Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study.

OBJECTIVE: To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS: One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION: Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:97-102, 2024.

Single-Port Robotic Removal of a Submucosal Foreign Body in the Distal Hypopharynx.

In this report, we present a 55-year-old female with cervical stenosis that underwent C5-C7 anterior cervical discectomy and fusion surgery complicated by hardware failure requiring removal. One screw remained after transcervical hardware removal due to operative difficulty with the risk of exposing the hypopharyngeal submucosal space. The retained screw caused the patient significant discomfort and dysphagia prompting a transoral attempt at removal. Using a hypopharynx blade on an oral retractor for access, the single-port surgical robot successfully removed the foreign body from the distal hypopharynx. In this case, a single-port surgical robot expanded access to the inferior hypopharynx. Laryngoscope, 134:588-591, 2024.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review.

OBJECTIVE: To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD). METHODS: Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report. RESULTS: A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03). CONCLUSION: KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2110-2115, 2023.

Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study.

OBJECTIVE: To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula. METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool [EAT-10]) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance. RESULTS: A total of 250 persons were included. The mean age (standard deviation [SD]) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03). CONCLUSION: ZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1349-1355, 2023.

Tracheotomy care simulation training program for inpatient providers.

Objectives: Tracheotomy complications can be life-threatening. Many of these complications may be avoided with proper education of health care providers. Unfortunately, access to high-quality tracheotomy care curricula is limited. We developed a program to address this gap in tracheotomy care education for inpatient providers. This study aimed to assess the efficacy of this training program in improving trainee knowledge and comfort with tracheotomy care. Methods: The curriculum includes asynchronous online modules coupled with a self-directed hands-on simulation activity using a low-cost tracheotomy care task trainer. The program was offered to inpatient providers including medical students, residents, medical assistants, nurses, and respiratory therapists. Efficacy of the training was assessed using pre-training and post-training surveys of learner comfort, knowledge, and qualitative feedback. Results: Data was collected on 41 participants. After completing the program, participants exhibited significantly improved comfort in performing tracheotomy care activities and 15% improvement in knowledge scores, with large effect sizes respectively and greater gains among those with little prior tracheotomy care experience. Conclusion: This study has demonstrated that completion of this integrated online and hands-on tracheotomy simulation curriculum training increases comfort and knowledge, especially for less-experienced learners. This training addresses an important gap in tracheotomy care education among health care professionals with low levels of tracheotomy care experience and ultimately aims to improve patient safety and quality of care. This curriculum is easily transferrable as it requires only access to the online modules and low-cost simulation materials and could be used in other hospitals, long-term care facilities, outpatient clinics, and home settings. Level of evidence: 4.

An Unusual Presentation of Immunoglobulin G4-Related Disease (IgG4-RD) Causing Subglottic Stenosis.

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition that is known to involve multiple organs and was first described as an entity in 2003. It is characterized by lesions with a dense lymphoplasmacytic infiltrate, IgG4-positive plasma cells, storiform fibrosis, and frequently elevated serum IgG4 levels. Organs that are commonly involved include the pancreas, biliary tree, salivary glands, periorbital tissues, kidneys, retroperitoneum, lungs, pleura, thyroid, aorta, and lymph nodes. Rarer manifestations of IgG4-RD include central nervous system (CNS) involvement, prostatitis, mastitis, midline destructive disease, and nasopharyngeal disease. In this report, we discuss an atypical case of a young woman with laryngeal subglottic involvement leading to stenosis and airway obstruction, which was ultimately successfully managed with systemic immunosuppression.

Glycogenic Acanthosis: An Unusual Cause of Vocal Fold Leukoplakia.

Glycogenic acanthosis is a common benign lesion of the esophagus; however, reports of extra-esophageal manifestations are exceedingly rare. This case represents the first report of laryngeal glycogenic acanthosis found in a living patient, presenting as vocal fold leukoplakia. Glycogenic acanthosis may be considered among the differential diagnoses of conditions presenting as vocal fold leukoplakia. Laryngoscope, 132:1641-1643, 2022.

Analysis of patient factors associated with 30-day mortality after tracheostomy.

