Prediction of behavioral MCL using electrophysiological responses in children using MED-EL implant.

The present study aimed to correlate the various electrophysiological tests of ECAP, EABR and ESRT with programming parameters. If there is a correlation between them, fitting formulae to be derived to predict programming parameters. Further this fitting formula was validated on a clinical population. 22 children between age range of 5-12 years using MED-EL implant participated study. Electrophysiological tests of Electrically evoked compound Action Potential (ECAP), Electrical Evoked Stapedial Reflex Threshold (ESRT) and Electrically Evoked Auditory Brain Stem Responses (EABR) were measured on electrodes no 1,4, 8, and 11. Based on Pearson correlation analysis, there was a moderate correlation observed between each of electrophysiological tests with MCL level. Fitting formulae of ECAP with either ESRT or EABR were found to be accurately predict the MCL level. These fitting formulae were clinically validated on 6 children using Sonata implant with OPUS 2 processor. Two new programs with MCL were predicted using combination of ECAP with EABR and ECAP with ESRT as parameters in the fitting formulae. These programs were given to the participants to use for two weeks. Predicted MCLs were found to slightly higher (about 2qu to 5qu) than original MCL level. Reliability analysis indicated that the formulae predicted MCL with good accuracy. Speech perception and sound field thresholds were measured in the participants' Everyday program and two predicted programs. When ECAP & EABR were the parameters, the predicted program had improved audibility as reflected in sound field thresholds as compared to those obtained with other two programs. Based on Freidman test, the results indicated that significantly lower thresholds were found for both ECAP & EABR, or ECAP & ESRT based programs when compared to Everyday program. However, speech perception scores were not significantly different among the program as per Freidman test. Thus, both the fitting models were clinically validated. The findings imply that it is not always advisable to run all three electrophysiological testing to predict the MCL levels in clinical population. It would save lot of time to run just two tests to predict the MCL in difficult to test population.

Postoperative Outcomes Following KTP-532 LASER Versus Coblation Assisted Paediatric Tonsillectomy.

Aim: The aim of the study was to compare postoperative outcomes such as pain, healing of tonsillar fossa and return to normal diet following KTP-532 LASER versus Coblation assisted tonsillectomy. Methods: A prospective randomised clinical study was conducted over a 24-month period at a tertiary referral centre. Children aged 3-16 years underwent KTP-532 LASER assisted versus Coblation assisted tonsillectomy. A total of 60 children were randomly allocated into two groups-Group A underwent KTP-532 LASER assisted tonsillectomy, and Group B underwent Coblation assisted tonsillectomy (n = 30 in each). Postoperative pain and tonsillar fossa slough formation was evaluated on postoperative day 0, 1, 7, 14 and 28, and average duration taken to resume regular diet. Result: There was no statistically significant difference in postoperative pain between the two groups. There was significantly lesser slough formation in Group B on 1st postoperative day (p < 0.000), 7th postoperative day (p < 0.014), and 14th postoperative day (p < 0.010) when compared with Group A. Complete mucosalisation was achieved significantly earlier in Group B when compared to Group A (p < 0.01). Average duration for resumption of normal diet was 13.5 days for Group A and 12.6 days for Group B postoperatively, which was statistically insignificant (p < 0.830). Conclusion: There was no significant difference in postoperative pain between the two groups. Postoperative slough formation was significantly lesser and tonsillar fossa mucosalisation was faster in Group B. There was no statistical difference in time taken to resume normal diet.

An eclectic Voice Therapy Program for the Treatment of Hyperfunctional Voice Disorders (HFVD).

PURPOSE: An eclectic voice therapy program includes sequenced and structured set of exercises combining direct and indirect intervention methods. Tailor-made exercise prescription with specific cultural adaptations are needed to provide a holistic change to voice quality.1 This study detailed the construction of an exercise prescription for participants with hyperfunctional voice disorder [HFVD] in the Indian context. METHOD: The exercise program was developed based on literature related to vocal therapy approaches and delivery methods. Adaptations were introduced to a selected set of exercises. Five voice experts verified the exercises and their prescription for content and feasibility of use in the Indian context. Modification suggested by the experts were included for framing the final version of the exercise program. This structured therapy program was planned for 6 weeks (30 minutes duration/session offered individually twice per week, with a gap of two days between sessions in a week) with the goals to improve voice quality, flexibility, and endurance while speaking. Five participants with HFVD partook in the study for pilot testing. Stroboscopy, perceptual voice analysis, Dysphonia Severity Index (DSI) and Vocal Fatigue Index in Tamil (VFI-T) were used to report the therapy outcomes. Participants' report on the learning process and generalization of the program were documented. Wilcoxon-signed rank test was used to test the pre-post outcome measures. RESULTS: An eclectic voice therapy program, i.e., Comprehensive Voice Habilitation Program [CVHP] was constructed and it included vocal hygiene instructions, warm-up & cool-down, easy onset, resonant voice, and carry over exercises. Participants completed the program in 14-18 sessions (over 7 to 9 weeks of therapy). All participants showed significant changes in vocal fold movement patterns, reduction in ventricular hyperadduction, overall grade of voice quality, DSI and VFI-T. Participants reported that pictorial illustrations, feedback, and monitoring sheets were useful in learning the exercises. CONCLUSION: CVHP showed significant change in the voice-related outcome measures and was a viable program for treating HFVD.

