Development and Psychometric Evaluation of the Laryngeal Palpation Pain Scale (LPPS).

INTRODUCTION: One of the most important assessment and therapy methods for patients with muscle tension dysphonia (MTD) and other voice disorders is laryngeal palpation. However, there is no comprehensive scale for measuring pain during laryngeal palpation. The goal of the present study was to develop and validate a new scale to evaluate pain during palpation for patients with MTD. METHODS: The present study consisted of two phases: (1) Development of the Laryngeal Palpation Pain Scale (LPPS) based on an in-depth literature review, the palpatory evaluation of MTD patients, interviews with experts in the field of voice disorders, and consultation with a registered pain expert, and (2) evaluation of the validity and reliability of the LPPS. The validity of the LPPS was investigated using qualitative and quantitative content validity, qualitative face validity, discriminant validity, and convergent validity. Content validity of the LPPS was assessed by experts' opinions (10 speech-language pathologists and five laryngologists), and face validity was investigated using the opinions of speech-language pathologists. The reliability of the LPPS was determined using test-retest and inter-rater reliability. RESULTS: The item generation phase of the study led to the development of a scale to assess pain during palpation that included eleven locations in the neck region for palpatory assessment. These 11 items were divided into 13 different items (neck locations) based on the opinions of the experts. The content validity ratio values of all scale items were higher than 0.78. The content validity index (CVI) value for each of the items of the scale was higher than 0.79 and for the entire scale CVI (S-CVI) was 0.915. The results of the reliability of the LPPS items were satisfactory with weighted kappa values ranging from 0.655 to 1 for the test-retest and 0.77-1 for the inter-rater reliability. Convergent validity of the LPPS was shown with a significant positive correlation (r = 0.68) between the LPPS and the pain severity of vocal tract discomfort (P < 0.001). Moreover, MTD patients had more pain severity than the control group in all items of the LPPS (P < 0.05) except for the submental item (P = 0.89). These results indicate that the LPPS can differentiate MTD patients from healthy subjects. The final version of the LPPS includes 13 potential pain locations. The severity of pain at each of these locations is determined on a numeric pain rating scale of zero (no pain) to ten (the most severe pain). CONCLUSION: The study showed that the LPPS is a valid and reliable scale to assess pain in MTD patients during palpation evaluations. More studies are recommended for further psychometric evaluation of the LPPS including responsiveness to change (the use in before-and-after intervention studies) and concurrent validity of the LPPS. The LPPS can be used for clinical and research purposes.

Relationship among five-factor personality traits and psychological distress with acoustic analysis.

Objectives: The relationship between personality traits and psychological distress with acoustic characteristics was investigated in the present study, regarding the existence of dysphonia, abnormal overall voice quality (AOVQ), and dysphonia type. Methods: Fifty-five participants with dysphonia and 64 participants without dysphonia completed NEO Five-Factor Inventory and Depression, Anxiety, and Stress Scale-21. Jitter, shimmer, noise-to-harmonic ratio (NHR), cepstral peak prominence (CPP), and cepstral peak prominence-smoothed (CPPS) were calculated in sustained vowel /a/ by Praat. Three expert speech and language pathologists divided participants with dysphonia into mild, moderate, and severe, based on the AOVQ. Pearson and Spearman correlation tests were performed by IBM SPSS Statistics. Results: The findings were indicative of large correlations between agreeableness with CPP, conscientiousness with shimmer, depression with jitter and shimmer, and anxiety with shimmer in patients with functional dysphonia (p < 0.05). The results showed small to medium significant correlations between agreeableness with jitter and NHR, conscientiousness with CPP in participants without dysphonia, and depression with jitter in the participants with dysphonia (p < 0.05). Lastly, no significant correlation was observed between personality traits and psychological distress with acoustic characteristics in mild, moderate, and severe AOVQ groups (p > 0.05). Conclusion: In participants with functional dysphonia, personality traits and psychological distress can provide some information about acoustic characteristics and vice versa. Level of Evidence: 3.

The Persian Version of Reflux Sign Assessment Scale: Validity and Reliability for the Examination of Patients with Laryngopharyngeal Reflux Disease.

