Adult Normative Data for the OMNI-Vocal Effort Scale (VES).

PURPOSE: To establish normative values for the OMNI-Vocal Effort Scale (VES) in healthy adults without voice complaints. Secondary objective is to determine if there are differences in perceived vocal effort across age groups and between sexes. STUDY DESIGN: Prospective data collection across groups. METHOD: A nine-item survey was administered by speech-language pathologists with specialization in voice to consenting adults 18 years or older. Participants underwent an auditory perceptual evaluation of voice and answered questions regarding age, history of voice problems, history of voice surgery, smoking history and hearing loss. Participants were instructed to rate their perceived vocal effort in conversational speech using the OMNI-VES. Multivariant analysis was conducted. RESULTS: Two hundred and fifty-one participants were recruited. The majority of adults without voice complaints reported that producing conversational voice was within the "extremely easy" to "easy" range, 0-3 (92.4%). CONCLUSIONS: This study provides preliminary data for perceived vocal effort. The OMNI-VES may be a useful tool in understanding changes in perceived vocal effort as a result of treatment for voice disorders. Further normative data are needed between sexes, across the gender spectrum, and older adult populations. Future directions include examining the magnitude of difference between numeric values on the scale and use of the scale with other dysphonic populations. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Validation of an AI-assisted Treatment Outcome Measure for Gender-Affirming Voice Care: Comparing AI Accuracy to Listener's Perception of Voice Femininity.

OBJECTIVES: There is currently a lack of objective treatment outcome measures for transgender individuals undergoing gender-affirming voice care. Recently, Bensoussan et al developed an AI model that is able to generate a voice femininity rating based on a short voice sample provided through a smartphone application. The purpose of this study was to examine the feasibility of using this model as a treatment outcome measure by comparing its performance to human listeners. Additionally, we examined the effect of two different training datasets on the model's accuracy and performance when presented with external data. METHODS: 100 voice recordings from 50 cisgender males and 50 cisgender females were retrospectively collected from patients presenting at a university voice clinic for reasons other than dysphonia. The recordings were evaluated by expert and naïve human listeners, who rated each voice based on how sure they were the voice belonged to a female speaker (% voice femininity [R]). Human ratings were compared to ratings generated by (1) the AI model trained on a high-quality low-quantity dataset (voices from the Perceptual Voice Quality Database) (PVQD model), and (2) the AI model trained on a low-quality high-quantity dataset (voices from the Mozilla Common Voice database) (Mozilla model). Ambiguity scores were calculated as the absolute value of the difference between the rating and certainty (0 or 100%). RESULTS: Both expert and naïve listeners achieved 100% accuracy in identifying voice gender based on a binary classification (female >50% voice femininity [R]). In comparison, the Mozilla-trained model achieved 92% accuracy and the previously published PVQD model achieved 84% accuracy in determining voice gender (female >50% AI voice femininity). While both AI models correlated with human ratings, the Mozilla-trained model showed a stronger correlation as well as lower overall rating ambiguity than the PVQD-trained model. The Mozilla model also appeared to handle pitch information in a similar way to human raters. CONCLUSIONS: The AI model predicted voice gender with high accuracy when compared to human listeners and has potential as a useful outcome measure for transgender individuals receiving gender-affirming voice training. The Mozilla-trained model performed better than the PVQD-trained model, indicating that for binary classification tasks, the quantity of data may influence accuracy more than the quality of the data used for training the voice AI models.

Reliability of Phonemically Loaded Sentences in Spanish for Identifying Laryngeal Dystonia by Non-Spanish Speaking Speech-Language Pathologists.

INTRODUCTION: Laryngeal dystonia (LD) is a focal dystonia affecting the intrinsic laryngeal muscles. Clinical diagnosis requires subjective evaluation by experienced clinicians and is primarily based on auditory-perceptual assessment. Several speech tasks are widely accepted to elicit diagnosis specific auditory-perceptual symptoms of glottal stops in adductor LD or breathy breaks in abductor LD in spoken English. With the growing Spanish speaking population in the US and lack of Spanish speech tasks to assist in identifying LD in Spanish speaking subjects, assessing the reliability of phonemically loaded sentences in Spanish for use by non-Spanish speaking providers is critical. The first aim of this study was to develop and assess the reliability of a set of Spanish language phonemically loaded sentences designed to elicit signs and symptoms of LD. The second aim was to determine the effectiveness of non-Spanish speaking speech-language pathologists (SLPs) in identifying LD in Spanish speaking subjects using these stimuli. METHODS: Phonemically loaded sentences were developed for this study following current guidelines for assessment of LD. Voice samples were obtained from native Spanish speaking individuals. Participant-speakers included 20 people with LD and 20 people without LD who served as controls. All participant-speakers were assessed by a Spanish-speaking laryngologist. Audio samples were presented to non-Spanish speaking SLPs with expertise in working with people with LD who served as raters and classified the samples as either presence or absence of LD. Kappa and the intra-class correlation coefficient were calculated and mixed effects logistic regression was used for prediction. RESULTS: The inter and intra-rater reliability indicated statistically significant agreement. Sensitivity, specificity, and predictive values for the diagnosis of LD by the raters were overall strong. CONCLUSIONS: Findings demonstrate that non-Spanish speaking SLPs with expertise in the assessment and treatment of LD can reliably identify the presence of LD using Spanish language stimuli in Spanish-speaking individuals. This study supports the use of newly developed Spanish language phonemically loaded voiced and voiceless sentences by English speaking clinicians as an effective tool for identifying LD in Spanish speakers, perhaps mitigating diagnostic delays experienced by patients with LD.

