Position Statement of the Union of European Phoniatricians (UEP): Fees and Phoniatricians' Role in Multidisciplinary and Multiprofessional Dysphagia Management Team.

The need for multidisciplinary and multiprofessional management of dysphagia is constantly increasing and creating a major challenge for healthcare professionals and society, especially in terms of professional expertise and human resources. The distribution of tasks among the dysphagia team members, which includes phoniatricians, otolaryngologists, and speech-language therapists, is flexible and overlapping. For assessing dysphagia, the (fibreoptic) flexible endoscopic evaluation of swallowing (FEES), with or without videofluoroscopy, is a pivotal diagnostic tool. This position paper aims to illustrate the phoniatrician's role in performing a FEES, which is an indispensable component of the diagnostic workup of patients suffering from oropharyngeal dysphagia. It is based on the current collaborative expert view of the Swallowing Committee of the Union of European Phoniatricians and a literature review. A FEES is one of the core competences of phoniatricians due to their endoscopic expertise and experience in the field of dysphagia and diseases of the upper aerodigestive tract. Therefore, the phoniatrician is an important member of the dysphagia team, for the medical diagnostics of the aerodigestive tract and dysphagia as well as for FEES. Phoniatric competence is especially important for head and neck cancer patients, infants, and complex cases.

'Malregulative' Rather Than 'Functional' Dysphonia: A New Etiological Terminology Framework for Phonation Disorders-A Position Paper by the Union of European Phoniatricians (UEP).

Practitioners in the field of voice are often faced with patients who are 'dysphonic', but who do not have identifiable abnormalities of the vocal tract structures or any neural or hormonal alteration affecting the phonatory function. For lack of better nomenclature describing the origin of the disorder, this group of patients has been labeled as having 'non-organic' or 'functional' dysphonia. 'Non-organic' only states what the dysphonia is not, and 'functional' does not have any etiological implication. Hence 'functional disorder' as a determination of the origin is at best vague, imprecise and often misleading. In truth, the terms "functional" and 'non-organic' are by now so muddled and confused in everyday clinical usage and parlance that it is unclear what they mean in any given clinical setting or for any particular clinical case. Thus, the UEP Voice Committee (VC) has come to the conclusion that it is best to adopt a new term that is clearly defined, universally agreed to, and indicative of a different and more useful perspective. We have reviewed the literature relating to terminology of these phonatory disorders. We now propose replacement of the phrase 'functional dysphonia' with 'malregulative dysphonia', since the indication of faulty regulation represents an etiological connotation. We also propose a restructuring of the etiological terminology of phonation disorders. We believe this to be a biologically clearer framework for the labeling of 'non-organic' phonatory disorders, and hope that its routine use will allow for more clarity of presentation and discussion in the future.

Spasmodic dysphonia, perceptual and acoustic analysis: presenting new diagnostic tools.

In this article, we investigate whether (1) the IINFVo (Impression, Intelligibility, Noise, Fluency and Voicing) perceptual rating scale and (2) the AMPEX (Auditory Model Based Pitch Extractor) acoustical analysis are suitable for evaluating adductor spasmodic dysphonia (AdSD). Voice recordings of 12 patients were analysed. The inter-rater and intra-rater consistency showed highly significant correlations for the IINFVo rating scale, with the exception of the parameter Noise. AMPEX reliably analyses vowels (correlation between PUVF (percentage of frames with unreliable F0/voicing 0.748), running speech (correlation between PVF (percentage of voiced frames)/voicing 0.699) and syllables. Correlations between IINFVo and AMPEX range from 0.608 to 0.818, except for noise. This study indicates that IINFVo and AMPEX could be robust and complementary assessment tools for the evaluation of AdSD. Both the tools provide us with the valuable information about voice quality, stability of F0 (fundamental frequency) and specific dimensions controlling the transitions between voiced and unvoiced segments.

Laryngeal Chondrosarcoma: an Exceptional Localisation of a not Unfrequent Bone Tumor.