OBJECTIVES/HYPOTHESIS: The non-specificity of signs associated with laryngopharyngeal reflux disease (LPRD) makes the diagnosis challenging. This study aimed to evaluate the psychometric properties of the Persian version of reflux sign assessment (RSAp) in LPRD. STUDY DESIGN: This was a methodological study. METHODS: The prefinal version of RSAp was developed in a forward and backward translation protocol. It was completed by a speech-language pathologist (SLP) and an otolaryngologist for 20 LPRD patients to provide a final version. The final version was completed by a SLP (rater 1) for 42 LPRD patients and 42 healthy people. To study intra and inter-rater reliability, the RSAp was recompleted after 21 days by rater 1 and another SLP (rater 2), respectively. For construct validity, the reflux finding score and reflux symptom index was completed in the patients. RESULTS: There were significant differences in the subscales and total scores of RSAp between the patient and healthy groups (P < 0.001). The Cronbach's alpha of the total score was 0.76 and 0.72 for rater 1 and 2, respectively. Concordance correlation coefficient and intraclass correlation coefficient values for all scores showed excellent intra and inter-rater reliability. The total score had a significant positive correlation with the scores of reflux finding score and reflux symptom index (rp = 0.813, P < 0.001 and rp = 0.811, P < 0.001 respectively). CONCLUSIONS: The current study indicated the RSAp is a valid and reliable scale for the examination of the vocal tract in LPRD. The RSAp can be used as a useful tool in clinical and research settings for Persian LPRD patients.

The Relationship Between Voice Handicap Index and Voice-Related Quality of Life in Patients with Early Laryngeal Cancer.

Introduction: Voice production can be affected in early laryngeal cancer. The purpose of this study was to investigate the correlation between Voice Handicap Index (VHI) and Voice-Related Quality of Life (V-RQOL) among patients with early laryngeal cancer. Methods: Twenty-seven patients with early laryngeal cancer (T1, T2) and a mean age of 59.35 ± 7.77 years who were visited in Amir-Alam hospital, took part in this study. After a diagnosis of early laryngeal cancer by a laryngologist, the patients filled out the Persian versions of the VHI and V-RQOL questionnaires. Results: The results showed the mean total score of VHI and V-RQOL were 65.94 ± 14.21 and 48.64 ± 9.75% in patients with early laryngeal cancer, respectively. These results indicated the total and subscales' scores of VHI increased while the scores of VRQOL decreased. The Pearson correlation between total scores of the VHI and V-RQOL was - 90. Also, there was a negative significant correlation between total and subscales' scores of VH and VRQOL (r Pearson= -0.46 to -0.90, p ≤ 0.05). Conclusion: Our findings demonstrated decreased quality of life related to voice in patients with laryngeal cancer who were in the early stages of tumor growth (T1, T2). Regarding the high negative significant correlation between results of VHI and V-RQOL in patients with early laryngeal cancer, both questionnaires can be used instead of each other for saving time in voice clinics.

Relationship Between Aerodynamic Measurement of Maximum Phonation Time With Acoustic Analysis and the Effects of Sex and Dysphonia Type.

OBJECTIVES/HYPOTHESIS: This study set out to uncover the correlation between maximum phonation time (MPT) with acoustic and cepstral analysis in the dysphonic and control groups, considering the effects of sex and dysphonia type. METHODS: For this cross-sectional study, a sample of 179 attendees (141 dysphonic and 38 control) were randomly selected and requested to sustain the vowel /a/ as long as they could with their habitual pitch and loudness. Reading standard sentences and conversational connected speech tasks were obtained too. Using Praat, the MPT, jitter, shimmer, noise-to-harmonic ratio, cepstral peak prominence (CPP), and smoothed cepstral peak prominence (CPPS) were calculated in the target vocal tasks. RESULTS: There was a very low to low significant correlation (r = 0.00-0.50) between MPT amounts and acoustic analysis in the dysphonic group (P < 0.05), except for between MPT with shimmer (P > 0.05). In contrast, findings showed no significant correlation between MPT and acoustic analysis in the control group, not even separated by sex (P > 0.05). There was a very low to low correlation between MPT amounts and acoustic analysis in the male dysphonic group (P < 0.05), except for the MPT with shimmer (P > 0.05). There was no significant correlation between MPT and acoustic analysis in the female dysphonic group (P > 0.05), except for MPT with CPP (sustained vowel) (P < 0.05). Finally, very low to high correlations between MPT and some of the acoustic analysis in all the different dysphonia types were observed (P < 0.05). CONCLUSIONS: MPT contains some information about the acoustic features of the dysphonic voice, specifically the CPP and smoothed cepstral peak prominence. The data suggested that the observed relationship between MPT and the acoustic analysis has the capacity to be considered for the development of new multiparametric tests of voice assessment in dysphonia, regarding the sex and dysphonia type.

