Vocal fold electromyography in patients with endoscopic features of unilateral laryngeal paralysis.

<b><br>Introduction:</b> Electromyography (EMG) of the larynx provides information on the electrophysiological condition of laryngeal muscles and innervation. Integration of information obtained from the EMG exams with the clinical parameters as obtained by other methods for laryngeal assessment (endoscopy, perceptual and acoustic analysis, voice self-assessment) provides a multidimensional picture of dysphonia, which is of particular importance in patients with vocal fold (VF) mobility disorders accompanied by glottic insufficiency.</br> <b><br>Aim:</b> The aim of this study was to evaluate laryngeal EMG records acquired in subjects with unilateral vocal fold immobilization with signs of atrophy and glottic insufficiency.</br> <b><br>Material and methods:</b> From the available material of 74 EMG records of patients referred for the exam due to unilateral laryngeal paralysis, records of 17 patients with endoscopic features suggestive of complete laryngeal muscle denervation were selected. The EMG study of thyroarytenoid muscles of mobile and immobile VFs was evaluated qualitatively and quantitatively at rest and during volitional activity involving free phonation of vowel /e/ [ε].</br> <b><br>Results:</b> In all patients, the EMG records from mobile VFs were significantly different from those from immobile VFs. Despite endoscopic features of paralysis, no VF activity whatsoever was observed in as few as 2 patients so as to meet the neurophysiological definition of paralysis. In 88% of cases, electromyographic activity of the thyroarytenoid muscle was observed despite immobilization and atrophy of the vocal fold. In these patients, neurogenic type of record was observed with numerous high- -amplitude mobility units. On the basis of the results, quantitative features of EMG records indicative of paralysis and residual activity of the thyroarytenoid muscle were determined.</br> <b><br>Conclusions:</b> Qualitative and quantitative analysis of laryngeal EMG records provides detailed information on the condition of vocal fold muscles and innervation. EMG records of mobile vs immobile VFs differ significantly from each other. Endoscopic evaluation does not provide sufficient basis for the diagnosis of complete laryngeal muscle denervation.</br>.

Effect of Akson Therapy on Acoustic Parameters in Patients with Functional Dysphonia.

OBJECTIVE: Functional dysphonia can impair the language expression ability and adversely affect the career development of some patients. Therefore, an active exploration of effective treatment options is imperative. This study investigated the effect of Akson therapy on acoustic parameters in patients with functional dysphonia. MATERIALS AND METHODS: In this retrospective analysis, 79 patients with functional dysphonia who received conventional voice correction training from June 2020 to June 2021 were included in the reference group (RG). Our hospital has implemented Akson therapy since July 2021. Correspondingly, 72 patients with functional dysphonia who underwent Akson therapy from July 2021 to July 2022 were enrolled in the observation group (OG). The acoustic parameters such as fundamental frequency (F0), jitter, shimmer, and normalized noise energy (NNE); the aerodynamic parameters including maximum phonation time (MPT), mean airflow rate (MFR), and Voice Handicap Index-10 (VHI-10) score; and the Grade, Roughness, Breathiness, Asthenia, and Strain scale (GRBAS) score were measured before and after treatment and compared between the two groups. RESULTS: The F0, jitter, shimmer, NNE, MPT, and MFR values as well as the VHI-10 score and the grade (G), roughness (R), and breathiness (B) scores on the GRBAS did not significantly differ between the two groups before treatment (P > 0.05). However, significantly lower F0, jitter, shimmer, NNE, and MFR values and higher MPT levels were found in the OG compared to the RG after treatment (P < 0.001). Furthermore, the VHI-10 score and the G, R, and B scores were significantly lower in the OG than in the RG after treatment (P < 0.001), whereas the asthenia (A) and strain (S) scores remained at 0 before and after treatment. CONCLUSION: Akson therapy can improve the acoustic parameters of patients with functional dysphonia to a certain extent, indicating its potential application value.

The influence of listener experience, measurement scale and speech task on the reliability of auditory-perceptual evaluation of vocal quality.