Outcomes of Vocal Hygiene Program in Facilitating Vocal Health in Female School Teachers With Voice Problems.

BACKGROUND: Teachers suffer greater impacts of voice problems due inappropriate voice use and other contributing factors such as physiological, environmental, and individual & work related issues. Structured vocal hygiene programs (VHP) prevent/reduce the risk of vocal trauma and promote vocal health in teachers. This study aimed to estimate the outcome of instituting a sociocultural relevant vocal hygiene program in facilitating vocal health among female school teachers using a comprehensive voice assessment protocol. METHOD: VHP was developed emphasizing adequate hydration, healthy vocal diet, posture and alignment, vocal practices while teaching, and ideal speaking environment. This was administered via a face to face session to seventeen female teachers with voice concerns. All underwent a comprehensive voice assessment (subjective, objective, and self-perceptual vocal measures) before and four weeks after the VHP. Inter-rater reliability for perceptual and visual examination was estimated using Intra-Class Coefficient. Wilcoxon signed ranks test was used to compare the pre- and post-treatment measures of continuous variables (acoustic, Maximum phonation time, s/z ratio, Vocal Fatigue Index [VFI] & Voice Disorder Outcome Profile [V-DOP]), and McNemar test was used for categorical variables (vocal health questionnaire, visual examination of larynx and perceptual evaluation of voice). RESULTS: Teachers reported reduction of unhealthy vocal & nonvocal practices after VHP. Improvements in vocal and related symptoms such as sensation of heart burn (P = 0.031), discomfort around the throat (P = 0.008), inadequate breath control while speaking (P = 0.016) were noticed. Perceptually, minimal improvement was seen in voice quality (overall grade). However, MPT & s/z ratio showed no significant difference. Improvement was observed in frequency range (P = 0.004), low I0 (P = 0.044), shimmer (P = 0.017), and DSI (P = 0.013). Changes were evident in all parameters of stroboscopic evaluation (except nonvibratory portion & ventricular fold hyper-adduction). V-DOP scores indicated positive change in the overall severity (P = 0.002), physical (P = 0.003) and functional domain (P = 0.034). VFI indicated improvement in teachers voice after a period of voice rest (P = 0.048). CONCLUSION: Though VHP facilitated in improving the teachers' awareness of at risk phono-traumatic behaviors and vocal health, its efficiency was limited in producing physiological improvement in teachers' voice. The comparison of vocal metrics before & after the treatment provides information on changes that can be expected in teachers after guiding them through a systematic VHP.

Assessment of Olfaction Following Endoscopic Sinus Surgery.

To assess the olfactory outcomes following Endoscopic Sinus Surgery (ESS) in patients diagnosed with Chronic Rhinosinusitis (CRS) and Sinonasal polyposis (SNP). To assess and compare the pre-operative and post-operative olfactory scores of patients undergoing ESS/ ESS + polypectomy/ESS + Septoplasty by subjective and objective methods. This is a prospective, cohort study which included a total of 60 patients. Subjective assessment was done using a Questionnaire. Preoperative olfactory assessment was performed with Sniffing Sticks. Olfactory assessment was done at 1st,3rd, 6th and 12th week following surgery. The preoperative and postoperative scores were statistically analysed and compared. In patients who underwent ESS, there was a significant reduction in olfactory scores in the immediate few weeks after surgery which improved over time by the end of 3 months. In patients who underwent ESS with polypectomy, there was a significant improvement in olfactory scores from the third week following surgery which was sustained over 3rd month follow-up. In patients who underwent ESS with Septoplasy, there was a significant decrease in olfactory scores during the initial few weeks with a marginal improvement during 3 months follow-up. At the end of 12 weeks post ESS, no patient was found to be anosmic. Patients with pre-existing hyposmia did not show statistically significant change post surgery.However patients with anosmia showed statistically significant improvement in olfactory function, but did not become normosmic at 12th post-operative week. Majority of normosmics did not have alteration in their olfactory perception at 12th post-operative week.