Relationship of cepstral analysis with voice self-assessments in dysphonic and normal speakers.

PURPOSE: This study aimed to investigate the relationship of cepstral analysis (Cepstral Peak Prominence [CPP] and Cepstral Peak Prominence-Smoothed [CPPS]) with voice self-assessments (The Persian version of vocal tract discomfort [VTDp] scale and non-standard hoarseness self-assessment [NHS] questionnaire). METHODS: 223 participants (159 with and 64 without dysphonia) were asked to utter the vocal tasks namely vowels /a/ and /e/, six standard sentences, and a non-standard connected speech sample. CPP and CPPS were calculated in these three vocal tasks using the "Praat" software. The participants also asked to complete the VTDp scale and the NHS questionnaire. RESULTS: The means of frequency and severity the VTDp and the means of NHS were statistically different between the dysphonic and normal voice groups (P < 0.05), except for tickling (P > 0.05). There was a very low significant correlation between cepstral analysis with aching and in the dysphonic group (P < 0.05). However, a very low to low significant correlation between cepstral analysis with burning, tight, aching, tickling, sore, and both frequency and severity subscales scores of the VTDp in the normal voice group (P < 0.05). Moreover, the means of the cepstral analysis did not differ significantly between all scores of the NHS in the dysphonic the normal voice groups (P > 0.05), except for 1 with 3, 4, and 5 in the dysphonic group (P < 0.05). CONCLUSION: The cepstral analysis can provide some information about the status of vocal tract and person's perception of his/her own voice quality.

Multidimensional Voice Assessment After Management of Early Laryngeal Cancer: A Comparative Study.

Laryngeal Squamous Cell Carcinoma is one of the most common head and neck cancers, and patients experience dysphonia after treatment with transoral laser microsurgery (TLM) or radiotherapy (RT). This study aimed to investigate the multidimensional assessment of voice, based on objective and subjective evaluation. In this cross-sectional study, a group of 120 patients (mean = 57.59 years, SD = 4.87), including men (n = 116) and women (n = 4) with early laryngeal carcinoma, were divided into two groups; Patients who had undergone TLM (n = 60) or RT (n = 60). The multidimensional assessment of voice was conducted using the acoustic analysis, the dysphonia severity index (DSI), the Persian versions of Consensus Auditory Perceptual Evaluation of Voice, and the voice handicap index (VHI). Results revealed that objective voice assessment only shows differences (P < 0.001) in the DSI between TLM and RT groups, despite there being no significant differences (P = 0.196) in overall severity of voice disorder in comparison between them. Also, there is a significant difference (P < 0.05) based on the Emotional subscale of VHI, between irradiated and TLM-treated patients. This finding showed that TLM-treated patients with early laryngeal carcinoma had severe voice disorder compared to irradiated patients. In addition, radiotherapy has a greater impact on the emotions of patients with early glottic cancer.

The Validity of Cepstral Analysis to Distinguish Between Different Levels of Perceptual Dysphonia in the Persian Vocal Tasks

