thirty-one studies are included in this systematic review. Our meta-analysis shows that noise can impede children's accuracy in listening tasks across all processing dimensions (Cohen's d between -0.67 and -2.65, depending on signal-to-noise ratio) and that impaired voice lowers children's accuracy in listening comprehension tasks (d = -0.35). A handful of studies assessed RT, but results are inconclusive. The impact of noise and impaired voice can be moderated by listener, task, environmental, and exposure factors. The interaction between noise and impaired voice remains underinvestigated. CONCLUSIONS: Overall, this review suggests that children have more trouble perceiving speech, processing verbal messages, and recalling verbal information when listening to speech in noise or to a speaker with dysphonia. Impoverished speech input could impede pupils' motivation and academic performance at school. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.17139377.

Can ambulatory biofeedback help a transgender woman speak at a higher pitch?

Purpose: Voice feminization for transgender women remains a challenge. The fundamental frequency of the voice (fo) is one of the main parameters contributing to the perception of gender. One of the aims of voice therapy is to help transgender women acquire a new vocal motor behavior to increase their fo. We hypothesized that ambulatory biofeedback could help extend the new vocal behavior to daily life.Materials and methods: This prospective case study assessed the impact of two weeks of ambulatory vibrotactile biofeedback (VTBF) applied to one transgender woman, following two weeks of voice therapy (three 60-minute sessions). The VTBF was activated when the participant's voice was lower than 150 Hz for more than 500 ms and was accompanied by two 60-minute counseling sessions.Results: The results showed that mean fo monitored in daily activities tended to increase following the two weeks of voice therapy (Δ = 8 Hz or 1 semitone) and then increased significantly immediately after the two weeks of VTBF (Δ = 13 Hz or 1.5 semitones). The increase in mean fo from day to day and the decrease in the activation percentage from the first to the second week of VTBF (Δ = 6%) indicated a gradual integration of the motor behavior, making it possible to achieve the targeted female frequency.Conclusions: The results suggest that ambulatory VTBF helped the participant to generalize the techniques acquired during the voice therapy sessions to real-life communication situations. These results are promising for therapeutic programs that integrate tools that can be used outside the clinical context. Design: Prospective case study.

Which teachers are most at risk for voice disorders? Individual factors predicting vocal acoustic parameters monitored in situ during a workweek.

PURPOSE: To identify the factors affecting teachers' vocal acoustic parameters, with the aim of detecting individuals at risk of phonotrauma. METHOD: The voicing time, voice sound pressure level [SPL] and fundamental frequency [fo] of 87 teachers were measured during one workweek using a voice dosimeter. We retrospectively investigated the impact of 10 factors (gender, age, teaching experience, teaching level, tobacco, gastro-esophageal problems, nonoccupational voice activity, voice education, past voice problems, and biopsychosocial impact of voice problems measured using the Voice Handicap Index [VHI]) on each voice parameter. RESULTS: None of the above factors affected voicing time or SPL. fo depended significantly on gender, teaching level, nonoccupational voice activity and VHI score. Specifically, fo was higher in women (Δ = 69 Hz), in individuals without nonoccupational voice activities (Δ = 11 Hz), and in individuals with a lower VHI score (increase of 0.7 Hz for each additional point). For females, post hoc comparisons revealed a substantial impact of teaching level on fo: university instructors had deeper voices than kindergarten (Δ = 66 Hz), elementary (Δ = 52 Hz), or secondary teachers (Δ = 41 Hz). CONCLUSIONS: Since higher fo increases the mechanical stress related to vocal fold vibration, the screening and prevention of phonotrauma should focus primarily on women, particularly those who teach at lower levels, and teachers with more self-rated voice problems. The lower fo of teachers who engage in nonprofessional voice activities may suggest acute inflammation or muscle fatigue due to voice overload.

Listening to a Dysphonic Speaker in Noise May Impede Children's Spoken Language Processing in a Realistic Classroom Setting.