PURPOSE: To assess the influence of the listener experience, measurement scales and the type of speech task on the auditory-perceptual evaluation of the overall severity (OS) of voice deviation and the predominant type of voice (rough, breathy or strain). METHODS: 22 listeners, divided into four groups participated in the study: speech-language pathologist specialized in voice (SLP-V), SLP non specialized in voice (SLP-NV), graduate students with auditory-perceptual analysis training (GS-T), and graduate students without auditory-perceptual analysis training (GS-U). The subjects rated the OS of voice deviation and the predominant type of voice of 44 voices by visual analog scale (VAS) and the numerical scale (score "G" from GRBAS), corresponding to six speech tasks such as sustained vowel /a/ and /ɛ/, sentences, number counting, running speech, and all five previous tasks together. RESULTS: Sentences obtained the best interrater reliability in each group, using both VAS and GRBAS. SLP-NV group demonstrated the best interrater reliability in OS judgment in different speech tasks using VAS or GRBAS. Sustained vowel (/a/ and /ɛ/) and running speech obtained the best interrater reliability among the groups of listeners in judging the predominant vocal quality. GS-T group got the best result of interrater reliability in judging the predominant vocal quality. CONCLUSION: The time of experience in the auditory-perceptual judgment of the voice, the type of training to which they were submitted, and the type of speech task influence the reliability of the auditory-perceptual evaluation of vocal quality.

Oncocytic papillary cystadenoma of the larynx: a case report.

BACKGROUND: Cystadenoma of the salivary glands is a rare benign clinical condition affecting both major and minor salivary glands equally. It constitutes approximately 2% of total neoplasms and 4.2-4.7% of benign formations in minor salivary glands. Typically presenting as a slow-growing, painless neoplasm, it can be distinguished from Cystadenolymphoma (Whartin's Tumor) by the absence of lymphoid elements in histological examination. While mostly located in the oral cavity and oropharynx, it can also be found in sinonasal mucosa, and rare cases have been identified in the larynx. CASE PRESENTATION: A 75-year-old Caucasian woman presented to the ear, nose, and throat department with complaints of dysphonia and headaches persisting for several months. Dysphonia had developed months after an unspecified vocal cord surgery elsewhere. Flexible laryngoscopy identified a left-sided cystic swelling affecting the supraglottic space, leading to respiratory obstruction and dysphonia. Head and neck computed tomography confirmed a 1.9 × 1.7 cm bilobed cystic mass originating from the left Morgagni ventricle. Microlaryngoscopy with CO2 laser excision and biopsy revealed a histopathological diagnosis of oncocytic papillary cystadenoma. Post-surgery, the patient fully recovered from dysphonia, with no significant complications noted. Long-term clinical surveillance was advised to detect potential recurrences promptly. CONCLUSION: Ectopic minor salivary gland tumors, both benign and malignant, should be taken into consideration as potential differential diagnosis for any swelling arising within the upper digestive tract mucosa. Ears, nose, and throat clinical examination completed by videolaryngoscopy can easily point out the location of the mass. Imaging is mandatory for differential diagnosis and for surgical planning. Surgical excision can provide both diagnosis and definitive cure.

Functional and structural abnormalities of the speech disorders: a multimodal activation likelihood estimation meta-analysis.

Speech disorders are associated with different degrees of functional and structural abnormalities. However, the abnormalities associated with specific disorders, and the common abnormalities shown by all disorders, remain unclear. Herein, a meta-analysis was conducted to integrate the results of 70 studies that compared 1843 speech disorder patients (dysarthria, dysphonia, stuttering, and aphasia) to 1950 healthy controls in terms of brain activity, functional connectivity, gray matter, and white matter fractional anisotropy. The analysis revealed that compared to controls, the dysarthria group showed higher activity in the left superior temporal gyrus and lower activity in the left postcentral gyrus. The dysphonia group had higher activity in the right precentral and postcentral gyrus. The stuttering group had higher activity in the right inferior frontal gyrus and lower activity in the left inferior frontal gyrus. The aphasia group showed lower activity in the bilateral anterior cingulate gyrus and left superior frontal gyrus. Across the four disorders, there were concurrent lower activity, gray matter, and fractional anisotropy in motor and auditory cortices, and stronger connectivity between the default mode network and frontoparietal network. These findings enhance our understanding of the neural basis of speech disorders, potentially aiding clinical diagnosis and intervention.

Patient With Dysphonia.