OBJECTIVES/HYPOTHESIS: The validity of cepstral analysis (Cepstral Peak Prominence [CPP] and Cepstral Peak Prominence-Smoothed [CPPS]) as an indicator of perceptual dysphonia was investigated in the Persian language STUDY DESIGN: Cross-sectional study. METHODS: A total of 223 participants (159 with and 64 without dysphonia) uttered vowels /a/ and /i/, six standard sentences, and non-standard connected speech. All vocal samples were perceptually evaluated by three raters on a visual analog scale and put into four groups (normal voice, mild, moderate, and severe perpetual dysphonia). CPP and CPPS of sustained vowel /a/, reading the second standard sentence, and a sentence extracted from non-standard connected speech were established using "Praat" software. Statistical analysis involved a one-way factorial analysis of variance (ANOVA), Kruskal-Wallis H, Kendall's Tau-b correlation, t test, and receiver operating characteristics (ROC) curve. RESULTS: The results showed that CPP of sustained vowels and reading the standard sentence and CPPS of sustained vowel differed significantly (P < 0.05), except between the normal voice and mild perpetual dysphonia groups (P > 0.05). The CPP of non-standard connected speech, CPPS of reading the standard sentence, and non-standard connected speech differed significantly between all groups (P < 0.05). The mean of cepstral analysis of all tasks, "averaged CPP," and "averaged CPPS" were significantly different between two groups of the normal voice and perceptual dysphonia (P < 0.05). Correlation between the cepstral analysis and the perceptual ratings demonstrated that the correlation coefficients for CPP and CPPS were between 0.4 and 0.6 (P < 0.05). ROC curve analysis revealed that the area under the ROC curve for "averaged CPP" and "averaged CPPS" was greater than 0.8 (P < 0.05). The values of 22.11 and 12.29 were determined as cut-off scores of "averaged CPP" and "averaged CPPS," respectively. CONCLUSIONS: Cepstral analysis was known as useful clinical tool for diagnosis of perpetual dysphonia and determining its severity level in the Persian language.

Construct and Discriminant Validity of the Persian Version of the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V).

PURPOSE: Five dimensions of voice assessment are considered as visual evaluation, videostroboscopy, acoustic, aerodynamic, patient-based, and auditory-perceptual. Auditory-perceptual voice assessment scales are the standard scales for clinicians to document voice therapy outcomes in dysphonic patients. The primary objective of the present study was to investigate the construct and discriminant validities of the Persian Version of the CAPE-V (ATSHA). A secondary objective was to determine the differences between experienced and inexperienced raters in the auditory-perceptual assessment of voice. METHOD: Forty normal and forty individuals with dysphonia were rated by five experienced and five inexperienced raters. Pathological subgroups were vocal fold nodules, vocal fold polyps, unilateral vocal fold paralysis (UVFP), and Reinke's edema. The differences between normal and pathologic groups were observed by independent t tests for all perceptual parameters (P < 0.05). Construct validity was documented for the scale of interest. The Kruskal-Wallis and Mann-Whitney comparisons were used to examine discriminant validity. RESULTS: Findings of these tests showed that scores of all pathological subgroups were significantly different except for the parameter of "strain" in sustained vowels (P < 0.05). Results of the Wilcoxon Matched-Pairs Signed Rank Test indicated that experienced and inexperienced raters were significantly different in auditory-perceptual judgments of voice. CONCLUSION: It seems that the Persian Version of the CAPE-V is a consistent predictor of normal and pathological voices. Moreover, we found that experienced listeners have different auditory-perceptual skills in evaluation of voice that make them more precise than inexperienced listeners.

Effect of Muscle Tension Dysphonia on Self-perceived Voice Handicap and Multiparametric Measurement and Their Relation in Female Teachers.

OBJECTIVES: Muscle tension dysphonia (MTD) is a common voice disorder in teachers in which subjective and objective dimensions of quality of voice can be impaired. The study aimed to compare voice handicap index (VHI) and dysphonia severity index (DSI) in teachers with and without MTD as well as study correlation between them. STUDY DESIGN: Cross-sectional survey. METHOD: Fifty female teachers were enrolled in the study in two different groups (1) twenty-five teachers with MTD (with mean age of 42.62 ± 3.58 years) and (2) 25 teachers without MTD (with mean age of 44.50 ± 3.49 years). All participants completed the Persian version of VHI and underwent multiparametric measurement of voice by the DSI; these subjective and objective voice measures were compared between two groups and their relation was studied. RESULTS: There was significant difference in the VHI, DSI, and their components in teachers with and without MTD (P < 0.05). No significant correlation was found between the total score of VHI and DSI score in the teachers with MTD (rPearson: 0.04, p: 0.82), although there was significant correlation between them in the teachers without MTD (rPearson: -0.75, p: 0.001). CONCLUSION: Teachers with MTD demonstrated higher voice handicap and lower voice quality compared to the teachers without MTD. Moreover, dysphonia interrupted relation between the results of self-perceived evaluation and multiparametric measurement of voice in the teachers with MTD in while these assessments were parallel in the healthy teachers. Further studies are recommended to transparent relation between objective and subjective voice assessments in healthy population.

