Validity, reliability and reproducibility of the VLS parameters form for the collection of videolaryngostroboscopic basic findings.

OBJECTIVE: The videolaryngostroboscopy parameters form (VLSP form) is a diagnostic tool for the collection of videolaryngostroboscopic basic findings through the evaluation of 12 parameters. The aim of the present study is to preliminarily investigate intra- and inter-rater reliability, validity and responsiveness of the VLSP form. METHODS: A study on a total amount of 160 forms for the evaluation of VLS basic findings was carried out. 80 forms were scored through the VLSP form and 80 with the Voice Vibratory Assessment with Laryngeal Imaging (VALI) form Stroboscopy (S) by four expert phoniatricians, that blindly scored the VLS recordings of 5 subjects without voice disorders and 5 patients with organic voice disorder before and after successful phonosurgery. Intra-rater and inter-rater analysis have been performed for both forms. The scores obtained through VLSP form and VALI form S have been compared to analyse concurrent validity, while VLSP scores before and after phonosurgery have been compared to analyse responsiveness. Finally, each rater annotated the "difficulty" in rating every parameter and its "importance" for the diagnosis. RESULTS: The VLSP form showed good inter- and intra-rater reliability. It showed a good accuracy for the documentation of changes of laryngeal anatomy and function after phonosurgery, similarly to the VALI form S. The 12 parameters of the VLSP form were judged "Slightly Important" in 28.3% of the samples, "Very Important" in 64.8% of the samples, "Not Difficult" in 73.1% of the samples. CONCLUSIONS: The results of the present study suggest that the VLSP form is comparable to the VALI form S for the evaluation of videolaryngostroboscopic parameters and is a valid, reliable and reproducible diagnostic tool. It can help voice clinicians in the evaluation of VLS examinations and it allows for a punctual assessment of modifications in laryngeal anatomy and function in pathological conditions and after phonosurgery.

Proposal of a form for the collection of videolaryngostroboscopy basic findings.

Videolaryngostroboscopy is a useful investigation required for a correct diagnosis of laryngeal diseases and voice disorders. We present a form for the collection of basic laryngostroboscopic findings, which provides for the evaluation of the classical six parameters codified by Hirano (symmetry and periodicity of glottic vibration, glottic closure, profile of vocal fold edge, amplitude of vocal fold vibration, mucosal wave) and six other parameters which we have included in the form for an essential and complete laryngostroboscopic evaluation (supraglottic framework behaviour, seat of phonatory vibration, vocal fold morphology and motility, level of the vocal fold, stops of vocal fold mucosa vibration). This form was created in 2002 during the elaboration of the protocol for the assessment of dysphonia of the Italian Society of Phoniatrics and Logopedics, which follows the guidelines of the European Laryngological Society published in 2001. We used this form for 15 years in our daily laryngological practice with great satisfaction. We propose a more detailed version of this form, which provides for drawings which show the various videolaryngostroboscopic findings, helping the laryngologist in the collection of videolaryngostroboscopic examination basic findings.

Surgical and Functional Outcomes of Posterior Cordotomy and Partial Arytenoidectomy with CO2 LASER in the Treatment of Bilateral Vocal Cord Immobility: A Single Institution Experience.

Background/Objectives: The purpose of this study is to investigate surgical and functional outcomes of patients affected by bilateral vocal cord immobility (BVCI) and treated with posterior cordotomy and partial arytenoidectomy. Methods: We performed a retrospective analysis on pre- and postoperative findings on a series of 27 patients affected by BVCI and treated with posterior cordotomy and partial arytenoidectomy from January 2017 to January 2022. Perceptual voice evaluations were performed using the GRBAS scale. The patients were requested to estimate the level of voice handicap experienced in their life using the Italian version of Voice Handicap Index 10 (VHI 10) questionnaire, while swallowing difficulties were self-evaluated through the Italian version of the Eating Assessment Tool (EAT-10) questionnaire. Results: Respiratory distress was evaluated according to the American Medical Research Council Dyspnoea Scale (MRC_DS) before and 1 year after the surgery. The mean of the preoperative values was 3.86 (±0.4), while 1 year after the procedure, we witnessed a significant (p ≤ 0.001) improvement, with a mean value of 1.09 (±0.9). After surgery, an overall worsening in voice quality was perceived, with a worsening in the GRBAS score. In contrast, the VHI10 does not show a statistically significant worsening. EAT 10 did not demonstrated worse scores after the surgery; rather, it showed a trend of improvement (preoperative EAT10 5.5 ± 5.8, postoperative 3.3 ± 2.9, p = 0.064). Conclusions: According to our results, posterior cordotomy plus partial arytenoidectomy is an effective procedure that provides stable and rapid respiratory improvement whilst preserving swallowing and the self-perception of voice quality.

