Nasalance Scores for Normal Speakers of American English Obtained by the Nasometer II Using the MacKay-Kummer SNAP-R Test.

OBJECTIVE: To establish nasalance score norms for adolescent and young adult native speakers of American English and also determine age-group and gender differences using the Simplified Nasometric Assessment Procedures (SNAP) Test-R and Nasometer II. DESIGN: Prospective study using a randomly selected sample of participants. SETTING: Greater Cincinnati area and Miami University of Ohio. PARTICIPANTS: Participants had a history of normal speech and language development and no history of speech therapy. Participants in the adolescent group were recruited from schools in West Clermont and Hamilton County, whereas the young adults were recruited from Miami University of Ohio. The participants of both groups were residents of Cincinnati, Ohio or Oxford, Ohio and spoke midland American English dialect. OUTCOME MEASURES: Mean nasalance scores for the SNAP Test-R. RESULTS: Normative nasalance scores were obtained for the Syllable Repetition/Prolonged Sounds, Picture-Cued, and Paragraph subtests. Results showed statistically significant nasalance score differences between adolescents and young adults in the Syllable Repetition, Picture-Cued, and Paragraph subtests, and between males and females in the Syllable Repetition and the Sound-Prolonged subtests. A significant univariate effect was found for the syllables and sentences containing nasal consonants and high vowels compared to syllables and sentences containing oral consonants and low vowels. Across all the SNAP Test-R subtests, the females' nasalance scores were higher than the males. A significant univariate effect was also found across nasal syllables, and high vowels such that the females' nasalance scores were higher than the males. Tables of normative data are provided that may be useful for clinical purposes. CONCLUSION: Norms obtained demonstrated nasalance score differences according to age and gender, particularly in the Syllable Repetition/Prolonged Sound subtest. These differences were discussed in light of potential reasons for their existence and implications for understanding velopharyngeal function. In addition, nasalance scores are affected by the vowel type and place of articulation of the consonant. These facts should be considered when nasometry is used clinically and for research purposes.

Effects of Vibratory Source on Auditory-Perceptual and Bio-Inspired Computational Measures of Pediatric Voice Quality.

OBJECTIVE: The vibratory source for voicing in children with dysphonia is classified into three categories including a glottal vibratory source (GVS) observed in those with vocal lesions or hyperfunction; supraglottal vibratory sources (SGVS) observed secondary to laryngeal airway injuries, malformations, or reconstruction surgeries; and a combination of both glottal and supraglottal vibratory sources called mixed vibratory source (MVS). This study evaluated the effects of vibratory source on three primary dimensions of voice quality (breathiness, roughness, and strain) in children with GVS, SGVS, and MVS using single-variable matching tasks and computational measures obtained from bio-inspired auditory models. METHODS: A total of 44 dysphonic voice samples from children aged 4-11 years were selected. Seven listeners rated breathiness, roughness, and strain of 1000-ms /ɑ/ samples using single-variable matching tasks. Computational estimates of pitch strength, amplitude modulation filterbank output, and sharpness were obtained through custom-designed MATLAB algorithms. RESULTS: Perceived roughness and strain were significantly higher in children with SGVS and MVS compared to children with GVS. Among the computational measures, only the modulation filterbank output resulted in significant differences among vibratory sources; a posthoc test revealed that children with SGVS had greater amplitude modulation than children with GVS, as expected from their rougher voice quality. CONCLUSIONS: The results indicate that the output of an auditory amplitude modulation filterbank model may capture characteristics of SGVS that are strongly related to the rough voice quality.

Perceptual Measures of Boychoir Voices During the Phases of Pubertal Voice Mutation.