Dysphonia Severity Index and Consensus Auditory-Perceptual Evaluation of Voice Outcomes, and Their Relation in Hospitalized Patients with COVID-19.

OBJECTIVES: This study aimed to compare the results of the Dysphonia Severity Index (DSI) and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) between patients hospitalized with COVID-19 and healthy subjects, as well as to investigate the correlation between DSI and CAPE-V. STUDY DESIGN: Cross-sectional survey. MATERIAL AND METHODS: Eighty subjects, 40 COVID-19 patients (with a mean age of 41.2± 5.41) and 40 healthy subjects (with a mean age of 44.50± 3.50) participated in this study. Assessments included the DSI for aerodynamic-acoustic measurement and the Persian version of Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) for evaluating auditory-perceptual voice quality. Data were analyzed by means of the independent t-test and Pearson correlation at the 5% significance level. RESULTS: The results showed COVID-19 patients got significantly lower score in DSI compared to healthy subjects (P < 0.05). Moreover, the patients with COVID-19 had higher scores in all categories of voice production (severity, roughness, loudness, pitch, strain and breathiness) than the healthy group (P < 0.05). Comparing the result of the two voice assessments in each group revealed that there was a greater negative significant correlation in the diseased group (r p: -0.68, P: 0.001) than in the healthy group (r p: -0.37,P: 0.049). CONCLUSIONS: Hospitalized COVID-19 patients experience deviations in the voice quality and acoustic-aerodynamic features of their voice. Also, the results of this study showed the patient group had higher perceptual dysphonia and lower voice quality compared to the healthy group. Further studies are recommended to determine the relationship between objective and subjective voice evaluation in patients with COVID-19 after recovery.

Comparative Study of Increased Supraglottic Activity in Normal Individuals and those with Muscle Tension Dysphonia (MTD).

OBJECTIVES: Excessive or disharmonious activity of internal and external laryngeal muscles causes a type of dysphonia known as muscle tension dysphonia (MTD). MTD is often diagnosed based on laryngoscopic findings and clinical history. Several diagnostic and classification systems have so far been proposed based on increased supraglottic activity to determine MTD. Various studies have shown that increased supraglottic activity may also be observed in those with normal voice. The present study aimed to precisely examine the incidence of abnormal muscle tension pattern (aMTP) in those with normal voice in comparison with those with MTD. The secondary goal of this study was comparative examination of acoustic parameters and maximum phonation time (MPT) in the group with MTD and normal individuals. MATERIAL AND METHODS: Participants were 75 people with MTD (41 women and 34 men) and 50 individuals with normal voice and no history of dysphonia (20 women and 30 men). Laryngoscopic evaluation was performed for all participants by considering four types of aMTP. Acoustic analyses, including cepstral peak prominence, jitter, shimmer and NHR, as well as MPT examination were performed. RESULTS: A significant difference between the MTD group and control group was observed in all MTPs except for MTP 2 (lateral-to-medial approximation of the false vocal folds) (P = 0.367, χ2(1) = 0.81). In other MTPs, a significant difference existed between the control and MTD groups in terms of aMTP incidence (P < 0.05). CONCLUSION: On the four aMTPs, results revealed that one must exercise caution in diagnosing MTD based on MTP 2 (medial compression of ventricular folds), and this must not be the sole criterion for diagnosis. Moreover, cepstral peak prominence and MPT analyses are of high clinical significance.

Quality of Life After Botulinum Toxin Injection in Patients With Adductor Spasmodic Dysphonia; a Systematic Review and Meta-analysis.