Trends in Performance Using Early Speech Perception Test in Typically Developing Tamil-Speaking Children.

BACKGROUND AND OBJECTIVES: The study attempted to trace age-related changes in speech perception in typically developing children (≥3 to ≤6 years) using the "Early Speech Perception (ESP)" in Tamil. The test was developed in line with the original English version of ESP but adapted to suit the linguistic requirement of the Tamil language. SUBJECTS AND METHODS: Using a cross-sectional design, the test was administered to 205 children with normal hearing who were classified into three age groups (≥3 to ≤4, >4 to ≤5, and >5 to ≤6 years). The developed test had three subtests (syllable categorization, bisyllable word identification, and trisyllable word identification). RESULTS: All three age groups obtained perfect or near-perfect scores on the three subtests of ESP. There was no significant difference observed between the two adjacent age groups (≥3 to ≤4 vs. >4 to ≤5 years, >4 to ≤5 vs. >5 to ≤6 years) for all three subtests. However, significant differences were seen only between the youngest and the oldest age groups for the three subtests (≥3 to ≤4 vs. >5 to ≤6 years). CONCLUSIONS: The results indicated that ESP in Tamil can be performed effectively in all the three age groups studied.

Effect of modified programming parameters on sound field thresholds, speech perception and CAEP among children using CP802 processor.

Optimizing and validating programming parameters of Thresholds(T) and most comfortable levels(C) is very important in young children using a cochlear implant who may not be able provide behavioral responses. The present study attempts to describe the changes in T/C level with behavioral and Cortical Auditory Evoked Potentials (CAEP) responses. Twenty participants using CI24RE (ST) implant with CP802 speech processor participated in the study. Three experimentally 'sham' programs were created by a) decreasing T levels, b) raising T levels or c) decreasing C levels in the 'everyday' program. Sound field thresholds and speech perception at 50dBHL were measured for all experimental and everyday programs. Acoustically evoked CAEP measures, namely thresholds for three different stimuli of/ba/,/da/and/ga/, along with amplitude and latency at 80dBnHL were recorded for all programs. The results indicated that modification of T levels did not have significant effect on CAEP threshold, latency, amplitude as also on behavioral measures of sound field thresholds and speech perception. However, reduction of C levels resulted in significantly poor sound field thresholds, speech perception as well as CAEP thresholds. Furthermore, it was found that there was a significant correlation between behavioral measures of sound field threshold and speech perception with CAEP measures. Thus, from the present study it may be concluded that behavioral and CAEP responses can be used as indicator to reflect changes in C levels resulting changes in behavioral measures in users of CP802 speech processors.

Cepstral Measures to Analyze Vocal Fatigue in Individuals With Hyperfunctional Voice Disorder.

OBJECTIVE: Cepstral measures are sensitive to slightest deviance in voice quality. Vocal fatigue is an initial symptom of a voice disorder. This study aimed (1) to assess the correlation of vocal fatigue and cepstral measures and (2) to identify a measure for analyzing voice change due to vocal fatigue in individuals with hyperfunctional voice disorders. STUDY DESIGN: Cross-sectional. METHODS: A total of 100 subjects participated in the study, that is Group I (50 cases) and Group II (50 controls). Vocal Fatigue Index (VFI-T) in Tamil was administered to identify the presence of fatigue. Voice samples (sustained vowel and conversational speech) were recorded using the Computerized Speech Lab (Model 4150). Mic to mouth distance was maintained at 10 cm. Extraction of cepstral peak prominence (CPP) and smoothened cepstral peak prominence (CPPS) for a vowel (v) and connected speech (cs) was done using Praat software (version 6.0.39, Boersma & Weenink, 2018). RESULTS: Independent t test was used to compare the cepstral measures between cases and controls. Individuals with vocal fatigue (cases) showed significantly lower cepstral values and higher VFI scores compared to the controls. Spearman's rho revealed moderate to strong negative correlation between factors of VFI and cepstral measures. On stepwise multiple linear regression, CPPcs was retained as a sensitive measure to analyze vocal fatigue in individuals with hyperfunctional voice disorder. CONCLUSION: Cepstral measures can be applied to analyze vocal fatigue.

Management of Post-Traumatic Subglottic Stenosis and Pharyngosubglottic Fistula.