A male individual in his 60s presented with a hoarse and weak voice and a history of follicular lymphoma with multiple relapses treated with an allogeneic stem cell transplant complicated by graft-vs-host disease treated with sirolimus and steroids. What is your diagnosis?

Development and Validation of the Bilingual Catalan/Spanish Cross-Cultural Adaptation of the Consensus Auditory-Perceptual Evaluation of Voice.

PURPOSE: This study aimed to develop a valid and reliable bilingual version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) for the auditory-perceptual evaluation of voice in Catalan and Spanish speakers. METHOD: The development of this CAPE-V adaptation included Delphi methodology with 20 voice and speech experts reaching consensus on the optimal adapted terminology of the perceptual vocal attributes, considering also input from the original instrument authors. The adaptation and validation of vocal tasks followed a sequential validation procedure, with input from phoneticians and speech-language pathologists. Following pilot testing with a large sample of speech-language pathology students, a refined adapted version was empirically tested for validity and reliability. Concurrent validity was assessed by comparing the adapted CAPE-V with the reference Grade, Roughness, Breathiness, Asthenia, Strain scale. Construct validity was assessed through convergent and discriminant validity analysis. Intrarater and interrater reliability were assessed via intraclass correlation coefficient calculations. User experience was evaluated through a questionnaire. Scale properties were validated using a confusion matrix, and cutoff values were calculated to achieve the optimal balance between sensitivity and specificity. RESULTS: Through a formalized consensus process, optimal Catalan/Spanish terminology was determined for the perceptual attributes of voice present in the CAPE-V. An adapted protocol of tasks was obtained that preserves the objectives of the original instrument and the relevance of the phonetic criteria in the target languages. The results demonstrated concurrent validity, construct validity, and intrarater reliability. Interrater reliability was found to depend on the extent to which evaluators shared their internal standards. The raters identified CAPE-V as an effective and preferred instrument. CONCLUSION: An adapted, validated version of the CAPE-V is made available to clinical professionals for the evaluation of voice in Catalan and Spanish speakers.

Clinical effectiveness of telerehabilitation in voice therapy programs for dysphonia.

PURPOSE: The main aim of this study was to investigate the clinical efficacy of speech therapy, delivered via tele-practice to patients with dysphonia. A secondary aim was to verify whether a telerehabilitation-only protocol could have a clinical efficacy similar to a combined telerehabilitation and in-person approach. METHODS: Thirty-two consecutive patients undergoing telerehabilitation for dysphonia were retrospectively considered. Patients were divided into two groups: those who received combined in-person and telerehabilitation treatment, and those who underwent telerehabilitation only. RESULTS: Overall, patients included in this study showed a significant improvement in their VHI-10 scores after treatment (p < 0.001). Such an improvement was also significant in both combined therapy and telerehabilitation only groups (p = 0.019, and p = 0.002, respectively). A significant reduction in general degree of dysphonia (G), roughness (R), breathiness (B) and strain (S) scores (p < 0.001, p = 0.012, p < 0.001, and p < 0.001, respectively) was noticed over the whole sample after treatment. The same parameters showed a significant improvement also in the combined therapy group, while in the telerehabilitation only group, only G, B and S scores significantly improved. Mean phonation time, Jitter and Shimmer values significantly improved in the overall sample as well as in the combined therapy group. A significantly more favorable spectrographic class relative to the vowel /a/ was found after treatment in the whole sample, as well as in both combined therapy and telerehabilitation only groups (p < 0.001, p = 0.002, p = 0.004, respectively). CONCLUSION: This study's results seem to support telerehabilitation as a potentially effective tool to administer speech therapy in dysphonic patients, both as a single modality and in combination with traditional in-person sessions. To better characterize the clinical results of telerehabilitation in dysphonia treatment, large-scale prospective investigations are mandatory.

Intensive Voice Treatment following Botulinum Neurotoxin Injection for a Speaker with Abductor Laryngeal Dystonia: An Exploratory Case Study.