After osteosarcoma, chondrosarcoma is the second most common primary bone tumor accounting for 26% of all malignancies. In the laryngeal region however, chondrosarcomas are rather rare. Only 300 cases are reported in literature. Considering laryngeal chondrosarcoma, about 75% occur in the cricoid cartilage, whereas 20% occur in the thyroid cartilage. In this paper we report a case of thyroidal chondrosarcoma, and based on a thorough literature search we suggest some practical guidelines concerning diagnosis and therapy.

Vocal Tract Morphology in Inhaling Singing: Characteristics During Vowel Production-A Case Study in a Professional Singer.

BACKGROUND: A professional singer produced various vowels on a comfortable loudness and pitch in an inspiratory and expiratory phonation manner. The present study investigates the morphological differences and tries to find a link with the acoustical characteristics. OBJECTIVES/HYPOTHESIS: We hypothesize that features, constantly present over all vowels, characterize inhaling phonation and that the formant frequencies reflect the morphological findings. STUDY DESIGN: A prospective case study was carried out. METHODS: A female singer uttered the vowels /a/, /e/, /i/, /o/, and /u/ in a supine position under magnetic resonance imaging, on a comfortable loudness and pitch, in both inhaling and exhaling manner. The exact same parameters as in previous reports were measured (1-3). Acoustical analysis was performed with Praat. RESULTS: Wilcoxon directional testing demonstrates a statistically significant difference in (1) the distance between the lips, (2) the antero-posterior tongue diameter, (3) the distance between the lips and the tip of the tongue, (4) the distance between the epiglottis and the posterior pharyngeal wall, (5) the narrowing of the subglottic space, and (6) the oropharyngeal and the hypopharyngeal areas. Acoustical analysis reveals slightly more noise and irregularity during reverse phonation. The central frequency of F0 and F1 is identical, whereas that of F2 and F3 increases, and that of F4 varies. CONCLUSIONS: A smaller mouth opening, a narrowing of the subglottic space, a larger supralaryngeal inlet, and a smaller antero-posterior tongue diameter can be considered as morphological characteristics for reverse phonation. Acoustically, reverse phonation discretely contains more noise and perturbation. The formant frequency distribution concurs with a mouth narrowing and pharyngeal widening during inhaling.

Cricopharyngeal Botox injection: indications and technique.

PURPOSE OF REVIEW: Botulinum injection is a widespread technique for treating oropharyngeal dysphagia although there are no standards or guidelines. Based on the literature review we try to make some recommendations. RECENT FINDINGS: In the last 12 months molecular and pharmacological research has reported the working mechanism of the various botulinum toxin types which tries to explain former clinical observations such as variable response rate and therefore dosage, and toxin type specific resistance. Recent dose-ranging studies or comparisons of different toxin preparations or types rarely focus on oropharyngeal dysphagia. SUMMARY: Injection of botulinum toxin A should be considered in cases of relative hypertonicity of the cricopharyngeal muscle and has an onset around day 7 and an offset of at least 4 months. The technique is simple and the complication rate is extremely low (7/100). There are some conditions for success: injection in the horizontal part of the cricopharyngeal muscle, and a high enough start dose. Botulinum injection may be preferred over surgical myotomy because of the low risk, low cost and effectiveness of the procedure. Only in cases of BoNT/A resistance should other toxin types be used.

Physiology and Acoustics of Inspiratory Phonation.

INTRODUCTION: Inspiratory phonation (IP) means phonating with inspiratory airflow. Some vocalists remarkably master this technique, to such an extent that it offers new dramatic, aesthetic, and functional possibilities in singing specific contemporary music. The present study aims to a better understanding of the physiological backgrounds of IP. MATERIAL AND METHODS: A total of 51 inhaling utterances were compared with 61 exhaling utterances in a professional soprano highly skilled in inhaling singing, by means of high-speed single-line scanning and advanced acoustic analysis. Ranges of intensity and Fo were kept similar. RESULTS: The main differences are: (1) an inversion of the mucosal wave, (2) a smaller closed quotient in IP, (3) a larger opening/closing quotient in IP with the additional difference that in IP, the quotient is larger than 1 (opening slower than closing), whereas it is less than 1 in expiratory mode (opening faster than closing), (4) a larger vocal-fold excursion in IP, (5) higher values of adaptive normalized noise energy in IP, and (6) a steeper slope of harmonic peaks in IP. However, jitter values are similar (within normal range), as well as damping ratios and central formant frequencies. The two voicing modes cannot be differentiated by blind listening. CONCLUSION: The basic physiological mechanisms are comparable in both voicing modes, although with specific differences. IP is actually to be considered as an "extended vocal technique," a term applied to vocalization in art music, which falls outside of traditional classical singing styles, but with remarkable possibilities in skilled vocalists.