BACKGROUND/OBJECTIVES: Vocal changes in the male singing voice associated with puberty are variable and often unpredictable resulting in challenges for the singer and the choral director. Limited knowledge regarding the physiologic changes in the vocal mechanism as they correlate to perceptual variations observed in the male adolescent singer exists in the literature. The purpose of this study was to examine pitch breaks and perceptual characteristics of vocal quality during singing tasks for boys in various stages of the male changing voice. STUDY DESIGN: Prospective Study. METHODS: Twenty-eight boys were initially evaluated at Cooksey Stage 0 (Pubertal Unchanged; n = 15) or Cooksey Stage 1 (Mid-Voice; n = 13). Range of age was 8-13 years old. Participants performed vocal slide intervals (1-3-1, 1-5-1, 1-8-1) with discrete starting frequencies on G3, C4, F4, and A4 and sang the "Star-Spangled Banner" in the key of Ab. Pitch breaks and perceptual qualities were evaluated on the recorded tasks by expert raters. Seven boys were evaluated again when they progressed to Cooksey Stage 4 (Baritone) performing the same singing tasks. RESULTS: For the participants evaluated at Cooksey Stage 0/1, pitch breaks were observed more in the higher frequencies and increased interval spacing regardless of starting frequency. Participants at Cooksey Stage 0 had more pitch breaks than Stage 1. At Cooksey Stage 4, an increase in the number of pitch breaks was observed in comparison to their tasks performed at Stage 0/1 and the perceptual quality of breathiness was significantly greater. CONCLUSIONS: Pitch breaks are a characteristic perceptual change that indicates a young man may be transitioning through puberty. Findings from the present study demonstrate that in addition to perceived pitch breaks, breathiness was noted to significantly increase as the male progressed through puberty. Breathiness was noted to be more significant than vocal timbre and overall vocal quality. This research provides acoustic evidence to enhance the perceptual characteristics of voice change for those who teach and train male voices through puberty.

Endoscopic Findings in Male Prepubertal Choir Singers.

OBJECTIVES/HYPOTHESIS: The male singing voice through puberty undergoes many changes that present challenges for the singer and choral director. The purpose of this study was to discuss the endoscopic findings seen in prepubescent choir singers. STUDY DESIGN: Single-institution prospective study. METHODS: Subjects were recruited from the Cincinnati Boychoir and were described as Cooksey stage unchanged or mid-voice I, as described by the Boychoir artistic director. Vocal history was obtained via questionnaire at the initial visit. Subjects with known laryngeal pathologies were excluded. Endoscopic laryngeal examinations were performed using videoendoscopy. During examination, each subject sang four discrete frequencies. Findings of the endoscopic exam were judged by a board-certified pediatric otolaryngologist specializing in pediatric voice. RESULTS: We evaluated 28 subjects prior to vocal maturation. Their age range was 8 to 13 years old (mean = 10.2 ± 1.2 years). The singing voice category of all 28 subjects was described as soprano vocal range by the Boychoir artistic director. The subjects had a mean of 1.7 ± 1.1 years in the Boychoir (0-5 years). None reported history of vocal issues or voice problems in the past; seven (25%) subjects had vocal fold lesions seen at one or more frequencies; 24 (85%) subjects had a posterior gap seen at one or more frequencies. Two subjects (7%) had a posterior gap at one frequency, C3 and G3, respectively. Five subjects (18%) had a posterior gap at two frequencies, seven subjects (25%) at three frequencies, and 10 subjects (36%) in all four frequencies. CONCLUSIONS: Our study aimed to describe the laryngeal examination of dedicated Boychoir singers prior to undergoing pubertal development and vocal maturation. In elite pediatric singers we found that vocal nodules are common (25%) and are not correlated with vocal symptoms. These findings may suggest that asymptomatic lesions may be more prevalent than previously thought. In these individuals, posterior glottic gap is common and can be considered a normal glottal configuration. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:592-597, 2021.

Characterization of supraglottic phonation in children after airway reconstruction.