Purpose The aim of this study was to investigate children's processing of dysphonic speech in a realistic classroom setting, under the influence of added classroom noise. Method Typically developing 6-year-old primary school children performed two listening tasks in their regular classrooms: a phoneme discrimination task to assess speech perception and a sentence-picture matching task to assess listening comprehension. Speech stimuli were played back in either a typical or an impaired voice quality. Children performed the tasks in the presence of induced classroom noise at signal-to-noise ratios between +2 and +9 dB. Results Children's performance in the phoneme discrimination task decreased significantly when the speaker's voice was impaired. The effect of voice quality on sentence-picture matching depended on task demands: Easy sentences were processed more accurately in the impaired-voice condition than in the typical-voice condition. Signal-to-noise ratio effects are discussed in light of methodological constraints. Conclusions Listening to a dysphonic teacher in a noisy classroom may impede children's perception of speech, particularly when phonological discrimination is needed to disambiguate the speech input. Future research regarding the interaction of voice quality and task demands is necessary.

Noise and a Speaker's Impaired Voice Quality Disrupt Spoken Language Processing in School-Aged Children: Evidence From Performance and Response Time Measures.

Purpose Our aim was to investigate isolated and combined effects of speech-shaped noise (SSN) and a speaker's impaired voice quality on spoken language processing in first-grade children. Method In individual examinations, 53 typically developing children aged 5-6 years performed a speech perception task (phoneme discrimination) and a listening comprehension task (sentence-picture matching). Speech stimuli were randomly presented in a 2 × 2 factorial design with the factors noise (no added noise vs. SSN at 0- dB SNR) and voice quality (normal voice vs. impaired voice). Outcome measures were task performance and response time (RT). Results SSN and impaired voice quality significantly lowered children's performance and increased RTs in the speech perception task, particularly when combined. Regarding listening comprehension, a significant interaction between noise and voice quality indicated that children's performance was hindered by SSN when the speaker's voice was impaired but not when it was normal. RTs in this task were unaffected by noise or voice quality. Conclusions Results suggest that speech signal degradations caused by a speaker's impaired voice and background noise generate more processing errors and increased listening effort in young school-aged children. This finding is vital for classroom listening and highlights the importance of ensuring teachers' vocal health and adequate room acoustics.

Imitating dysphonic voice: a suitable technique to create speech stimuli for spoken language processing tasks?

PURPOSE: The aim of this study was to assess the suitability of imitated dysphonic voice samples for their application in listening tasks investigating the impact of speakers' voice quality on spoken language processing. METHODS: A female voice expert recorded speech samples (sustained vowels and connected speech) in her normal voice and while imitating a dysphonic voice. Voice characteristics, authenticity, and consistency of the two voice qualities were evaluated by means of acoustic measurements (Acoustic Voice Quality Index [AVQI], jitter, shimmer, harmonics-to-noise ratio [HNR]) and perceptual evaluation (GRBAS scale, consistency, and authenticity rated by five speech-language pathologists). RESULTS: Based on acoustic and perceptual assessments, the degree of voice impairment for the imitated dysphonic voice was found to be moderate to severe. Roughness and asthenia were the predominant perceptual features. The perceptual rating indicated a high consistency and acceptable authenticity of the imitated dysphonic voice. CONCLUSIONS: Results suggest that an imitation of dysphonic voice quality may resemble the voice characteristics typically found in dysphonic patients. IMPLICATIONS: The voice samples validated here shall be applied in future listening tasks and may promote our understanding of how dysphonic speech is processed.

Vocal characteristics of 5-year-old children: proposed normative values based on a French-speaking population†.

Purpose: Previous research proposed normative data on gender- and age-specific voice acoustics for adults. Such reference values are lacking for children, particularly under the age of 6. This study was intended (1) to collect reliable normative data for the acoustic parameters of 5-year-old children's voices, and (2) to investigate potential gender-specific differences.Study: Prospective and cross-sectional.Methods: Acoustic analyses were done on the voices of 53 normophonic children (26 girls; 27 boys) aged 5;0-5;11 years, using Praat software. The fundamental frequency, local jitter, local shimmer, and noise-to-harmonics ratio (NHR) were measured on the sustained vowels [a], [i], and [u]. The highest frequency, lowest frequency, and frequency range were measured using ascending and descending glissandi on the vowel [a].Results: For the three sustained vowels, the mean fundamental frequency ranged from 255 Hz to 277 Hz, mean jitter ranged from 0.394% to 0.591%, mean shimmer ranged from 2.571% to 5.824%, and mean NHR ranged from 0.009 to 0.034. The frequency range was from 190 Hz to 750 Hz, which corresponds to 23.7 semitones. No gender difference was found, except for NHR on the vowel [a].Conclusions: The lack of gender differences - other than for NHR on the vowel [a] - led us to propose mixed norms for 5-year-old boys and girls combined.Implications: These normative data will allow clinicians to compare children's voice assessments to specific references in order to enhance diagnostic accuracy and measure therapy outcomes.