OBJECTIVE: Mortality has been reported to be 22% to 45% in patients with a tracheostomy. To better counsel patients and families, we aimed to determine the effect of body mass index (BMI), socioeconomic status (SES), and the 17 conditions of the Charlson comorbidity index (CCI) on 30-day survival posttracheostomy. METHODS: This retrospective cohort study identified adult patients enrolled from our institution in the Global Tracheostomy Collaborative database from March 2014 to June 2015. Data collected included age, BMI, residential zip code, and comorbidities. Cox proportionate univariate and multivariate analyses were used to measure the impact of BMI, SES, and CCI variables with 30-day posttracheostomy survival. We used geocoding as a surrogate for patients' SES. We used Deyo's modification of the CCI, which utilized International Classification of Diseases, 9th Revision, codes to identify comorbidities. RESULTS: Of 326 tracheostomies identified, the 30-day mortality rate was 15.6%. No significant differences were noted in BMI or in any of the SES categories between survivors and nonsurvivors. CCI was significantly higher in the 30-day mortality group. Congestive heart failure (hazard ratio [HR] = 2.39), severe liver disease (HR = 3.15), and peripheral vascular disease (HR = 2.62) were found to significantly impact 30-day survival. CONCLUSION: Higher CCI and specifically severe liver disease, congestive heart failure, and peripheral vascular disease were associated with increased 30-day mortality posttracheostomy. No association was found between BMI or SES and 30-day survival. This study identified three comorbidities that independently affect mortality in tracheostomy patients, which should be discussed with patients and families before tracheostomy. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:847-851, 2019.

Mobile applications and patient education: Are currently available GERD mobile apps sufficient?

OBJECTIVES/HYPOTHESIS: Despite the increasing role of mobile applications (apps) in patient education, there has been little inquiry evaluating the quality of these resources. Because poor health literacy has been associated with inferior health outcomes, evaluating the quality of patient education materials takes on great importance. Our objective was to employ validated readability tools for the evaluation of gastroesophageal reflux (GERD) mobile apps. METHODS: GERD-specific apps found in the Apple App Store (Apple Inc., Cupertino CA) were evaluated using the Readability Studio Professional Version 2015 for Windows (Oleander Software, Ltd, Vandalia, OH). All text was evaluated using nine validated algorithms measuring readability including Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook grading, Gunning Fog index, Coleman-Liau, New Fog Count formula, Raygor Readability Estimate, FORCAST, Fry graph, and Flesch Reading Ease score. RESULTS: Average reading grade levels for individual GERD apps ranged from 9.6 to 12.9 (interquartile range 10.3-12). The average reading grade level for all apps analyzed was 11.1 ± 0.2 standard error of the mean (SEM), with an average Flesch Reading Ease score for all mobile apps analyzed of 51 ± 2.05 (SEM), falling into the "fairly difficult" category given by this measure. Raygor Readability estimates that most mobile apps have a reading grade level between 10 and 12, with the majority of this outcome due to long words. CONCLUSION: This analysis demonstrates the feasibility of assessing readability of mobile health apps. Our findings suggest significant gaps in potential comprehension between the apps analyzed and the average reader, diminishing the utility of these resources. We hope our findings influence future mobile health-related app development and thereby improve patient outcomes in GERD and other chronic diseases. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:1775-1779, 2017.

Evaluating the utility of serological testing in laryngotracheal stenosis.

OBJECTIVES/HYPOTHESIS: Whereas mechanical (traumatic) causes of laryngotracheal stenosis (LTS) are identified based on history, autoimmune laryngotracheal stenosis (aLTS) and idiopathic laryngotracheal stenosis (iLTS) are often more difficult to differentiate. The objective of this study was to evaluate serologic testing in a large cohort of nonmechanical LTS patients to determine which tests, if any, lead clinicians to the etiology of the LTS. STUDY DESIGN: Retrospective chart review. METHODS: This study reviewed nonmechanical LTS patients seen at a tertiary medical center from 2007 to 2014. Data were obtained on patient demographics, associated preexisting autoimmune conditions, comorbidities, intubation history, and serologic testing. RESULTS: Ninety-two records were reviewed. Twenty-three (25%) patients were found to have autoimmune disease; 69 (75%) met criteria for iLTS. A history of cigarette smoking was more significant in the aLTS group than the iLTS group (P < .001). Antineutrophil cytoplasmic antibody (ANCA) was positive only in patients with known granulomatosis with polyangiitis (GPA). All other serological testing was equivocal between the two cohorts. CONCLUSIONS: Differentiating iLTS from aLTS has proven difficult. The lack of information about the two entities has resulted in variability in the diagnostic workup to distinguish them. This study's finding of a more significant smoking history in the aLTS group correlates with the literature, which suggests an inflammatory effect of smoking cigarettes and an association with autoimmune disease. The only significant cohort of patients in this study found to have positive serological testing correlated with a diagnosable condition responsible for LTS was GPA patients with positive ANCA. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1408-1412, 2017.