OBJECTIVES: We examined select acoustic (signal type), aerodynamic, and perceptual measures and associated surgical data in a cohort of children who were endoscopically identified as using supraglottic phonation after undergoing airway reconstruction. METHODS: Twenty-one children (4 to 18 years of age) who were seen in the Cincinnati Children's Hospital Medical Center for Pediatric Voice Disorders and identified as using supraglottic phonation were included in this study. According to standard protocol, each of these children underwent acoustic, aerodynamic, and perceptual analyses and laryngeal imaging. Their medical records were reviewed for surgical history. RESULTS: Four primary supraglottic compression patterns and 3 distinct sound sources for voice were identified. Signal type classification revealed that 20 of 21 voice signals were either type II or type III. Signal type was moderately associated with compression pattern (p = 0.01). No statistically significant findings were found in testing the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) Overall Severity score against compression patterns and vibration source. The mean Strain scores for participants who used a combined source of vibration were significantly higher than for those who used their ventricular folds. CONCLUSIONS: The compensatory compression patterns and alternate sources of vibration used by these children resulted in moderate to severe dysphonias. How children compensate after undergoing airway reconstruction has important implications for behavioral and surgical interventions aimed at improving voice quality. Not all aspects of traditional voice evaluation are suitable for this population.

Comparison of pediatric voice handicap index scores with perceptual voice analysis in patients following airway reconstruction.

OBJECTIVES: We performed a retrospective review to compare a subjective parental proxy-derived voice handicap survey to an observer-derived method of measuring voice perturbation in children who have undergone airway reconstruction. The main outcome measures were the Pediatric Voice Handicap Index (pVHI) total score and the Overall Severity score on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). METHODS: The percent Overall Severity CAPE-V score (score divided by 100) and the percent pVHI score (score divided by 92) were calculated. A Wilcoxon signed rank test was used to compare CAPE-V scores with the pVHI total scores. The relationship between the pVHI scores and the CAPE-V scores was investigated with a Spearman correlation. Subgroup analysis was performed to determine the relationship of surgery type to CAPE-V and pVHI scores. RESULTS: Fifty subjects with a history of airway surgery who were evaluated between 2005 and 2008 were identified. Forty-two of the 50 subjects had complete data for review. Their median age was 7.1 years (range, 3.3 to 17.9 years). Their pVHI total scores had a median of 30 (range, 1 to 80). Their Overall Severity CAPE-V scores had a median of 50.5 (range, 0 to 98). Their median CAPE-V percent was higher than their median pVHI percent (50.5% versus 32.6%; p = 0.0003). A weak correlation was found between the Overall Severity CAPE-V score and the pVHI total score (rho = 0.41; p = 0.0003). There was a trend toward higher Overall Severity CAPE-V scores in patients who underwent cricotracheal resection. The total number of airway surgeries was significantly correlated with the Overall Severity CAPE-V score (rho = 0.6; p <0.0001) but not with the pVHI score. CONCLUSIONS: Children who undergo airway reconstruction often have a resulting voice disturbance that can affect their lives in multiple dimensions. The results of this study revealed a weak-to-fair correlation between the parent-reported pVHI total score and expert ratings of voice quality using the CAPE-V. In this patient population, both of these tools provided important information regarding the relationship of the severity of voice disturbance to its handicapping effects.

The effect of task type on fundamental frequency in children.

OBJECTIVE: The purpose of this study was to examine the influence of task type on the fundamental frequency (F(0)) produced by young children. Fundamental frequency is a parameter which describes the rate of vocal fold vibration. The influence of task type on F(0) values is important for health professionals designing and implementing assessment protocols for children with voice disorders. METHODS: Forty-eight healthy children between the ages of 5.0 and 7.11 years were evaluated in this study. Each child completed four tasks used to elicit a voice sample for subsequent analysis of F(0). The tasks included: (a) sustaining the vowel/a/(Vowel), (b) sustaining the vowel embedded in a word at the end of a phrase (Phrase), (c) repeating a sentence (Sentence), and (d) counting from 1 to 10 (Counting). Each child was evaluated by one of two clinicians who had an equal number of years of training and were the same age and gender. RESULTS: A repeated measures analysis of variance (ANOVA) was used to examine the influence of task type on F(0) values. The results revealed a significant difference in F(0) between the four elicitation tasks (p=.002). Pair wise comparisons revealed that Counting elicited higher F(0) values compared to Phrase (p=.018) and Sentence tasks (p=.001). There were no significant interaction effects for task by age, gender, or clinician who evaluated the child (p>.05). CONCLUSIONS: The results of this study revealed that task type does significantly influence F(0) values in young children. This finding is clinically important as it indicates that the same task should be used to monitor changes in the voice over time in relationship to surgical or behavioral interventions.