Vocal Change Patterns During a Teaching Day: Inter- and Intra-subject Variability.

OBJECTIVES: To describe the mean voice changes of 22 female teachers during a typical workday, examine the inter- and intra-subject variability, and establish a typology of different voice patterns during the workday. METHODS: For each participant, fundamental frequency (F0), harmonics-to-noise ratio (HNR), jitter, and shimmer were measured on sustained vowels at the beginning and at the end of the workday, at three different times during the school year. RESULTS: The group mean pattern showed significant increases in F0 and HNR during the workday and significant decreases in jitter and shimmer. However, considerable inter- and intra-subject variability was observed. Based on the variation in the acoustic parameters during the workday, three different voice patterns were identified. The first is characterized by a greater F0 increase during the day, interpreted as a common, appropriate adaptation to vocal load. The second is characterized by a greater increase in HNR during the day and greater decreases in jitter and shimmer, interpreted as hyperfunctional voice production. The third is characterized by greater decreases in F0 and HNR and greater increases in jitter and shimmer, suggesting acute inflammation or muscle fatigue following the workday. CONCLUSIONS: The observed variety of vocal patterns during the workday emphasizes the need to study this phenomenon individually and target different types of behaviors to develop tailored prevention and treatment methods.

Voice Use Among Music Theory Teachers: A Voice Dosimetry and Self-Assessment Study.

OBJECTIVES: This study aimed (1) to investigate music theory teachers' professional and extra-professional vocal loading and background noise exposure, (2) to determine the correlation between vocal loading and background noise, and (3) to determine the correlation between vocal loading and self-evaluation data. METHODS: Using voice dosimetry, 13 music theory teachers were monitored for one workweek. The parameters analyzed were voice sound pressure level (SPL), fundamental frequency (F0), phonation time, vocal loading index (VLI), and noise SPL. Spearman correlation was used to correlate vocal loading parameters (voice SPL, F0, and phonation time) and noise SPL. Each day, the subjects self-assessed their voice using visual analog scales. VLI and self-evaluation data were correlated using Spearman correlation. RESULTS: Vocal loading parameters and noise SPL were significantly higher in the professional than in the extra-professional environment. Voice SPL, phonation time, and female subjects' F0 correlated positively with noise SPL. VLI correlated with self-assessed voice quality, vocal fatigue, and amount of singing and speaking voice produced. CONCLUSIONS: Teaching music theory is a profession with high vocal demands. More background noise is associated with increased vocal loading and may indirectly increase the risk for voice disorders. Correlations between VLI and self-assessments suggest that these teachers are well aware of their vocal demands and feel their effect on voice quality and vocal fatigue. Visual analog scales seem to represent a useful tool for subjective vocal loading assessment and associated symptoms in these professional voice users.

Brain plasticity after implanted peroneal nerve electrical stimulation to improve gait in chronic stroke patients: Two case reports.