Vocal Tract Morphology in Inhaling Singing: An MRI-Based Study.

OBJECTIVES/HYPOTHESIS: Inhaling singing is a recently developed singing technique explored by the soprano singer Françoise Vanhecke. It is based on an inspiratory airflow instead of an expiratory airflow. This article describes the anatomical structural differences of the vocal tract between inhaling and exhaling singing. We hypothesize that the vocal tract alters significantly in inhaling singing, especially concerning the configuration of the anatomical structures in the oral cavity and the subglottal region. STUDY DESIGN: This is a prospective study. METHODS: A professional singer (F.V.) performed sustained tones from F5 chromatically rising up to Bb5 on the vowel /a/. Vocal tract anatomy is assessed by magnetic resonance imaging. RESULTS: Wilcoxon directional testing demonstrates (1) that the vocal tract volume above the glottal region does not differ statistically in contrast to the subglottal region and (2) significant changes in the configuration of the tongue, the upright position of the epiglottis, the length of the floor of mouth, and the distance between the teeth. CONCLUSIONS: The narrowing of the subglottis is considered to be secondary to suction forces used in the inhaling singing technique. The changes in the anatomical structures above the vocal folds possibly suggest a valve-like function controlling the air inlet together with the regulator function of the resonator capacities of the vocal tract.

Multidimensional assessment of strongly irregular voices such as in substitution voicing and spasmodic dysphonia: a compilation of own research.

This article is a compilation of own research performed during the European COoperation in Science and Technology (COST) action 2103: 'Advance Voice Function Assessment', an initiative of voice and speech processing teams consisting of physicists, engineers, and clinicians. This manuscript concerns analyzing largely irregular voicing types, namely substitution voicing (SV) and adductor spasmodic dysphonia (AdSD). A specific perceptual rating scale (IINFVo) was developed, and the Auditory Model Based Pitch Extractor (AMPEX), a piece of software that automatically analyses running speech and generates pitch values in background noise, was applied. The IINFVo perceptual rating scale has been shown to be useful in evaluating SV. The analysis of strongly irregular voices stimulated a modification of the European Laryngological Society's assessment protocol which was originally designed for the common types of (less severe) dysphonia. Acoustic analysis with AMPEX demonstrates that the most informative features are, for SV, the voicing-related acoustic features and, for AdSD, the perturbation measures. Poor correlations between self-assessment and acoustic and perceptual dimensions in the assessment of highly irregular voices argue for a multidimensional approach.

Postoperative radiotherapy for adenocarcinoma of the ethmoid sinuses: treatment results for 47 patients.