INTRODUCTION: Adductor spasmodic dysphonia is an extremely disabling voice disorder that negatively impacts a patient's quality of life (QOL). We performed a systematic review to determine if Botulinum Toxin (BT) injections improved voice related QOL in patients with this disorder. METHODS: PubMed, EMBASE, Web of Science, Cochrane Library, ProQuest, and Scopus from 2000, to and including November 1st, 2018, were searched. We identified randomized controlled trials, controlled trials, and observational studies of the effects of BT injections on the QOL in patients with adductor spasmodic dysphonia. The two authors, separately and individually chose the studies based on inclusion criteria, assessed study quality, and relevant extracted data. RESULTS: Nine studies used the Voice Handicap Index (VHI). The results showed significant changes pre- to post-BT injection (SMD = -0.357; 95% CI: -0.579, -0.136; z = 3.16; P = 0.002; I-squared = 0.000%). Five studies used the Voice-Related QOL; their results also showed a significant improvement pre- to postinjection (SMD = -2.99; 95% CI: -3.27, -1.32; z = 4.61; P < 0.001; I-squared = 87%). Three other studies used other, shortened versions of the VHI, VHI-10. They also showed significant results (SMD = -0.145; 95% CI: -0.349, 0.06; z = 1.38; P = 0.17; I-squared = 0.000). CONCLUSION: BT injections positively affect patients' QOL. However, patients' QOL scores may never be normalized, in line with perceptual voice quality and acoustic parameters.

Voice Component Relationships with High Reflux Symptom Index Scores in Muscle Tension Dysphonia.

OBJECTIVE: To analyze the Reflux Symptom Index (RSI) and the Voice-Related Quality of Life (V-RQOL) scores based on the perceptual and analytical parameters in primary MTD patients with no reflux. STUDY DESIGN: Cross-sectional study. METHODS: One hundred and eighteen participants, that is, sixty patients with normal voices and fifty-eight patients with primary MTD were recruited in this study. The diagnosis of primary MTD was made by perceptual voice analysis, neck palpation, video-laryngoscopic examination, and exclusion of other etiologies. Acoustic analysis and the GRBAS (Grade, Roughness, Breathiness, Asthenia, and Strain) scale were evaluated for all participants. The V-RQOL and RSI questionnaires were then given to all participants. RESULTS: This study included 118 participants of 29 males (48.3%) and 31 females (51.7%) in the normal group. MTD group also included 27 males (46.6%) and 31 (53.4%) female patients. Mean (SD) RSI and V-RQOL scores were 12.35 (3.84) and 11.09 (2.20) for the normal group, and 22.87 (6.97) and 22.89 (7.94) for the MTD group (P = .000). In the MTD group, V-RQOL had a positive correlation with jitter for /i/ and /u/, Noise to Harmonic Ratio (NHR) for /i/, /a/, and /u/, and Grade, Roughness, and Strain of GRBAS scale (P < .05). In addition, RSI had a positive correlation with Strain in the MTD group (P < .05). CONCLUSION: MTD patients in the absence of laryngopharyngeal reflux findings may have high RSI scores. Hence, patients with high RSI scores and disproportionate acoustic and perceptual analysis would require a thorough evaluation of MTD. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1573-E1579, 2021.

Transcutaneous Electrical Nerve Stimulation Combined With Voice Therapy in Women With Muscle Tension Dysphonia.