BACKGROUND: Recent studies have shown that stimulation of the peroneal nerve using an implantable 4-channel peroneal nerve stimulator could improve gait in stroke patients. OBJECTIVES: To assess structural cortical and regional cerebral metabolism changes associated with an implanted peroneal nerve electrical stimulator to correct foot drop related to a central nervous system lesion. METHODS: Two stroke patients presenting a foot drop related to a central nervous system lesion were implanted with an implanted peroneal nerve electrical stimulator. Both patients underwent clinical evaluations before implantation and one year after the activation of the stimulator. Structural magnetic resonance imaging (MRI) and [18F]-fluorodeoxyglucose-positron emission tomography (FDG-PET) were acquired before and one year after the activation of the stimulator. RESULTS: Foot drop was corrected for both patients after the implantation of the stimulator. After one year of treatment, patient 1 improved in three major clinical tests, while patient 2 only improved in one test. Prior to treatment, FDG-PET showed a significant hypometabolism in premotor, primary and supplementary motor areas in both patients as compared to controls, with patient 2 presenting more widespread hypometabolism. One year after the activation of the stimulator, both patients showed significantly less hypometabolism in the damaged motor cortex. No difference was observed on the structural MRI. CONCLUSION: Clinical improvement of gait under peroneal nerve electrical stimulation in chronic stroke patients presenting foot drop was paralleled to metabolic changes in the damaged motor cortex.

Description of patients consulting the voice clinic regarding gender, age, occupational status, and diagnosis.

The purpose of this paper was to describe the gender, age, occupational status, and diagnosis of dysphonic patients. We retrospectively analyzed the medical records of 1079 patients examined at the Voice clinic of the University hospital of Liège in French-speaking Belgium. Overall, seven out of ten patients who attended the voice clinic for dysphonia were females. The patients' ages ranged from 4 to 93 (mean = 43.5). Females predominantly consulted at the age of 54 and males at the age of 9. Regarding the occupational status, workers represented more than half of our patients (53 %), while 11.2 % were unemployed, 15.4 % were students, and 19.9 % were retired. Regarding the diagnoses of the 1079 patients, nodules were the most common pathologies (n = 182, 16.9 % of the patients), prevailing in females (n = 142, 18.8 % of the females), and encountered in 16.8 % of the workers and 42.8 % of the students consulting the voice clinic. Following nodules, laryngeal mobility disorders were diagnosed in 16.4 % of the patients (n = 177), mainly females (n = 115), and was the most frequent diagnosis in retirees (n = 75, 34.9 %). The majority of the patients consulting the voice clinic for dysphonia were adult females, in their workforce, diagnosed with vocal nodules. The identification of the patients' characteristics and diagnoses is important to develop treatments and prevention of dysphonia, estimate their costs, and allow comparisons across referral centers.

Influence of a rhythmic auditory stimulation on asymptomatic gait.

The direct effects of a rhythmic auditory stimulation (RAS) on the gait of asymptomatic subjects are not clear. Previous studies only showed modifications in the gastrocnemius activity, inconsistent effects on temporal parameters, and no modification of spatial parameters. Furthermore, the influence of RAS on kinematics and kinetics has only been reported in pathological gait. The objective of this study was to perform a full comparison of gait characteristics in asymptomatic subjects at preferred and reduced walking speed between without and with RAS conditions. Spatiotemporal parameters, kinematics, kinetics and EMG signals datasets were collected for each condition. RAS conditions were obtained by asking subjects to walk on metronomic beats. 17 asymptomatic subjects were included in the study (12M/5W, 37.4±15.7years, 74.0±14.8kg, 1.77±0.09m). Comparisons between without and with RAS conditions were then performed using the Statistical Parametric Mapping method. For all combined subjects, the effect of RAS was limited whatever the walking speed. Meanwhile, global effects were observed for kinematics, kinetics and EMG at both spontaneous and reduced walking speed, which can only be explained by covariances (i.e., no effect on individual time-series). The use of RAS to impose a specific cadence matching the desired walking speed (e.g., to collect normative data) appears thus possible, as none parameters were modified individually. However, RAS should be used with caution taking into account covariances (i.e., muscle synergy or joint coordination patterns). This study has to be extended to a larger number of subjects to confirm these observations.

Proposition of a Classification of Adult Patients with Hemiparesis in Chronic Phase.