PURPOSE: Ethmoid sinus cancer is a rare malignancy. Treatment results are mostly reported together with other sinonasal tumors, grouping a wide range of different histologies and treatment approaches. This study reports on the treatment outcome of 47 patients diagnosed with adenocarcinoma of the ethmoid sinuses and treated with surgery and high-dose postoperative radiation therapy. METHODS AND MATERIALS: Between September 1985 and October 2001, 51 patients with adenocarcinoma of the ethmoid sinuses were referred to the Ghent University Hospital. Four patients were treated with low-dose palliative radiation because of very extended inoperable disease or distant metastasis at the time of diagnosis. They were not included in this analysis. The other 47 patients, all staged as N0M0, were treated with surgery and postoperative high-dose radiation therapy. The median follow-up was 32 months. The T-stages were T1 for 2, T2 for 17, T3 for 11, and T4 for 17 patients. All 47 patients were staged as N0M0. RESULTS: The 3-year, 5-year, and 7-year overall survival are respectively 71%, 60%, and 38%. The 3-year and 5-year disease-free survival are respectively 62% and 36%. The 3-year and 5-year disease-free survival for T1-T2 stages are respectively 87% and 55%, for T3 stages 57% and 28%, and for T4 stages 41% and 25%. The locoregional tumor control was 70% and 59% at respectively 3 and 5 years. Patients presenting with intracranial tumor invasion at the time of diagnosis relapsed within 7 months after the end of radiotherapy. Radiation-induced severe dry eye syndrome and optic neuropathy was observed in respectively 7 and 2 of the 47 cases. CONCLUSION: Postoperative radiotherapy for adenocarcinoma of the ethmoid sinuses is associated with good local control rates. Crucial for a favorable prognosis is the absence of intracranial invasion. The rarity of these tumors makes it difficult to evaluate new therapeutic advances.

Colonization of voice prostheses by albicans and non-albicans Candida species.

OBJECTIVES: The purposes of the study were to assess the colonization of tracheoesophageal voice prostheses by albicans and non-albicans Candida species and to determine their susceptibility for three antimycotics that are frequently used for prophylaxis or treatment of oral candidiasis (i.e., miconazole, fluconazole, and nystatin). STUDY DESIGN: In total, 101 patients, corresponding to 170 voice prostheses, were monitored over a period of 28 months. METHODS: An enzymatic two-step method was used for differentiation and presumptive identification of Candida species colonizing the voice prostheses. The identity of the isolates was confirmed by the germ-tube test, morphological appearance on cornmeal agar with 0.5% Tween 80, sugar assimilation tests, and appearance on CHROMagar Candida (CHROMagar Co., Paris), Albicans ID (BioMérieux Vitek, Hazelwood, MO), and Fluoroplate Candida (Merck, Darmstadt, Germany). Susceptibility testing for miconazole, fluconazole, and nystatin was performed according to the microdilution method of the National Committee for Clinical Laboratory Standards. RESULTS: The predominant species isolated were Candida albicans (41.4%), Candida glabrata (33.1%), Candida krusei (15.9%), and Candida tropicalis (5.3%). A broad range of minimal inhibitory concentrations of the isolates was observed for miconazole and fluconazole. In contrast, minimal inhibitory concentration values for nystatin were narrowly distributed around 4 microg/mL for all isolates, suggesting uniform sensitivity. CONCLUSION: Our data on the prevalence and susceptibility of yeast isolates will contribute to a rational choice of an antimycotic for prophylaxis of the early deterioration and leakage of tracheoesophageal voice prostheses.

Nasalance, nasality, voice, and articulation after uvulopalatopharyngoplasty.

OBJECTIVES/HYPOTHESIS: The main purpose of the study was to determine the impact of uvulopalatopharyngoplasty (UPPP) on nasalance and nasality. It was hypothesized that nasalance would change from the presurgical to the postsurgical condition because the surgical protocol involves removal of palatal tissue. An additional objective of the study was to provide objective and subjective data about changes in voice and articulation after UPPP. Because the surgical procedure of UPPP does not involve laryngeal tissue, it was hypothesized that the voice characteristics remain relatively stable. Because of removal of effective velar length, articulation problems of the uvular /R/ can occur in the Dutch language. STUDY DESIGN: Prospective study in which 26 men were studied before (1 week before UPPP) and after (3 weeks after UPPP) surgery. METHODS: The Nasometer was used to obtain nasalance scores. The mirror-fogging test, a perceptual evaluation of each subject's readings, and the Gutzmann and the Bzoch hypernasality tests were used for the assessment of nasality. For the assessment of articulation, a phonetic analysis was performed. Voice assessment included a perceptual rating of the voice and a determination of fundamental frequency. RESULTS: No significant differences were found between the conditions before and after surgery regarding nasalance (except for the vowel /i/), nasality, and voice. Regarding articulation, only 1 patient showed a derhotacized /R/. CONCLUSIONS: The findings of the study indicate that UPPP does not have an impact on nasality, voice, and articulation. Regarding nasalance, no significant nasalance change occurred after UPPP, except for the high vowel /i/.