Influence of preoperative voice assessment on treatment plan prior to airway surgery.

OBJECTIVES/HYPOTHESIS: Voice quality has emerged as an additional long-term outcome measure for patients with a history of airway surgery. The goal of this study was to evaluate the impact of preoperative voice assessment on the surgical management of patients who required complex airway surgery. STUDY DESIGN: Retrospective case series. METHODS: We analyzed clinical data for all patients who underwent an airway reconstruction procedure from September 1, 2012 to September 1, 2017 and had a voice clinic evaluation prior to surgery at a tertiary-care pediatric hospital. Each participant underwent a full clinical voice evaluation that yielded acoustic, imaging, perceptual, and handicapping index data. RESULTS: Six hundred forty-three patients underwent 831 airway surgeries (laryngotracheoplasty, cricotracheal resection, slide tracheoplasty, laryngeal cleft repair). Ninety-one (14.2%) of the 643 patients underwent a formal voice clinic evaluation prior to airway surgery; 39/91 (42.9%) were female. The mean age was 10.4 years (95% confidence interval [CI]: 9.2-11.6) with 31/91 (32.9%) participants demonstrating vocal fold immobility and 33/91 (36.3%) vocal fold hypomobility. A voice clinic evaluation provided new information for 62/91 (68.1%) patients, mainly for laryngeal dynamic components (vocal fold motion, source of phonation, arytenoid prolapse) and confirmed suspected disorders for the remaining patients. The average baseline Pediatric Voice Handicap Index overall score was 38.9 (95% CI: 33.3-44.5), and the average overall severity rating of the Consensus Auditory-Perceptual Evaluation of Voice was 54 (95% CI: 45.2-62.8). A voice clinic evaluation influenced management of 56/91 (61.5%) patients either by modification of the surgical plan (26/56, 46%) and/or adjusting voice therapy (21/56, 37.5%). CONCLUSIONS: Voice evaluation prior to airway reconstruction provided key information that influenced the management for most of the patients. Formal voice evaluation should be considered prior to complex airway surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2858-2863, 2018.

Examination of aerodynamic measures and strain by vibratory source.

OBJECTIVES: Patients with laryngotracheal stenosis often require airway reconstruction. Following surgical intervention, voicing may be produced with either a glottic or supraglottic vibratory source. The objective of this study was to compare average airflow, estimated subglottal pressure, and expert perceptual rating of strain between children with glottic and supraglottic vibratory sources post-airway reconstruction. STUDY DESIGN: This study was a non-randomized prospective study conducted at the Cincinnati Children's Hospital Medical Center (CCHMC), Center for Pediatric Voice Disorders, and included 12 participants with a diagnosis of subglottic stenosis, post-laryngotracheal reconstruction. RESULTS: Expert perceptual ratings of strain were significantly higher for participants with supraglottic versus glottic voicing (P = 0.0001). Although the mean airflow measure was higher for participants with glottic phonation and mean pressure measure was higher for those with supraglottic voicing, these comparisons failed to reach significance. CONCLUSIONS: Patients who exhibit supraglottic phonation patterns demonstrate greater strain during speech, as well as potential alterations to aerodynamic patterns. SIGNIFICANCE: The significant differences in perceived strain by vibratory source are noteworthy, as perceptual quality is always a patient's motivation to seek treatment.

Vibratory source, vocal quality and fundamental frequency following pediatric laryngotracheal reconstruction.