Cost-effectiveness of routine computed tomography in the evaluation of idiopathic unilateral vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: To evaluate the cost-effectiveness of routine computed tomography (CT) in individuals with unilateral vocal fold paralysis (UVFP) STUDY DESIGN: Health Economics Decision Tree Analysis METHODS: A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of CT imaging in UVFP patients. Univariate sensitivity analysis was utilized to calculate what the probability of having an etiology of the paralysis discovered would have to be to make CT with contrast more cost-effective than no imaging. We used two studies examining findings in UVFP patients. The decision pathways were utilizing CT neck with intravenous contrast after diagnostic laryngoscopy versus laryngoscopy alone. The probability of detecting an etiology for UVFP and associated costs were extracted to construct the decision tree. The only incorrect diagnosis was missing a mass in the no-imaging decision branch, which rendered an effectiveness of 0. RESULTS: The ICER of using CT was $3,306, below most acceptable willingness-to-pay (WTP) thresholds. Additionally, univariate sensitivity analysis indicated that at the WTP threshold of $30,000, obtaining CT imaging was the most cost-effective choice when the probability of having a lesion was above 1.7%. Multivariate probabilistic sensitivity analysis with Monte Carlo simulations also showed that at the WTP of $30,000, CT scanning is more cost-effective, with 99.5% certainty. CONCLUSIONS: Particularly in the current healthcare environment characterized by increasing consciousness of utilization defensive medicine, economic evaluations represent evidence-based findings that can be employed to facilitate appropriate decision making and enhance physician-patient communication. This economic evaluation strongly supports obtaining CT imaging in patients with newly diagnosed UVFP. LEVEL OF EVIDENCE: 2c. Laryngoscope, 2016 127:440-444, 2017.

A Novel Approach to the Challenging Injection Laryngoplasty.

INTRODUCTION: Injection laryngoplasty (IL) is typically performed either awake or under general anesthesia with paralysis. There is a subgroup of patients, however, for whom neither of these is a good option. For such patients, we report a hybrid technique that allows for a percutaneous injection without paralysis but with sedation to increase patient tolerance. Supraglottic airway laryngotracheal intervention (SALTI) brings the benefits of injection laryngoplasty to a group of patients previously underserved. METHODS: Injection laryngoplasty cases using SALTI technique from July 1, 2013, to October 21, 2014, were reviewed. Data were collected regarding the indication, success of injection, comorbidities, and outcomes. RESULTS: Seventeen subjects were reviewed. All were successfully injected without complications. Follow-up data were available for 15 subjects. The majority of patients experienced improved symptoms of dysphonia and/or dysphagia after the procedure. DISCUSSION AND CONCLUSIONS: This study demonstrates the feasibility of the SALTI technique for IL. The technique may also be useful for other procedures. Advantages include maintenance of spontaneous ventilation without paralysis, no neck extension, improved patient tolerance, and accommodation of difficult anatomy. Disadvantages are increased time and cost related to the operating room and the need for an assistant. Overall, SALTI permits IL in previously ineligible patients.

Laryngoscopic and spectral analysis of laryngeal and pharyngeal configuration in non-classical singing styles.