Effects of Sidetone Amplification on Vocal Function During Telecommunication.

PURPOSE: Society has become increasingly dependent on telecommunication, which has been shown to negatively impact vocal function. This study explores the use of sidetone regulation during audio-visual communication as one potential technique to alleviate the effects of telecommunication on the voice. METHOD: The speech acoustics of 18 participants with typical voices were measured during conversational tasks during three conditions of sidetone amplification: baseline (no sidetone amplification), low sidetone amplification, and high sidetone amplification. Vocal intensity, vocal quality (estimated using acoustic measures of the low-high ratio and the smoothed cepstral peak prominence), and self-perceived vocal effort were used to measure the impacts of sidetone amplification on vocal function. RESULTS: Compared to baseline, there were statistically significant decreases in vocal intensity and increases in low-high ratio in the high level of sidetone amplification condition. Changes in these measures were not significantly correlated. When asked to rank conditions based on their perceived vocal effort, participants most often ranked the high level of sidetone amplification as least effortful; however, the visual-analog ratings of vocal effort were not significantly different between conditions. The smoothed cepstral peak prominence did not change with varying levels of sidetone amplification. CONCLUSIONS: Vocal intensity decreased with high levels of sidetone amplification. High levels of sidetone amplification also resulted in increases in the low-high ratio, which were shown to be more than just a byproduct of decreased vocal intensity. The impact of sidetone amplification on vocal effort was less clear, but results suggested that participants generally decreased their vocal effort with increased levels of sidetone amplification. This was a preliminary study and future work is warranted in a population of participants with voice complaints and in a more noisy, realistic environments.

Clinician and Consumer Perspectives on Gender-Affirming Voice Services.

INTRODUCTION: A significant portion of the transgender, nonbinary, and gender-expansive community experiences gender-related voice issues. However, barriers exist to accessing gender-affirming voice care, and most existing voice research does not include the gender-nonbinary population. Our study aimed to examine transgender, nonbinary, and gender-expansive consumer/potential consumer (hereafter referred to as consumer) engagement and compare/contrast consumer and speech-language pathologist perspectives on gender-affirming voice services. A secondary aim was to assess possible voice impairments in transgender, nonbinary, and gender-expansive individuals. METHODS: Two surveys were distributed via listservs for SLPs and flyers and social media posts for consumers. Surveys included items regarding experience with and accessibility of gender-affirming voice services and clinician competence. Consumers and clinicians answered the same questions from their respective positions. Consumers additionally completed the Voice Handicap Index-10 (VHI-10). RESULTS: Forty-eight consumer and 54 clinician responses were collected. Twenty (41.7%) consumers were trans women, 15 (31.2%) were trans men, 12 (25%) were gender-nonbinary, and one (2.1%) was gender fluid. VHI-10 responses were in the abnormal range for 61.4% of consumers, and 68.8% indicated desire to receive gender-affirming voice services, including 58.3% of gender-nonbinary respondents. However, only 6.25% of consumers considered themselves as having a voice disorder and 29.2% reported that their voice impairs communication. In contrast, 24.1% of clinicians felt consumers seeking gender-affirming voice services have a voice disorder and 51.2% felt they have an impaired communication ability. Consumers indicated positive perceptions of voice services/providers but reported a variety of barriers to access. SLPs indicated mixed confidence in accessibility of services. Both groups perceived an affordability barrier. CONCLUSIONS: This study demonstrates the desire and need for gender-affirming voice services and is the first to our knowledge to explicitly include gender-nonbinary individuals' perspectives on them. Understanding how consumer and clinician perspectives differ can help focus provider efforts in improving experiences with, access to, and visibility of gender-affirming voice services.

Platelet-Rich Plasma for Vocal Fold Scar: A Preliminary Report of Concept.