OBJECTIVE: Surgeons who perform pediatric laryngotracheal reconstruction (LTR) have traditionally measured outcomes based on successful airway restoration. Additional information regarding post-surgical vocal function may help guide outcomes toward optimal voice. This investigation documented the relationship between the site of vocal tract vibratory source (glottic versus supraglottic versus mixed) and vocal function in children following LTR. METHODS: Endoscopic evaluation of voice source was completed in 16 participants who had LTR as children. Three judges rated vocal quality using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Acoustic analysis was completed to obtain fundamental frequency and determine the periodicity of the vibratory signal. RESULTS: Seven participants were identified to have glottic vibration and nine had supraglottic or mixed-source vibration for voice. All participants were rated as having some degree of voice disorder. Those who used primarily supraglottic/mixed phonation exhibited significantly worse overall severity, roughness, and pitch deviance ratings than did those who used primarily glottic phonation. Significant differences in strain were also noted; however, poor inter-rater reliability rating of strain confounded this result. No significant differences in breathiness or loudness ratings were exhibited. Periodic vibration was observed in 10 of 16 participants (5 of 7 in the glottic group and 5 of 9 in the supraglottic/mixed group). Three of the five participants who had periodic supraglottic phonation had fundamental frequency measures (F(0)) that were below normative ranges, 1 approximated normal, and 1 was above normal range. Two of the five participants who had periodic glottic phonation had lower than expected F(0)s, 1 was within normal range, and 2 were high. CONCLUSIONS: As observed in earlier studies, voices produced with supraglottic phonation were generally less acceptable than those with glottic phonation. However, phonation with supraglottic structures yielded highly variable voice that may be amenable to change. Some children achieved periodic vibration with alternate structures, suggesting inherent flexibility and adaptability in the tissues used to make sound.

Pediatric Voice Handicap Index (pVHI): a new tool for evaluating pediatric dysphonia.

PURPOSE: The Voice Handicap Index (VHI) is widely used and accepted into adult clinical practice. The present study was initiated to adapt the VHI to the pediatric population and to validate it in the form of a parental proxy. METHODS: The initial modification of the adult VHI involved changing the language of the statements to reflect a parent's responses about their child and eliminating questions that would not relate to children. It was administered in conjunction with 10 open-ended questions regarding the impact of the child's voice quality on overall communication, development, education, social and family life. The pVHI was then modified in content and language, and the final 23-item parental proxy product was used for the validation process. The modified pVHI was administered to two groups of patients following IRB approval from Cincinnati Children's Hospital Medical Center. RESULTS: Normative data was obtained from 45 parents of healthy children. The group consisted of 21 males, age ranges 3-12 years old. The mean scores of the total pVHI and its subscales are: functional (F) 1.47, physical (P) 0.20, emotional (E) 0.18 and total (T) 1.84. The test group consisted of 33 guardians of children presenting for a voice evaluation pre- or post-laryngotracheal reconstruction. This group differed greatly from the control group on each subscale and total score. The mean scores of the airway group were as follows: F 13.94, P 15.48, E 12.15 and T 41.58. Test-retest reliability of the total pVHI score was measured using Pearson's correlation coefficient. The scores were 0.95, 0.77, 0.79 and 0.82, respectively. A correlation matrix for pVHI subscore and total score showed significance, with results similar to those reported for the original adult VHI. CONCLUSIONS: The aim of the present study was to modify the VHI to serve a similar role in the evaluation of the effects of dysphonia on the pediatric population. The statistical results reveal a high correlation between the VHI and the pVHI. The pVHI provides a high internal consistency and test-retest reliability. This tool will be utilized to follow a child's development following surgical, medical and behavioral interventions.

Voice problems of future speech-language pathologists.

Students training to be educators frequently exhibit voice disorders prior to employment. To date, there exist no similar studies of future speech-language pathologists (SLPs). The study is designed as a prospective, nonrandomized survey. The objective of this study is to determine the voice problems of first year graduate students training to be SLPs. Participants were 104 first year graduate students majoring in speech-language pathology at two universities. The Quick Screen for Voice was administered. Participants who failed completed a questionnaire regarding voice problems, medical history, daily habits, and voice use. When responses further indicated voice-related problems, endoscopic examination was completed. Fourteen percent (N=15) of the participants failed the screening by demonstrating two or more abnormal voice characteristics. These included persistent glottal fry (present in all who failed), low habitual pitch, juvenile resonance, hoarse, breathy, or strained phonation, abnormally low pitch on sustained vowels, and voice breaks during the frequency range. Twelve percent (N=12) failed both the screening and follow-up questionnaire. Responses included self-reported dysphonia, medical history with voice-related side effects, difficulty with excessive voice use, and voice problems occurring daily or weekly. Endoscopic evaluation showed one participant with bilateral vocal nodules. The results suggest that voice problems among future SLPs (12%) are more common than the 3-9% reported in the general population and similar to the 11% previously reported for teachers. However, future SLP voice problems are less frequent than those reported among education majors (21%) and all college students (17%). Faculty should identify students with voice problems and emphasize optimal voice use in classroom and clinical settings.