PURPOSE: The present study aimed to assess three different singing styles (pop, rock, and jazz) with laryngoscopic, acoustic, and perceptual analysis in healthy singers at different loudness levels. Special emphasis was given to the degree of anterior-posterior (A-P) laryngeal compression, medial laryngeal compression, vertical laryngeal position (VLP), and pharyngeal compression. STUDY DESIGN: Prospective study. METHODS: Twelve female trained singers with at least 5 years of voice training and absence of any voice pathology were included. Flexible and rigid laryngeal endoscopic examinations were performed. Voice recording was also carried out. Four blinded judges were asked to assess laryngoscopic and auditory perceptual variables using a visual analog scale. RESULTS: All laryngoscopic parameters showed significant differences for all singing styles. Rock showed the greatest degree for all of them. Overall A-P laryngeal compression scores demonstrated significantly higher values than overall medial compression and VLP. High loudness level produced the highest degree of A-P compression, medial compression, pharyngeal compression, and the lowest VLP for all singing styles. Additionally, rock demonstrated the highest values for alpha ratio (less steep spectral slope), L1-L0 ratio (more glottal adduction), and Leq (more vocal intensity). Statistically significant differences between the three loudness levels were also found for these acoustic parameters. CONCLUSIONS: Rock singing seems to be the style with the highest degree of both laryngeal and pharyngeal activity in healthy singers. Although, supraglottic activity during singing could be labeled as hyperfunctional vocal behavior, it may not necessarily be harmful, but a strategy to avoid vocal fold damage.

Demonstration of the role of an implantable bioscaffold in airway reconstruction: a pilot study utilizing an animal model.

INTRODUCTION: Laryngotracheal reconstruction is a common procedure to repair subglottic stenosis. Despite a success rate upwards of 85%, this procedure has significant morbidity associated with it, specifically with the site of the graft harvest and recurrence of stenosis. We propose that a recently described cellular bioscaffold xenograft may be useful in reducing these complications. METHODS AND MATERIALS: 10 Sprague Dawley rats were divided into 2 groups of 5. One group underwent incision through the cricoid and the first two tracheal rings followed by primary closure (G1); the second group underwent incision through the cricoid and the first two tracheal rings followed by placement of the xenograft (G2); additionally, a specimen was harvested from an animal which did not undergo any surgical procedure to compare to the two surgical groups. Specimen harvest occurred on post-operative days 1, 7, 14, 21, and 28. RESULTS: 6 of 10 animals provided usable data. All animals receiving the xenograft survived until the time of specimen harvest. Only 1 animal undergoing primary closure survived beyond post-operative day one. On histology review, the xenograft animals showed a progressive decrease in fibrosis relative to the animals that underwent primary closure. On POD 28, restoration of the respiratory epithelium and intact basement membrane was noted in the xenograft group. CONCLUSION: We believe that this pilot study shows the potential of utilizing bio-implantable biomaterials, specifically a cellular bioscaffold which encourages the ingrowth of native tissue instead of fibrosis. Histologic analysis shows that use of the xenograft can initiate the proliferation of native tissues decreasing the amount of fibrosis present post-operatively, although significant further analysis is needed before definitively concluding that this approach is superior to utilization of a graft.

Analysis of supraglottic activity during vocalization in healthy singers.

OBJECTIVES/HYPOTHESIS: The present study aims to evaluate the degree of anterior-posterior and medial supraglottic laryngeal compression in healthy singers of different voice classifications while singing different pitches, loudness, and phonatory tasks. STUDY DESIGN: Prospective study. METHODS: Thirty-six classically trained singers (11 sopranos, 11 mezzo-sopranos, six tenors, and eight baritones) with at least 5 years of voice training and absence of any voice pathology within the past year were included. Flexible endoscopic voice evaluations were recorded and edited to include samples of different pitches, levels of loudness, and phonatory tasks. Sound was removed from the video samples. Two blinded laryngologists were asked to assess medial and anterior-posterior supraglottic compression using a visual analog scale for each sample. RESULTS: Medial compression was significantly greater in male subjects and specifically tenors during loud phonation, during high pitch, and while phonating the vowel /a/. Anterior-posterior compression was also significantly greater in males and specifically baritones during loud voice production and with phonation of the vowel /a/. No difference was noted in relation to pitch. Correlation between anterior-posterior and medial compression was demonstrated. Medial compression was less severe than anterior-posterior compression. CONCLUSIONS: Supraglottic hyperfunction is present in healthy singers. Recognizing factors that might affect supraglottic hyperfunction in the healthy voice may help us to understand when hyperfunction is truly contributing to a patient's vocal pathology. LEVEL OF EVIDENCE: 4.