INTRODUCTION: Vocal fold atrophy and scar can lead to loss of normal superficial lamina propria, negatively affecting the vibratory function of the vocal fold. These changes can lead to dysphonia, vocal fatigue, decreased volume, and altered pitch. Treatment options for these conditions are limited. Platelet-rich plasma (PRP) consists of platelets, growth factors, and cytokines derived from the patient's own blood and is believed to activate tissue regeneration. The purpose of this study was to review the technical aspects of collecting PRP and injecting it into the vocal fold injection - based on our initial experience with this procedure. CASE: A patient with vocal fold scar was identified and enrolled in an ongoing prospective clinical trial study of a series of 4 monthly subepithelial vocal fold PRP injections, which was temporarily halted due to the COVID-19 pandemic. Patient underwent a single injection of autologous PRP into the left vocal fold. There were no adverse events during the study period. Subjective improvement in voice was noted at 1 month after injection with subsequent return to baseline over the next 4 months. Videostroboscopy performed on postinjection day 1 and day 7 and demonstrated no concerning exam changes. Compared to the preinjection baseline, the patient-reported voice-handicap index-10 (VHI-10) and voice catastrophization index were similar at 4 months following injection (20 to 20 and 4 to 3, respectively). Independent perceptual analysis of voice showed improvement at 4 months postinjection, compared to baseline consensus auditory-perceptual evaluation of voice 60 to 44. CONCLUSIONS: This preliminary report was part of a prospective trial investigating the use of PRP to treat vocal fold atrophy and scar. This work highlights the technical considerations for injecting PRP into the vocal fold. Planned prospective enrollment in this study will help to validate the safety and efficacy of PRP injections.

VHI-10 Scores in a Treatment-Seeking Population With Dysphonia.

INTRODUCTION: The VHI-10 is a patient-reported outcome measure used to record the patient's perception of impairment or handicap due to a voice problem. Scores above 11 are abnormal and indicate voice handicap. Amongst a treatment-seeking population in a large tertiary voice center, scores below the VHI-10 cutoff score of 11 were frequently noted. The aim of this study was to examine the number of people seeking voice therapy for dysphonia who scored below the established VHI-10 cutoff score. METHODS: A retrospective chart review was completed of all patients attending a voice evaluation with a speech-language pathologist by referral of a laryngologist between February 1, 2017 and February 28, 2018. Patients aged 18+ years with a primary diagnosis of dysphonia were included. Sex, age, primary diagnosis, and VHI-10 score were recorded. Patients were categorized as scoring above or below the cutoff score of 11. Logistic regression was performed to determine the variables that predicted scoring below the VHI-10 cutoff. RESULTS: A total of 225 patients were included. There were 91 males (40.4%) and 134 females (59.6%). Sixty-one patients (27.1%) scored below the VHI-10 cutoff of 11 at their evaluation. Younger age and male sex were predictive of scoring below the VHI-10 cutoff score. Diagnosis was not predictive of scoring above or below the cutoff score. CONCLUSION: A notable proportion of treatment-seeking patients scored below the VHI-10 cutoff of 11. If treatment-seeking behavior is related to patient perception of voice handicap, one would expect fewer patients to score below the cutoff. Possible explanations might include that the VHI-10 did not sufficiently capture patient perception of handicap in the study population or the published cutoff score may be too high. Alternatively, another motivator besides handicap may have spurred treatment-seeking behavior. Given these findings, additional or alternative patient-reported outcome measures may be useful in developing a complete clinical picture regarding voice handicap.

Gauging Stakeholder Perspectives on Artificial Intelligence in Gender-Affirming Voice Care.

BACKGROUND: As the main objective outcome measure used in gender-affirming voice care (GAVC), fundamental frequency (f0 ) often fails to accurately reflect patient perceptions of their voice. Our team developed an artificial intelligence (AI) program that provides an alternative objective outcome measure that has the potential to more accurately align with patient perceptions. OBJECTIVE: To gauge stakeholder receptivity to the use of AI in GAVC before employing a novel outcome measure in transgender and nonbinary communities. METHODS: This prospective qualitative study used online focus groups composed of speech-language pathologists (SLPs), transgender men (TGM), transgender women (TGW), and nonbinary (NB) individuals. Participant age, race, gender, and geographic location were recorded. Each cohort participated in a series of two focus group sessions. The first session focused on participant experiences in GAVC, whereas the second ascertained participant perspectives on the use of AI in GAVC. Transcripts of each discussion were coded using Nvivo to perform inductive thematic analysis. RESULTS: Seven SLPs, seven TGW, three TGM, and two NB individuals (mean [range] age, 35.5 [26-48] years) participated. Transgender and nonbinary participants were generally amenable to the technology, whereas SLPs were more hesitant about its use. Positive findings included appreciation for AI as an objective outcome measure and enthusiasm for its potential to longitudinally track progress. Hesitations concerned the actionability of using the AI and unease about the black box nature of the AI's analysis. CONCLUSION: Transgender and NB individuals were receptive to the use of AI technology in GAVC, whereas SLPs were more apprehensive about using AI. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1698-1705, 2023.