Examining the Impact of Video Modeling Techniques on the Efficacy of Clinical Voice Assessment.

OBJECTIVES: The purpose of the current study was to determine whether or not presenting patients with a video model improves efficacy of the assessment as defined by efficiency and decreased variability in trials during the acoustic component of voice evaluations. METHODS: Twenty pediatric participants with a mean age of 7.6 years (SD = 1.50; range = 6-11 years), 32 college-age participants with a mean age of 21.32 years (SD = 1.61; range = 18-30 years), and 17 adult participants with a mean age of 54.29 years (SD = 2.78; range = 50-70 years) were included in the study and divided into experimental and control groups. The experimental group viewed a training video prior to receiving verbal instructions and performing acoustic assessment tasks, whereas the control group received verbal instruction only prior to completing the acoustic assessment. Primary measures included the number of clinician cues required and instructional time. Standard deviations of acoustic measurements (eg, minimum and maximum frequency) were also examined to determine effects on stability. RESULTS: Individuals in the experimental group required significantly less cues, P = 0.012, compared to the control group. Although some trends were observed in instructional time and stability of measurements, no significant differences were observed. CONCLUSIONS: The findings of this study may be useful for speech-language pathologists in regard to improving assessment of patients' voice disorders with the use of video modeling.

Pediatric laryngotracheal stenosis and airway reconstruction: a review of voice outcomes, assessment, and treatment issues.

Laryngotracheal stenosis is defined as a congenital or acquired narrowing of the airway. Congenital causes may include subglottic membranous or cartilaginous narrowing. Acquired causes may include trauma due to prolonged endotracheal or tracheal intubation or laryngotracheal injury. Although advances have been made over the past 30 years in reconstructive surgeries to improve airway patency in these patients, long-term laryngeal function for voice production is not well defined in this population. This review examines causes, symptoms and signs, and methods for diagnosing laryngotracheal stenosis. Surgical management procedures are briefly summarized. The current literature on voice outcomes is summarized. The predominant voice characteristics in the population are presented, although results are challenged by the heterogeneity of voice presentation and paucity of data from instrumental measures. Considerations for subjective and instrumental assessment, measures of quality of life, instrumental methods, and treatment options specific to the needs of this population are discussed. Research strategies to identify long-term outcomes of surgical and behavioral treatments in this population are posed.

Feasibility of Clinical Endoscopy and Stroboscopy in Children With Bilateral Vocal Fold Lesions.

Purpose: The purpose of this study was to examine the utility of flexible and rigid endoscopy and stroboscopy for the identification of anatomical and physiological features in children with bilateral vocal fold lesions. The secondary purpose was to describe the age distribution of patients who could tolerate use of the different types of endoscopes. Method: This cross-sectional clinic-based study included 38 children (ages 5 to 12 years) diagnosed with bilateral vocal fold lesions via videoendoscopy. Vocal fold vibratory characteristics (e.g., mucosal wave) were rated by 4 clinicians by consensus. Results: Bilateral vocal fold lesions could be well described anatomically after visualization with both flexible and rigid endoscopes and were most commonly described as symmetrical and broad based. However, the clinicians' confidence in the accuracy of stroboscopy for rating vocal fold vibratory characteristics was limited for both flexible and rigid stroboscopes. Conclusions: Videoendoscopy was adequate for viewing and characterizing anatomical structures of bilateral vocal fold lesions in pediatric patients; however, vibratory characteristics were often not fully visualized with videostroboscopy. In view of the importance of visualizing vocal fold vibration in the differential diagnosis and treatment of vocal fold lesions, other imaging modalities, such as high-speed videoendoscopy, may provide more accurate descriptions of vocal fold vibratory characteristics in this population.