The INFVo perceptual rating scale for substitution voicing: development and reliability.

In this paper, an experimental study of inter-judge consistency for the different dimensions of a recently proposed new scale for the rating of substitution voices is presented. The IINFVo rating scale tries to score five parameters, namely impression, intelligibility, noise, fluency and voicing. Each parameter is scored between 0 (very good substitution voicing) and 10 (very deviant substitution voicing) on a visual analogue scale. Inter-judge consistencies were measured among semi-professional as well as among professional jury members. The consistencies among semi-professionals, expressed as Pearson correlation coefficients, ranged from moderate to good (0.57-0.68), whereas those among professionals were good to excellent (0.82-0.87) and compared favourably to consistency figures published for traditional perceptual evaluation scales such as the GRBAS scale for laryngeal dysphonia. Since there is a strong correlation between the scores of impression and intelligibility, and since intelligibility is hard to score by non-native listeners, we suggest taking the mean of the two scores as the "impression" of a modified dimensional INFVo rating scale. Our experiments demonstrate that the INFVo rating scale has good potential to become a routine perceptual evaluation method in a multidimensional assessment protocol for substitution voicing.

Secondary placement of a voice prosthesis after total pharyngolaryngectomy with colon interposition: voice restoration in colon interposition.

We present a patient treated by a total pharyngolaryngoesophagectomy and postoperative radiotherapy for a hypopharyngeal T4N2bM0 squamous cell carcinoma. The upper digestive tract was reconstructed with a pedicled left colon interposition through the posterior mediastinum. A voice prosthesis was placed 9 months after the initial treatment, following measurement of the tracheo-neopharyngeal wall thickness by sonography. Fifteen months after the total pharyngolaryngectomy, the patient remains free of recurrent disease and has successfully resumed speaking with the voice prosthesis.

A simple surgical technique for tracheoesophageal fistula closure.

Placement of a voice device in a tracheoesophageal fistula provides successful speech rehabilitation after total laryngectomy. However, in the long term, removal of the voice device and permanent closure of the fistula is sometimes necessary. This paper presents and evaluates a simple surgical technique for primary closure of tracheo-esophageal fistulae. We retrospectively review 12 laryngectomees who received this technique of primary closure from 1997 to 2000. In 58% of the patients, permanent fistula closure could be obtained. Six patients (50%) healed primarily; in one patient (8%) the residual fistula opening healed secondarily. Four patients (33%) needed a second surgical procedure, and in one patient (8%) inserting a new speech prosthesis obliterated the residual fistula. Radiotherapy seems to compromise wound healing and therefore may be considered as a contraindication. Complications such as tracheal stenosis, tissue necrosis and pneumonia, etc., did not occur.

Application of the Voice Handicap Index in 45 patients with substitution voicing after total laryngectomy.

We tested the Voice Handicap Index (VHI) in 45 patients with substitution voicing (that is, without the use of two vocal folds), the majority of them using tracheo-oesophageal speech. We introduced a corrected VHI score (VHI(corr)) whose values are in the range from 0 to 100 and which can be expressed as a percentage. As such, the VHI(corr) is a handy and transparent tool, and it seems to be suited for representing the handicap caused by the voice disorder when some items are unanswered as experienced in patients with substitution voicing. Interestingly, our data reveal that the voice handicap severity of this particular category of patients is (1) moderate and in the range of "common" dysphonia and (2) not affected by additional radiotherapy. It seems that the E domain is overstated due to the number of problematic items in the P and F domains.

The Belgian experience with the cyranose heat moisture exchange filter. A multicentric pilot study of 12 total laryngectomees.