Injury to the aerodigestive tract following external laryngeal trauma is rare. Reports of acquired laryngopharyngeal fistula are very few. We report a very rare presentation of penetrating neck trauma presenting with fracture of the cricoid cartilage, subglottic stenosis and pharyngosubglottic fistula. The term 'pharyngosubglottic fistula' is used here for the first time to describe a communication tract between hypopharynx and subglottis. The successful surgical management of this case is discussed.

Split Hollow Bulb Obturator to Rehabilitate Maxillary Defect: A Case Report.

The rehabilitation of a maxillectomy patient involves meticulous treatment planning and designing. Lack of retention and facial support and limited mouth opening are the major issues that lead to functional and psychological trauma in post-maxillectomy patients. The successful rehabilitation of a maxillary defect includes restoring the function, esthetics, and a complete obturation of the defect, enabling the patient to feed without nasal regurgitation. This case report describes the fabrication of an obturator with a modified design, namely a split-antral hollow bulb obturator and oral part that is retained with a ball attachment, for a patient with right-side acquired maxillary defect due to recurrent myxoma. The primary advantage of this modification is enhanced facial support and a self-retentive antral obturation that improved the quality of life of the patient after an extensive maxillectomy.

Multi parametric voice assessment: sri ramachandra university protocol.

Emergence of "Voice specialty clinics" in ENT and Speech Language Pathologist (SLP) practice in India necessitates development of standard protocols for assessment and management of voice disorders. Based on recommendations from European Laryngological Society in Dejonckere (Eur Arch Otorhinolaryngol 258:77-82, 2001), a comprehensive voice assessment protocol was adapted for Indian population. This study aimed at verifying the face validity and feasibility of using the developed voice assessment protocol in a multi specialty tertiary care hospital. It included: history, clinical examination, visual analysis, perceptual analysis, aerodynamic measures, acoustic analysis and patients' self assessment of voice. The developed protocol was administered on 200 patients with voice concerns and problems. Correlation of self assessment with the assessment by the professionals was done using Kendaul tau_b correlation test. The scores of self assessment did not correlate significantly with acoustic measures. Differences in lab findings and self percept of voice indicated that these two were complementary measures in the protocol. Further, diagnosis and management decisions were arrived through a consensus discussion involving the ENT surgeon, SLP and the patient. Vocal hygiene and voice conservation were advised to all patients. Recommendations for voice therapy and/or surgery were provided based on findings from the protocol. The study demonstrated feasibility of using a comprehensive protocol for effective documentation, comparisons, review, training and treatment planning.

Clinical voice analysis of Carnatic singers.

BACKGROUND AND OBJECTIVE: Carnatic singing is a classical South Indian style of music that involves rigorous training to produce an "open throated" loud, predominantly low-pitched singing, embedded with vocal nuances in higher pitches. Voice problems in singers are not uncommon. The objective was to report the nature of voice problems and apply a routine protocol to assess the voice. METHODS: Forty-five trained performing singers (females: 36 and males: 9) who reported to a tertiary care hospital with voice problems underwent voice assessment. The study analyzed their problems and the clinical findings. RESULTS: Voice change, difficulty in singing higher pitches, and voice fatigue were major complaints. Most of the singers suffered laryngopharyngeal reflux that coexisted with muscle tension dysphonia and chronic laryngitis. Speaking voices were rated predominantly as "moderate deviation" on GRBAS (Grade, Rough, Breathy, Asthenia, and Strain). Maximum phonation time ranged from 4 to 29 seconds (females: 10.2, standard deviation [SD]: 5.28 and males: 15.7, SD: 5.79). Singing frequency range was reduced (females: 21.3 Semitones and males: 23.99 Semitones). Dysphonia severity index (DSI) scores ranged from -3.5 to 4.91 (females: 0.075 and males: 0.64). Singing frequency range and DSI did not show significant difference between sex and across clinical diagnosis. Self-perception using voice disorder outcome profile revealed overall severity score of 5.1 (SD: 2.7). Findings are discussed from a clinical intervention perspective. CONCLUSIONS: Study highlighted the nature of voice problems (hyperfunctional) and required modifications in assessment protocol for Carnatic singers. Need for regular assessments and vocal hygiene education to maintain good vocal health are emphasized as outcomes.

Anomalous interposition of air cells between the middle and inner ear.

Combination of middle and inner ear anomaly is extremely rare. We describe a case where there was inner and middle ear anomaly on the right side and inner ear anomaly on the left side. This patient also had anomalous interposition of air cells between the middle and inner ear on the right side which precluded the use of cochlear implant. No such findings have been reported till date to the best of our knowledge.