Aerodynamic measurements: normative data for children ages 6:0 to 10:11 years.

Normative measures of open quotient, speed quotient, maximum flow declination rate (MFDR), and subglottal pressure were determined for 75 children between the ages of 6 years 0 months and 10 years 11 months. The participants produced a sustained /a/ at low, comfort, and high pitches for a minimum of 5 seconds, and five to seven repetitions of /pa/ at low, comfort, and high pitches. No statistically significant differences were found in the mean measures of any aerodynamic variables (open quotient, speed quotient, maximum flow declination rate, subglottal pressure) between the frequency levels (low, comfort, high pitches). Also, no strong evidence (P > .05) exists that age or sex effect differed between the frequency levels (low, comfort, high) for any of the aerodynamic measures. For /a/ response tasks, mean open quotient measures increased slightly from low to comfort frequency and from comfort to high frequency. Mean speed quotient measures showed minimal differences between low and comfort frequency, with decreased mean measures for high frequency. Mean MFDR measures increased from low to comfort frequency and from comfort to high frequency. Mean subglottal pressure measures increased slightly from low to comfort frequency and from comfort to high frequency.

Assessment of Vibratory Characteristics in Children Following Airway Reconstruction Using Flexible and Rigid Endoscopy and Stroboscopy.

IMPORTANCE: Up to half of children have substantial dysphonia after airway reconstruction. Visual assessment of vocal function is valuable. Feasibility of flexible and rigid endoscopy has been reported; however, the clinical utility of stroboscopy has not been examined. Rating of vibratory characteristics, such as mucosal wave and amplitude of vibration, is essential for the development of interventions to improve voice outcomes. OBJECTIVE: To examine (1) clinicians' ratings of anatomical and physiological features in children following airway reconstruction on initial voice evaluation using videolaryngostroboscopy and (2) the relationship of age to the type of endoscopy used. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 32 patients aged 3 to 21 years evaluated for post­airway reconstruction dysphonia between July 2011 and July 2012 at a quaternary care children's hospital. INTERVENTIONS: Clinical voice evaluation protocol including rigid and/or flexible endoscopy with stroboscopy. MAIN OUTCOMES AND MEASURES: Demographic and voice quality characteristics were collected. The ability to complete endoscopy and ratings of anatomical and/or physiological features were assessed by a consensus of 4 clinicians. A t test was used to determine whether age was a significant factor in successful completion of videolaryngostroboscopy. RESULTS: Of 31 children who underwent flexible videolaryngostroboscopy, 22 (71%) examinations were completed with a distal chip endoscope and 9 (29%) with a fiberoptic. Significant differences were found in age between children who completed the distal chip vs. fiberoptic examination (mean [SD], 7.3 [2.7] vs. 5.5 [6.2] years; P = .05). Rigid endoscopy was attempted for 14 (44%) of 32 patients; 9 examinations (64%) were successful. Significant differences were found in age between patients for whom a rigid endoscopy could be successfully completed vs. those for whom it was not (mean [SD], 12.9 [3.4] vs. 6.2 [2.1] years; P < .001). Eighteen (56%) were glottic phonators, 8 (25%) supraglottic, and 6 (19%) aphonic. Vibratory characteristics were visible in 10 of 37 examinations (27%); 6 (16%) had ratable characteristics. CONCLUSIONS AND RELEVANCE: Endoscopy can be successfully completed in most children who have undergone airway reconstruction, most often using a distal chip endoscope.We found that vibratory characteristics were often not assessed adequately using videolaryngostroboscopy. Further work identifying imaging modalities that better display vibratory characteristics, such as high-speed videoendoscopy, may provide new insight into vocal function and lead to a more thorough evaluation.

Three treatments for teachers with voice disorders: a randomized clinical trial.