Abductor laryngeal dystonia (ABLD) is a rare neurological voice disorder which results in sporadic opening of the vocal folds during speech. Etiology is unknown, and to date there is no identified effective behavioral treatment for it. It is hypothesized that LSVT LOUD®, which was developed to treat dysphonia secondary to Parkinson's disease, may have application to speakers with ABLD to improve outcomes beyond that with botulinum neurotoxin (BoNT) treatment alone. The participant received one injection of BoNT in each vocal fold 2 to 3 months prior to initiating intensive voice therapy via teletherapy. Objective measures of vocal loudness (dB sound pressure level), maximum phonation time, and high/low pitch frequency (Hz) were recorded in all treatment sessions and follow-up sessions. Over the course of treatment, the participant showed steady gains in phonation time, volume, pitch range, and vocal quality with a substantial reduction in aphonic voice breaks by the end of the treatment program. Perceptual symptoms of ABLD were nearly undetectable by the participant and the clinicians up to 12 months posttreatment, with no additional BoNT injections. The results suggest that LSVT LOUD® following BoNT was effective, with long-lasting improvement in vocal function, for this speaker with ABLD.

Predicting Dysphonia by Measuring Surface Electromyographic Activity of the Supralaryngeal Muscles.

PURPOSE: This study set out to investigate whether individuals with dysphonia, as determined by either self-assessment or clinician-based auditory-perceptual judgment, exhibited differences in perilaryngeal muscle activities using surface electromyography (sEMG) during various phonatory tasks. Additionally, the study aimed to assess the effectiveness of sEMG in identifying dysphonic cases. METHOD: A total of 77 adults (44 women, 33 men, Mage = 30.4 years) participated in this study, with dysphonic cases identified separately using either a 10-item Voice Handicap Index (VHI-10) or clinician-based auditory-perceptual voice quality (APVQ) evaluation. sEMG activities were measured from the areas of suprahyoid and sternocleidomastoid muscles during prolonged vowel /i/ phonations at different pitch and loudness levels. Normalized root-mean-square value against the maximal voluntary contraction (RMS %MVC) of the sEMG signals was obtained for each phonation and compared between subject groups and across phonatory tasks. Additionally, binary logistic regression analysis was performed to determine how the sEMG measures could predict the VHI-10-based or APVQ-based dysphonic cases. RESULTS: Participants who scored above the criteria on either the VHI-10 (n = 29) or APVQ judgment (n = 17) exhibited significantly higher RMS %MVC in the right suprahyoid muscles compared to the corresponding control groups. Although the RMS %MVC value from the right suprahyoid muscles alone was not a significant predictor of self-evaluated dysphonic cases, a combination of the RMS %MVC values from both the right and left suprahyoid muscles significantly predicted APVQ-based dysphonic cases with a 69.66% fair level. CONCLUSIONS: This study found that individuals with dysphonia, as determined by either self-assessment or APVQ judgment, displayed more imbalanced suprahyoid muscle activities in voice production compared to nondysphonic groups. The combination of the sEMG measures from both left and right suprahyoid muscles showed potential as a predictor of dysphonia with a fair level of confidence. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.25112804.

The mechanism of action for laryngeal manual therapies: the need for an update.

PURPOSE OF REVIEW: To propose a pathway for expanding the understanding of potential mechanisms of action with laryngeal-based manual therapy (LMT) for muscle tension dysphonia (MTD). This review may help determine if current LMT literature has kept up with advances in the more general manual therapy (MT) findings. RECENT FINDINGS: Studies over the past thirty years, including recently published articles, have confirmed the efficacy of various manual therapy interventions in treating MTD. However, gaps exist between current LMT literature and that being presented in the more general MT field. Instead of viewing peripheral manipulation's influences as a local cause/effect process, the MT literature paints a richer tapestry of centrally mediated impacts. SUMMARY: Evidence from outside the LMT field has introduced a broad tapestry of factors that may contribute to the efficacy of MT, extending beyond the local effects reported in LMT literature. To better understand the effect and mechanism of action touch-based interventions have on a patient's voice and to potentially improve outcomes, it is necessary to broaden investigations to include a broader range of perspectives.

Squamous Cell Carcinoma of the Supraglottis Presenting as Hoarseness.