Linguistic Relevance and Applicability of the Spanish VHI-10 in a Population outside Spain.

INTRODUCTION: The Voice Handicap Index 10 (VHI-10) has been translated to many languages. There are substantial differences between the translation methods. Translated questionnaires without appropriate linguistic validation may not capture cultural differences or be understood by the participants in the manner intended by the original developers. This also holds true between dialects within a language. There are two versions of the VHI-10 in Spanish, both translated in Spain. Considering the cultural and dialectical differences amongst Spanish speakers, it is hypothesized that these translations may not be applicable globally. The purpose of this study was to determine the linguistic relevance and applicability of the currently available versions of the VHI-10 in Spanish amongst Spanish speakers outside of Spain. METHODS: This study used mixed methods qualitative and quantitative procedures consisting of semi-structured interviews and quantitative analysis of data. Sixty-nine participants met the inclusion criteria. Participants with and without a diagnosis of dysphonia were included. Demographic data collected included age, gender, cultural/dialectical background, level of education, and number of years residing in Southern California. Participants were provided the currently available translated versions of the VHI-10 in Spanish (V1 and V2). After reading both questionnaires, a semi-structured interview was conducted by a bilingual SLP. Semi-structured interview responses were coded to determine patterns of words marked as problematic/not understood or non-representative of the Spanish dialect spoken by the participants. RESULTS: The majority of participants marked at least one word in both versions as problematic/not understood or non-representative of the Spanish dialect spoken (60/69, 87.0% for V1 and 63/69, 92.3%, for V2). The two words most frequently marked as problematic/not understood or non-representative of the Spanish dialect spoken were "hándicap" (marked by 51/69 participants, 73.9%) and "minusvalía" (marked by 52/69 participants, 75.4%). CONCLUSIONS: Data analysis demonstrates that the majority of participants marked words as not understood/non-representative of their dialect on either V1 or V2. One question not understood or not answered could have an impact on how we interpret this patient-reported outcome measure in clinical practice. Use of currently available Spanish translations of the VHI-10 may yield unreliable results when used amongst Spanish speakers outside Spain due to dialectal and cultural differences. Future work will include validation of a voice patient-reported outcome measure that is culturally and linguistically appropriate for Spanish speakers outside Spain.

Respiratory Particle Emission During Voice Assessment and Therapy Tasks in a Single Subject.

INTRODUCTION: SARS-CoV-2 is transmitted via respiratory particles. Respiratory particle emission is impacted by manner of breathing and voicing, as well as intersubject variability. Assessment and treatment of voice disorders may include tasks that increase respiratory particle emission beyond typical breathing and speaking. This could increase the risk of disease transmission via respiratory particles. METHODS: Respiratory particle emission was measured during a single-subject, repeated measures clinical simulation of acoustic and aerodynamic assessment and voice therapy tasks. An optical particle sizer was used to measure particle count (1-10 µm in diameter). Assessment and therapy tasks were completed in three conditions: (1) 15 cm from the device, (2) 1 m from the device, and (3) 1 m from the device with the subject wearing a surgical mask. RESULTS: Condition 1 generated the highest particle count, with a median of 5.1 (13) additional particles above baseline, which was statistically significant (U = 381.5, P= 0.002). In condition 1, therapy and acoustic tasks combined produced more particles compared to the baseline and speech tasks, with a median difference of 6.5 additional particles per time point (U = 309.0, P= 0.002). This difference was not significant for conditions 2 and 3. Peak particle generation occurred in specific phonatory tasks, which was most pronounced in condition 1. Voice therapy tasks during condition 1 generated the highest peaks of normalized total particles with classical singing and expiratory muscle strength training. There was a significant difference in the amount of particle generation between condition 1 and 2, with a median difference of 5.2 particles (U = 461.0, P= 0.002). The particle count difference between conditions 2 and 3 was 2.1 (U = 282.0, P= 0.292), and this difference was not significant. The normalized total particles were assessed over time for each condition. For all conditions, there was no significant accumulation of particles. CONCLUSIONS: For a single subject, production of voice assessment and therapy tasks combined resulted in an increased number of respiratory particles compared to speech and baseline (1-10 µm). EMST and classical singing generated the greatest concentration of particles. Respiratory particle counts were higher at 15 cm from the particle sizer compared to 1 m from the particle sizer, suggesting that physical distancing may reduce immediate clinician exposure to respiratory particles. Particle concentration did not accumulate over time.