Voice problems are a common occupational hazard of teaching school, yet few studies exist that have objectively evaluated treatment approaches aimed at rehabilitating these occupation-related voice disorders. This randomized clinical trial used patient-based treatment outcome measures to evaluate the effectiveness of three treatment programs. Sixty-four teachers with voice disorders were randomly assigned to 1 of 3 treatment groups: voice amplification using the ChatterVox portable amplifier (VA; n = 25), resonance therapy (RT; n = 19), and respiratory muscle training (RMT; n = 20). Before and after a 6-week treatment phase, all teachers completed (a) the Voice Handicap Index (VHI; B. H. Jacobson et al., 1997), an instrument designed to appraise the self-perceived psychosocial consequences of voice disorders, and (b) a voice severity self-rating scale. Both intention-to-treat and as-treated analyses revealed that only the VA and RT groups reported significant reductions in mean VHI scores and in voice severity self-ratings following treatment. Furthermore, results from a posttreatment questionnaire regarding the perceived benefits of treatment showed that compared to RT and RMT, teachers in the VA group reported significantly more overall voice improvement, greater vocal clarity, and greater ease of speaking and singing voice following treatment. These findings replicate previous results from an earlier clinical trial confirming the efficacy of VA and provide new evidence to support RT as an effective treatment alternative for voice problems in teachers. The results are discussed in the context of uneven levels of self-reported compliance and disparate dropout rates among the treatment groups.

Voice amplification versus vocal hygiene instruction for teachers with voice disorders: a treatment outcomes study.

Voice problems are common among schoolteachers. This prospective, randomized clinical trial used patient-based treatment outcomes measures combined with acoustic analysis to evaluate the effectiveness of two treatment programs. Forty-four voice-disordered teachers were randomly assigned to one of three groups: voice amplification using the ChatterVox portable amplifier (VA, n = 15), vocal hygiene (VH, n = 15), and a nontreatment control group (n = 14). Before and after a 6-week treatment phase, all teachers completed: (a) the Voice Handicap Index (VHI), an instrument designed to appraise the self-perceived psychosocial consequences of voice disorders; (b) a voice severity self-rating scale; and (c) an audiorecording for later acoustic analysis. Based on pre- and posttreatment comparisons, only the amplification group experienced significant reductions on mean VHI scores (p = .045), voice severity self-ratings (p = .012), and the acoustic measures of percent jitter (p = .031) and shimmer (p = .008). The nontreatment control group reported a significant increase in level of vocal handicap as assessed by the VHI (p = .012). Although most pre- to posttreatment changes were in the desired direction, no significant improvements were observed within the VH group on any of the dependent measures. Between-group comparisons involving the three possible pairings of the groups revealed a pattern of results to suggest that: (a) compared to the control group, both treatment groups (i.e., VA and VH) experienced significantly more improvement on specific outcomes measures and (b) there were no significant differences between the VA and VH groups to indicate superiority of one treatment over another. Results, however, from a posttreatment questionnaire regarding the perceived benefits of treatment revealed that, compared to the VH group, the VA group reported more clarity of their speaking and singing voice (p = .061), greater ease of voice production (p = .001), and greater compliance with the treatment program (p = .045). These findings clearly support the clinical utility of voice amplification as an alternative for the treatment of voice problems in teachers.

Phonetogram changes for trained singers over a nine-month period of vocal training.

Professional vocalists encounter demands requiring voluntary control of phonation, while utilizing a considerable range of frequency and intensity. These quantifiable acoustic events can be measured and represented in a phonetogram. Previous research has compared the phonetograms of trained and untrained voices and found significant differences between these groups. This study was designed to assess the effects of vocal training for singers over a period of nine months. Phonetogram contour changes were examined, with the primary focus on expansion of frequency range and/or intensity control. Twenty-one first-year, master's level, vocal music students, who were engaged in an intensive vocal performance curriculum, participated in this study. Following nine months of vocal training, significant differences were revealed in the subjects' mean frequency range and minimum vocal intensity across frequency levels. There was no significant difference for the mean maximum vocal intensity across frequency levels following vocal training.