Hoarseness is a well-known condition in primary care offices, with over 1% of primary care visits secondary to this ailment.1 The most common causes are acute laryngitis (40%), functional dysphonia (30%), benign and malignant tumors (2.2 to 30%), neurogenic factors such as vocal cord paralysis (8%), physiological aging (2%), and psychogenic factors (2.2%). Most of these cases are secondary to viral infections and do not require antibiotics on most occasions. These viral infections subside after 1 to 2 weeks, and in the case of persistent hoarseness (above 4 weeks) the American Academy of Otolaryngology recommends direct visualization with a laryngoscopy before treatment with proton pump inhibitors, antibiotics, or steroids. Our patient presented with prolonged hoarseness (greater than eight weeks) but had a quick turn around time interval between primary care visit and laryngoscopy evaluation (less than 2 weeks). This led to her diagnosis and treatment with chemo and radiation therapy within three months of diagnosis with Squamous Cell Carcinoma of the Supraglottis. The Primary care physician serves as the number one point of visitation by sufferers of hoarseness. It is important that they are knowledgeable and up to date with recommendations and guidelines for managing this condition, as unwarranted delay can affect overall outcome on the part of the patient. This is especially important in patients such as ours with high risk factors including Nicotine dependence, alcohol use, asbestos exposure, and HPV infection.

La voix rauque est une condition bien connue dans les cabinets de soins primaires, avec plus de 1 % des visites en soins primaires dues à ce problème. Les causes les plus courantes sont la laryngite aiguë (40%), la dysphonie fonctionnelle (30 %), les tumeurs bénignes et malignes (2,2 à 30 %), les facteurs neurogènes tels que la paralysie des cordes vocales (8 %), le vieillissement physiologique (2 %) et les facteurs psychogènes (2,2 %). La plupart de ces cas sont dus à des infections virales et ne nécessitent pas d'antibiotiques dans la plupart des cas. Ces infections virales disparaissent après 1 à 2 semaines, et en cas de voix rauque persistante (plus de 4 semaines), l'American Academy of Otolaryngology recommande une visualisation directe avec une laryngoscopie avant le traitement par inhibiteurs de la pompe à protons, antibiotiques ou stéroïdes. Notre patiente présentait une voix rauque prolongée (plus de huit semaines), mais a bénéficié d'un délai rapide entre la visite en soins primaires et l'évaluation par laryngoscopie (moins de 2 semaines). Cela a conduit à son diagnostic et à son traitement par chimiothérapie et radiothérapie dans les trois mois suivant le diagnostic de carcinome épidermoïde du supraglotte. Le médecin de soins primaires est le premier point de visite pour les personnes souffrant de voix rauque. Il est important qu'ils soient informés et à jour des recommandations et des lignes directrices pour la prise en charge de cette condition, car un retard non justifié peut affecter le résultat global pour le patient. Ceci est particulièrement important chez les patients comme le nôtre présentant des facteurs de risque élevés, y compris la dépendance à la nicotine, la consommation d'alcool, l'exposition à l'amiante. MOTS-CLÉS: Laryngoscopie, Supraglotte, Larynx, Enrouement.

Machine learning based estimation of hoarseness severity using sustained vowelsa).

Auditory perceptual evaluation is considered the gold standard for assessing voice quality, but its reliability is limited due to inter-rater variability and coarse rating scales. This study investigates a continuous, objective approach to evaluate hoarseness severity combining machine learning (ML) and sustained phonation. For this purpose, 635 acoustic recordings of the sustained vowel /a/ and subjective ratings based on the roughness, breathiness, and hoarseness scale were collected from 595 subjects. A total of 50 temporal, spectral, and cepstral features were extracted from each recording and used to identify suitable ML algorithms. Using variance and correlation analysis followed by backward elimination, a subset of relevant features was selected. Recordings were classified into two levels of hoarseness, H<2 and H≥2, yielding a continuous probability score y∈[0,1]. An accuracy of 0.867 and a correlation of 0.805 between the model's predictions and subjective ratings was obtained using only five acoustic features and logistic regression (LR). Further examination of recordings pre- and post-treatment revealed high qualitative agreement with the change in subjectively determined hoarseness levels. Quantitatively, a moderate correlation of 0.567 was obtained. This quantitative approach to hoarseness severity estimation shows promising results and potential for improving the assessment of voice quality.

Direct subthalamic nucleus stimulation influences speech and voice quality in Parkinson's disease patients.