BACKGROUND: Patients who have developed hemiparesis as a result of a central nervous system lesion, often experience reduced walking capacity and worse gait quality. Although clinically, similar gait patterns have been observed, presently, no clinically driven classification has been validated to group these patients' gait abnormalities at the level of the hip, knee and ankle joints. This study has thus intended to put forward a new gait classification for adult patients with hemiparesis in chronic phase, and to validate its discriminatory capacity. METHODS AND FINDINGS: Twenty-six patients with hemiparesis were included in this observational study. Following a clinical examination, a clinical gait analysis, complemented by a video analysis, was performed whereby participants were requested to walk spontaneously on a 10m walkway. A patient's classification was established from clinical examination data and video analysis. This classification was made up of three groups, including two sub-groups, defined with key abnormalities observed whilst walking. Statistical analysis was achieved on the basis of 25 parameters resulting from the clinical gait analysis in order to assess the discriminatory characteristic of the classification as displayed by the walking speed and kinematic parameters. Results revealed that the parameters related to the discriminant criteria of the proposed classification were all significantly different between groups and subgroups. More generally, nearly two thirds of the 25 parameters showed significant differences (p<0.05) between the groups and sub-groups. However, prior to being fully validated, this classification must still be tested on a larger number of patients, and the repeatability of inter-operator measures must be assessed. CONCLUSIONS: This classification enables patients to be grouped on the basis of key abnormalities observed whilst walking and has the advantage of being able to be used in clinical routines without necessitating complex apparatus. In the midterm, this classification may allow a decision-tree of therapies to be developed on the basis of the group in which the patient has been categorised.

Impact of vocal load on breathiness: perceptual evaluation.

OBJECTIVES: To evaluate the impact on voice of 2 hours of continuous oral reading. METHODS: Fifty normophonic women underwent two sessions of voice loading in which the required intensity level varied: 60-65 dB(A) for the first session, and 70-75 dB(A) for the second session. Ten expert judges evaluated the breathiness of one sentence recorded before and after each loading session. Pairs of stimuli were presented randomly to the judges, who were asked to designate the breathiest sample. RESULTS: A significant decrease in breathiness was observed following both sessions, suggesting an improvement of voice subsequent to loading. When comparing the two intensity levels, no difference was found for breathiness after vocal loading.

Comparison of vocal loading parameters in kindergarten and elementary school teachers.

PURPOSE Although a global picture exists of teachers' voice demands in general, few studies have compared specific groups of teachers to determine whether some are more at risk than others. This study compared the vocal loadings of kindergarten and elementary school teachers; professional and nonprofessional vocal load were determined for both groups. METHOD Twelve kindergarten and 20 elementary school female teachers without voice problems were monitored during 1 workweek using the Ambulatory Phonation Monitor. Vocal loading parameters analyzed were F0, SPL, time dose, distance dose, and cycle dose. RESULTS Comparisons between the groups showed significantly higher cycle dose and distance dose for kindergarten teachers than for elementary school teachers, in both professional and nonprofessional environments. Professional and nonprofessional voice use comparisons showed significant differences for all parameters, indicating that vocal load was higher in the professional environment for both groups. CONCLUSIONS The higher vocal doses measured in kindergarten teachers suggest that particular attention should be paid to this specific group of teachers. Although nonprofessional vocal load is lower than professional vocal load, it is important to take both into account because of their cumulative effects.

Vocal impact of a prolonged reading task in dysphonic versus normophonic female teachers.

OBJECTIVES: This study evaluates the effect of a 2-hour reading task between 70 and 75 dB(A) in 16 normophonic and 16 dysphonic female teachers with vocal nodules. METHODS: Objective measurements (acoustic analysis, voice range measurements, and aerodynamic measurements) and subjective self-ratings were collected before and every 30 minutes during the reading to determine the voice evolution in both groups. RESULTS: Fundamental frequency, lowest frequency, highest frequency (F-High), highest intensity, and intensity range increase through the reading, whereas shimmer decreases. Maximum phonation time decreases after 30 minutes. Estimated subglottal pressure (ESP) and sound pressure level increase during the first hour. Afterward, ESP decreases. Self-ratings worsen through time. When comparing the normophonic and the dysphonic teachers, self-ratings reveal more complaints in the dysphonic group. Few differences in objective measurements are found between both groups: normophonic teachers show lower ESP, higher F-High, and greater frequency range. CONCLUSIONS: Frequency modifications from acoustic analysis and voice range measurements suggest an increased laryngeal tension during vocal load, while subjects perceive a worsening of voice. Aerodynamic parameters depict first a deterioration of voice efficiency and then an adaptation to the prolonged reading. The comparison between both groups shows a discrepancy between objective measurements and self-ratings, suggesting that both approaches are necessary to have a complete view of vocal load effects. Surprisingly, both groups behave similarly through vocal load, without more or quicker deterioration of voice in the dysphonic group.