Effect on long-term average spectrum of pop singers' vocal warm-up with vocal function exercises.

Abstract This case-control study aimed to investigate if there is any change on the spectral slope declination immediately after vocal function exercises (VFE) vs traditional vocal warm-up exercises in normal singers. Thirty-eight pop singers with perceptually normal voices were divided into two groups: an experimental group (n = 20) and a control group (n = 18). One single session with VFE for the experimental group and traditional singing warm-up exercises for the control group was applied. Voice was recorded before and after the exercises. The recorded tasks were to read a phonetically balanced text and to sing a song. Long-term average spectrum (LTAS) analysis included alpha ratio, L1-L0 ratio, and singing power ratio (SPR). Acoustic parameters of voice samples pre- and post-training were compared. Comparison between VFE and control group was also performed. Significant changes after treatment included the alpha ratio and singing power ratio in speaking voice, and SPR in the singing voice for VFE group. The traditional vocal warm-up of the control group also showed pre-post changes. Significant differences between VFE group and control group for alpha ratio and SPR were found in speaking voice samples. This study demonstrates that VFE have an immediate effect on the spectrum of the voice, specifically a decrease on the spectral slope declination. The results of this study provide support for the advantageous effect of VFE as vocal warm-up on voice quality.

Influence on spectral energy distribution of emotional expression.

PURPOSE: The aim of this study was to determine the influence of emotional expression in spectral energy distribution in professional theater actors. STUDY DESIGN: The study design is a quasi-experimental study. METHOD: Thirty-seven actors, native Spanish speakers, were included. All subjects had at least 3 years of professional experience as a theater actor and no history of vocal pathology for the last 5 years. Participants were recorded during a read-aloud task of a 230-word passage, expressing six different emotions (happiness, sadness, fear, anger, tenderness, and eroticism) and without emotion (neutral state). Acoustical analysis with long-term average spectrum included three variables: the energy level difference between the F(1) and fundamental frequency (F(0)) regions, ratio between 1-5kHz and 5-8kHz, and alpha ratio. RESULTS: All the different emotions differ significantly from the neutral state for alpha ratio and 1-5/5-8kHz ratio. Only significant differences between "joy," "anger," and "eroticism" were found for L1-L0 ratio. Statistically significant differences between genders for the three acoustical variables were also found. CONCLUSION: The expression of emotion impacts the spectral energy distribution. On the one hand emotional states characterized by a breathy voice quality such as tenderness, sadness, and eroticism present a low harmonic energy above 1kHz, high glottal noise energy, and more energy on F(0) than overtones. On the other hand, emotional states such as joy, anger, and fear are characterized by high harmonic energy greater than 1kHz (less steep spectral slope declination), low glottal noise energy, and more energy on the F(1) than F(0) region.

Influence of emotional expression, loudness, and gender on the acoustic parameters of vibrato in classical singers.

OBJECTIVES: Vibrato is considered one of the most essential characteristics of the classical singing voice. Vibrato can be acoustically described by the rate, extent, onset, and regularity. The aim of this study was to determine the influence of emotional expression on acoustic parameters of vibrato in classically trained singers. STUDY DESIGN: A prospective cohort study was performed. METHODS: Thirty healthy classical singers were recruited for this study, 29 singers met inclusion criteria. Inclusion criteria for this study were as follow: 1) no history of vocal pathology in the past year, 2) to have at least 5 years of classical singing training. Each subject was asked to sing the phrase "I Love You," while expressing four different emotions (tenderness, anger, happiness, and sadness) and without emotion (neutral state). The musical tonality of the phrase was adapted to each singer's vocal classification. Subjects were also recorded at three levels of loudness (pianissimo, mezzo forte, and fortissimo), while expressing each emotion. Acoustical analysis was performed during the vowel /o/ of the word "Love" to determine rate of vibrato, the extent of vibrato, and vibrato jitter. RESULTS: Vibrato parameters did not vary significantly when different emotions were expressed. However, vibrato jitter and extent did vary significantly between different levels of loudness. Significant differences were also noted in both rate and extent of vibrato when compared between sexes. CONCLUSIONS: Expression of emotions does not affect the acoustic parameters of vibrato, although some parameters are affected by loudness and gender.