OBJECTIVES: The purpose of the present study was to investigate the effect of Voice Therapy (VT) with and without Transcutaneous Electrical Nerve Stimulation (TENS) in women with Muscle Tension Dysphonia (MTD). METHODS: A total of 20 women with MTD participated in the study. Participants underwent evaluation of auditory-perceptual assessment, acoustic voice analysis, Vocal Tract Discomfort (VTD), and musculoskeletal pain before and after the treatment. The participants were divided into two groups: (1) TENS + VT group (10 participants) and (2) VT group (10 participants). Both groups received 10 sessions of treatment, twice a week, each lasting 50 minutes. The statistical analysis was performed using Wilcoxon signed ranked and Mann-Whitney U tests (P < 0.05). RESULTS: After VT, significant improvements were observed in all auditory-perceptual parameters and all VTD items except for the tickling frequency and severity. The VT caused significant reduction in the frequency of pain in anterior neck, posterior neck, and the larynx. Also, VT resulted in a significant reduction in pain intensity only in the larynx. After VT + TENS, significant improvements were observed in all auditory-perceptual parameters, shimmer, and all VTD items. Moreover, the VT + TENS led to a significant decrease in the frequency and intensity of pain in anterior neck, posterior neck, the larynx, masseters, shoulders, and upper back. The findings of between-group comparison after treatment showed significantly more reduction in the frequency (dry and pain items) and severity (tight and pain items) of the VTD in VT + TENS group compared with VT group. Regarding the musculoskeletal pain, significantly more reduction in the frequency and intensity of pain in anterior neck and the larynx was observed in VT + TENS group compared with VT group. CONCLUSIONS: The VT and VT + TENS could lead to positive outcomes in auditory perceptual assessment, acoustic voice analysis, the VTD, and assessment of musculoskeletal pain. In some items of frequency and severity of VTD scale and assessment of musculoskeletal pain, VT + TENS also produced better results compared with VT. As a result, TENS was recommended as a complementary therapy for patients with MTD, especially when these patients had more complaints about VTD and musculoskeletal pain.

Quality of Life and Voice Changes After a Single Injection in Patients With ADSD Over Time.

INTRODUCTION: Adductor spasmodic dysphonia (ADSD) is one of the most disabling voice disorders with no permanent cure. Patients with ADSD suffer from poor voice quality and repeated interruption of phonation that leads to limitations in daily communication. Botox (BT) injection, considered the gold standard treatment for ADSD, reduces the amount of voice breaks and improves voice quality for a limited period. In this study, patients with ADSD were followed after a single BT injection to track the changes in QOL and perceptual voice quality over a 6-month period. METHOD: This is a prospective and longitudinal study. Fifteen patients with ADSD were evaluated preinjection and 1, 3, and 6 months postinjection. They completed the Voice Activity and Participation Profile-Persian Version (VAPPP) and read a passage at each recording period. Perceptual assessment was done by three expert speech-language pathologists with knowledge of ADSD using the grade, roughness, breathiness, asthenia, strain (GRBAS) scale. The data were analyzed using Friedman, Wilcoxon, and McNemar tests. The significance level was set at P < 0.05. RESULTS: The VAPPP total score and each of the domain scores reached their peak scores at 3 months postinjection. At 6 months postinjection, the VAPPP scores increased significantly in comparison with the 3-month scores and but were lower than preinjection scores. GRBAS results also indicated that patients' voices at 1 and 3 months postinjection were significantly less severe in terms of strain and roughness (P = 0.01; P < 0.001, respectively). CONCLUSION: BT injection resulted in improvement of subjects' QOL. The improvement was greatest at 3 months postinjection but remained above the preinjection values at 6 months after injection. The voice quality also improved but was not judged as normal.

The Design and Assessment of a Multiparametric Model for the Dysphonia Severity Index for Persian-speaking Populations.

OBJECTIVES: In instrumental voice assessment, multiparametric models reflect the multidimensional nature of voice and are therefore better than models that reflect only a single dimension of voice. The Dysphonia Severity Index (DSI) is one of the most common multiparametric models. In voice assessment, race, language, and structural and physiological features affect the acoustic, aerodynamic, and voice range profile measures. Given these differences, this study was conducted to design and evaluate a multiparametric and objective model for assessing the severity of dysphonia in Persian-speaking populations. MATERIAL AND METHODS: This study examined 300 participants with several types of dysphonia (104 women and 196 men) and 100 healthy individuals (63 women and 37 men). Five acoustic parameters, three aerodynamic parameters, and seven voice range profile parameters were measured for designing the model. Perceptual evaluation was performed using the grade, roughness, breathiness, asthenia, strain scale. The logistic regression analysis was used to determine the factors affecting the DSI and each component's coefficient. RESULTS: Of the 15 parameters assessed, shimmer, vital capacity, semitone range, and voice onset time of /pa/ remained in the model with their coefficients. This section presents the DSI model for the examined population. The discriminant analysis showed that this combination corresponds to 47.8 of the perceptual assessment: DSI = 0.289 (shimmer) + 0.0001 (VC) - 0.059 (STR) - 13.278 (VOT_Pa). CONCLUSION: In this study, the DSI corresponded to the physiological, linguistic, and racial characteristics of the Persian-speaking population with or without voice disorder.