It is known that heat and moisture exchangers have a positive effect on the respiratory system in patients after total laryngectomy. The ATOS and INHEALTH devices are most frequently used in Belgium. However, recently a new device, the HME filter Cyranose, has become available. As a pilot study, this device has been applied to a total of 12 patients in three different centres. The temperature of the inspired air was considered as good or excellent in 90% of our patients at the 1st week and up to 100% at the 3rd month. The air humidification was considered as good or excellent in 100% of the patient population, and the HME filter positively influenced the phlegm production in 78% of our laryngectomy population. Our study stresses the benefits of a HME filter in general and seems promising for the Cyranose HME filter.

Botulinum toxin for dysphagia due to cricopharyngeal dysfunction.

Botulinum injection in the cricopharyngeal muscle has not yet been described thoroughly. In reviewing the literature, only 24 cases were found in which botulinum injection was used to treat cricopharyngeal dysfunction. We want to add another four cases and discuss specific indications and necessary pre-treatment examinations. Depending on the patient's history and the clinical findings, botulinum injection may be performed. Manometry and videofluoroscopy are not mandatory. The type of functional pathology defines whether botulinum toxin will be a definite treatment or a temporary relief.

Objective evaluation of the quality of substitution voices.

This paper describes our first attempts to develop a method for the objective assessment of quality in substitution voices. The objective analysis deals with acoustic parameters characterising short voice and speech samples like a sequence of isolated vowels, a sequence of VCV and CVCVCV syllables, a short sentence, etc. A database of 113 registrations from 68 patients (53 total laryngectomy patients with tracheo-esophageal speech, 14 total laryngectomy patients with esophageal speech and 5 patients with partial frontolateral laryngectomy) and 6 registrations from healthy control persons was collected. Each registration consisted of seven speech utterances and was subjected to an acoustic analysis as well as to a perceptual evaluation, the latter involving eight parameters like "overall impression", "tonicity", etc. Since the goal of our work is to find out the best acoustical measurement for supporting perception and making it precise, it seemed logical to strive for a perceptually based acoustic analysis. We therefore performed the analysis by means of a peripheral auditory model with a built-in fundamental frequency (pitch) extractor. From the frame-level outputs (a frame is 10 ms) of the analyser, global objective parameters, such as (1) the percentage of voiced frames, (2) the average voicing evidence, (3) the voicing length distribution and (4) the fundamental frequency jitter, were computed for the different speech utterances. So as to reduce the parameter variability arising from the nature of the speech utterances (e.g., the presence of pauses in the signal, errors caused by the pitch extractor, etc.), the objective parameters were computed using non-standard averaging schemes involving energy weighting and frame selection. A statistical analysis of the objective parameters confirms that the quality of tracheo-esophageal speech is superior to that of esophageal speech, but inferior to that of normal speech and speech with the preservation of one vocal fold. Correlations between the objective parameters and the perceptual parameters are moderate.

Functional outcome following colon interposition in total pharyngoesophagectomy with or without laryngectomy.

Our study compares deglutition between a group who had undergone total esophagopharyngolaryngectomy and a group who had esophagectomy and partial pharyngectomy with preserved larynx, after reconstruction of the upper digestive tract with pedicled colon interposition. In four patients the laryngeal structures could be preserved (three caustic burns and one proximal esophageal tumor). Six patients underwent a total laryngopharyngectomy for large pharyngeal tumors. Swallowing was assessed by a questionnaire, clinical examination, and videofluoroscopy. All patients had normal intake of semisolid foods and fluids. All patients but three experienced some feeling of "narrowing" of the tract: four at the level of the hypopharynx, two at the oropharyngeal level, one at the oral level. In the laryngectomy group, solid food caused some degree of delayed swallowing in three patients. Dumping occurred in one case out of the nonlaryngectomy group. On clinical examination a tense motility in all laryngectomy patients appeared, food remnants in five and repeated swallowing movements in four. The videofluoroscopy confirmed repeated swallowing movements and presence of residual food in the oral cavity. Temporal stagnation occurred at the anastomosis site in all patients and in two patients at a place of colon redundancy. Colon interposition is a reliable reconstruction and gives the possibility of a good functional outcome. Although preservation of the larynx facilitates swallowing even in this reconstructive procedure, it may be better to perform a total laryngopharyngectomy and colon interposition in oncological cases where the pharyngeal remnant is borderline for primary closure.