BACKGROUND: DBS of the subthalamic nucleus (STN) considerably ameliorates cardinal motor symptoms in PD. Reported STN-DBS effects on secondary dysarthric (speech) and dysphonic symptoms (voice), as originating from vocal tract motor dysfunctions, are however inconsistent with rather deleterious outcomes based on post-surgical assessments. OBJECTIVE: To parametrically and intra-operatively investigate the effects of deep brain stimulation (DBS) on perceptual and acoustic speech and voice quality in Parkinson's disease (PD) patients. METHODS: We performed an assessment of instantaneous intra-operative speech and voice quality changes in PD patients (n = 38) elicited by direct STN stimulations with variations of central stimulation features (depth, laterality, and intensity), separately for each hemisphere. RESULTS: First, perceptual assessments across several raters revealed that certain speech and voice symptoms could be improved with STN-DBS, but this seems largely restricted to right STN-DBS. Second, computer-based acoustic analyses of speech and voice features revealed that both left and right STN-DBS could improve dysarthric speech symptoms, but only right STN-DBS can considerably improve dysphonic symptoms, with left STN-DBS being restricted to only affect voice intensity features. Third, several subareas according to stimulation depth and laterality could be identified in the motoric STN proper and close to the associative STN with optimal (and partly suboptimal) stimulation outcomes. Fourth, low-to-medium stimulation intensities showed the most optimal and balanced effects compared to high intensities. CONCLUSIONS: STN-DBS can considerably improve both speech and voice quality based on a carefully arranged stimulation regimen along central stimulation features.

Multitask and Transfer Learning Approach for Joint Classification and Severity Estimation of Dysphonia.

OBJECTIVE: Despite speech being the primary communication medium, it carries valuable information about a speaker's health, emotions, and identity. Various conditions can affect the vocal organs, leading to speech difficulties. Extensive research has been conducted by voice clinicians and academia in speech analysis. Previous approaches primarily focused on one particular task, such as differentiating between normal and dysphonic speech, classifying different voice disorders, or estimating the severity of voice disorders. METHODS AND PROCEDURES: This study proposes an approach that combines transfer learning and multitask learning (MTL) to simultaneously perform dysphonia classification and severity estimation. Both tasks use a shared representation; network is learned from these shared features. We employed five computer vision models and changed their architecture to support multitask learning. Additionally, we conducted binary 'healthy vs. dysphonia' and multiclass 'healthy vs. organic and functional dysphonia' classification using multitask learning, with the speaker's sex as an auxiliary task. RESULTS: The proposed method achieved improved performance across all classification metrics compared to single-task learning (STL), which only performs classification or severity estimation. Specifically, the model achieved F1 scores of 93% and 90% in MTL and STL, respectively. Moreover, we observed considerable improvements in both classification tasks by evaluating beta values associated with the weight assigned to the sex-predicting auxiliary task. MTL achieved an accuracy of 77% compared to the STL score of 73.2%. However, the performance of severity estimation in MTL was comparable to STL. CONCLUSION: Our goal is to improve how voice pathologists and clinicians understand patients' conditions, make it easier to track their progress, and enhance the monitoring of vocal quality and treatment procedures. Clinical and Translational Impact Statement: By integrating both classification and severity estimation of dysphonia using multitask learning, we aim to enable clinicians to gain a better understanding of the patient's situation, effectively monitor their progress and voice quality.

Perceptions of employability related to severity of hypernasality: a pilot study.

The primary aim of this investigation was to evaluate listener auditory-perceptual assessment of employability for individuals with hypernasal speech. Using an online survey platform, listeners with managerial experience evaluated speech samples from individuals with varying hypernasal resonance disorder severity to determine auditory-perceptual judgements regarding intelligence and employability. Speech samples of individuals with hypernasal speech were rated lower on scales of intelligence and employability, and more likely to be selected for jobs with infrequent rates of communication and lower levels of responsibility. Additionally, males with hypernasal speech were perceived as less intelligent, less employable, and more likely to be selected for a job with infrequent communication in comparison to females with hypernasal speech. Results of this preliminary investigation suggest that individuals with hypernasal speech may face employment barriers. The conclusions collected from this initial investigation open the doors for further research addressing linguistic considerations and aspects of employability. This is an important consideration for individuals with either acquired or congenitally related hypernasal resonance disorder.