Vocal impact of a prolonged reading task at two intensity levels: objective measurements and subjective self-ratings.

OBJECTIVES: The objectives of this study are to evaluate the impact on voice of both duration and intensity level of 2 hours of continuous oral reading. Voice modifications accompanying changes in intensity level during prolonged reading tasks are analyzed. METHODS: Fifty normophonic women undergo two sessions of voice loading in which the required intensity level of voice varied between 60-65 dB(A) for the first session and 70-75 dB(A) for the second session. The effects of loading on objective data (average fundamental frequency [F0], jitter%, shimmer%, noise-to-harmonic ratio, maximum phonation time, lowest frequency [F-Low], highest frequency [F-High], frequency range [Range], lowest intensity [I-Low] level, and highest intensity level) and self-ratings (voice quality, phonation effort, vocal fatigue, and laryngeal discomfort) are assessed every 30 minutes during the loading tasks. RESULTS: Results indicate that average F0, F-Low, I-Low, maximum phonation time, feeling of phonation effort, vocal fatigue, and laryngeal discomfort increase during prolonged reading, whereas shimmer% and self-rating of voice quality decrease. Average F0, F-High, and Range are the only parameters influenced by the required intensity of vocal load; they are significantly higher in the 70- to 75-dB session compared with the 60- to 65-dB session. Concerning the subjective self-ratings, similar results for the four ratings used suggest that only one would suffice in future studies. CONCLUSIONS: These results confirm the importance of both duration and intensity level as loading factors, even if intensity level affects fewer variables than duration.

Implantation of esterified hyaluronic acid in microdissected Reinke's space after vocal fold microsurgery: short- and long-term results.

In this study are reported the laryngeal and vocal results obtained after a microflap excision of benign vocal fold (VF) lesions and immediate implantation of esterified hyaluronic acid (EHA) in the surgical wound. In a previous pilot study on 11 cases, we have shown an excellent tolerance of this bioimplant. The objectives are to confirm the innocuity of the technique, to demonstrate the laryngeal and vocal evolution at short and long term, and to evaluate the eventual positive impact of EHA implantation on the pliability of the superficial layer of the lamina propria (SLLP) and on voice. This is a prospective and comparative study on 83 patients suffering from various benign VF lesions. Thirty-three patients were implanted with EHA, whereas 50 patients did not undergo implantation at the end of the microsurgical procedure. All patients undergo rigid laryngoscopy and microflap excision procedure under general anesthesia. After freeing up of the Reinke's space and creation of a mucosal microflap, a few fibers of EHA are inserted in the surgical wound, before closure of the incision with fibrin glue. Serial laryngeal and vocal assessments are performed in all patients using videostroboscopy (Wolff and Xion), perceptual and objective voice evaluation (MDVP software, Kay Elemetrics), and phonatory function measurements (Aerophone II). Pre- and early postoperative means are compared by analysis of variance. Delayed and long-term evolution of laryngeal and vocal data are compared by means of nonparametric statistical methods. The longest follow-up in the implanted group is 4 years. Early postoperative results are similar in both groups: a significant improvement of a majority of laryngeal and vocal data is observed after microsurgery. In the long term, the two groups exhibit a different behavior: further improvement of voice, as an ongoing process, is only observed in the EHA implanted group, together with improvement of some videostroboscopic characteristics. The nonimplanted group remains stable, with no further improvement of the voice quality obtained after microsurgery. Excellent short- and long-term tolerance of EHA implantation is confirmed by this larger series. The use of EHA implant in microdissected SLLP is safe and leads to good laryngeal and vocal outcomes in the treated patients. More interestingly, treated cases exhibit a continuous improvement over a long period of time.