Patient-Based Assessment of Effectiveness of Voice Therapy in Vocal Mass Lesions with Secondary Muscle Tension Dysphonia.

INTRODUCTION: Use of patient-based voice assessment scales is an appropriate method that is frequently used to demonstrate effectiveness of voice therapy. This study was aimed at determining the effectiveness of voice therapy among patients with secondary muscle tension dysphonia (MTD) and vocal mass lesions. MATERIALS AND METHODS: The study design was prospective, with within-participant repeated measures. Thirty-three patients with secondary MTD and vocal mass lesions participated in the study, selected on the basis of voice history, laryngeal palpation, and videostroboscopy examination. An experienced otolaryngologist and one experienced speech language pathologist undertook the diagnostic process. Voice therapy included both direct and indirect techniques and lasted approximately 2 months for all included patients. The voice handicap index (VHI) was used to evaluate the effectiveness of voice therapy among included patients. Paired t-test, size of the standardized effect (ESI), and mean standardized response (ESII) were used to analyze effectiveness of the target voice therapy. RESULTS: The findings of this study indicate a statistically significant improvement after the voice therapy protocol (P<0.05; t>1.96). Results of ESI and ESII demonstrate that the VHI scale is sufficiently responsive to detect voice therapy change (ES>0.8). CONCLUSION: This study recommends a combination of direct and indirect voice therapy in the vocal rehabilitation of patients with secondary MTD and vocal mass lesions. Furthormore, we recommend use of the VHI scale to show voice therapy changes for both clinical and research purposes.

Laryngotracheoesophageal Cleft Type 3 and Severe Laryngotracheomalacia; Delayed Surgical Repair, a Treatment Challenge with an Excellent Outcome.

Laryngotracheoesophageal clefts (LTEC) are rare malformations which involve the upper respiratory and digestive tract. Surgical repair should be undertaken promptly to maintain a secure airway and prevent serious pulmonary aspiration. This paper reports the first case of LTEC type 3 with severe laryngotracheomalacia that was brought to Mofid children's hospital in late infancy with a poor health status. Delayed defect correction was our team strategy for the patient when she had achieved good weight gain. At the age of 22 months in collaboration with the pediatric surgical and otolaryngologist team, the repair of the laryngeal cleft was done with lateral open approach method. She was discharged with tracheostomy and gastrostomy. In the next six months follow up after the surgery tracheostomy decannulation and gastrostomy tube removal were done and the infant is now in regular follow-up.

The Relationship Between the Aerodynamic Parameters of Voice and Perceptual Evaluation in the Iranian Population With or Without Voice Disorders.

OBJECTIVES: Aerodynamic evaluations can provide useful information about the interaction between the respiratory and the phonation systems. The present study was conducted to investigate the relationship of maximum phonation time (MPT), vital capacity (VC), and phonation quotient (PQ) with perceptual evaluation in different types of dysphonia. The relationship between these parameters and the type of dysphonia was also examined. MATERIALS AND METHODS: The study participants consisted of 300 individuals with different types of dysphonia (104 women and 196 men) and 100 healthy samples (63 women and 37 men). A professional speech-language pathologist conducted the perceptual evaluation based on the G (grade) component of the GRBAS scale, which stands for grade, roughness, breathiness, asthenia, and strain. VC was measured using a spirometer and MPT using a stopwatch. PQ was calculated as the ratio of VC to MPT. RESULTS: The difference between the mean ± standard deviation of PQ, VC, and MPT were found to be significant at all the four degrees of dysphonia severity (P < 0.001). There was a significant difference in mean MPT and VC between the genders (P < 0.001), but no significant gender differences were observed in terms of the mean PQ (P = 0.346). The study participants were classified into four groups, including the organic dysphonia group, neurologic dysphonia and functional dysphonia groups, and the normal group; the study variables measured were found to be significantly different between all the four groups (P < 0.001). CONCLUSION: As MPT and PQ were correlated with the perceptual G (grade) and differentiated dysphonic from healthy individuals, clinicians are recommended to take account of them in their instrumental evaluations.