Normative Values for the Children Voice Handicap Index-10 (CVHI-10) and for the Children Voice Handicap Index-10 for Parents (CVHI-10-P).

OBJECTIVES: The objective of this study was to establish normative data and cut-off scores for the Children Voice Handicap Index-10 (CVHI-10) and the Children Voice Handicap Index-10 for Parents (CVHI-10-P) METHODS: For normative data, CVHI-10 and CVHI-10-P questionnaires originally developed in the Italian language were completed by 201 children without dysphonia and with no history of voice disorders, and by 1 of their parents. The results were analyzed for mean, standard deviation (SD), and standard error of the mean (SEM) for both questionnaires. For cut-off values determination, data from 49 dysphonic children and from 1 of their parents were also used. This analysis was based on the sensitivity and specificity indicators of the questionnaires using the "receiver operating characteristic" (ROC) curve. RESULTS: Analysis of the questionnaires related to healthy children revealed a mean of 0.26 (SD 0.74; SEM 0.06) for CVHI-10 and a mean of 0.15 (SD 0.49; SEM 0.04) for CVHI-10-P for the normative values. ROC curve analysis allowed us to establish the cut-off scores of 2.5 for CVHI-10 and 1.5 for CVHI-10-P. CONCLUSIONS: This study offers normative data for CVHI-10 and CVHI-10-P and provides cut-off values for both questionnaires to distinguish healthy and pathologic responders.

Nasal Breathing Through a Damp Gauze Enhances Surface Hydration of the Vocal Folds and Optimizes Vocal Function.

OBJECTIVE: The present study proposes a direct surface hydration system based on nasal breathing through a damp gauze. The goal is to observe whether such direct hydration procedure positively modifies vocal fold functionality by improving voice quality and enhancing the mobility and pliability of the vocal fold mucosa. METHODS: Sixty-one young adults without voice problems were enrolled and were randomly divided into three double-blinded treatment groups. In the first group (the gauze group), participants breathed through the nose wrapped in a damp gauze for 10 minutes while doing vocal warm-up exercises to facilitate water penetration into the mucosal layers of the vocal folds. The second group (the exercise group) performed the same warm-up exercises as the gauze group for 10 minutes without hydration procedures. The third group (the control group) talked using their normal speaking voice for 10 minutes. The participants were evaluated before and after the treatment tasks with three tests: a laryngostroboscopic examination (ie, the glottic closure, the amplitude of the mucosal wave, and the maximum opening of the glottic space); voice acoustic analysis (multidimensional voice program); and a perceptual voice evaluation (GRBAS scale). RESULTS: Results showed that after the use of a damp gauze, glottic closure, the amplitude of the mucosal wave, the maximum opening of the glottic space, the shimmer, and the B of GRBAS all improved. CONCLUSION: Findings showed significantly better vocal results for the participants of the gauze group, suggesting the damp gauze procedure to be an effective, fast, and economical procedure to improve and optimize vocal fold functionality. It can be hypothesized that the obtained results are related to an improvement in vocal folds surface hydration and viscoelasticity.

Validation of the Acoustic Voice Quality Index (AVQI) Version 03.01 in Italian.

OBJECTIVE: The aim of the present study is to validate the Acoustic Voice Quality Index version 03.01 in the Italian language (AVQIv3-IT). METHODS: A total of 150 native Italian speakers with normal voices (n = 50) and with various voice disorders (n = 100) were enrolled. Voice samples of a sustained vowel (SV) [a:] and five phonetically balanced continuous speech (CS) samples were recorded. The most appropriate syllable number for a standardized voiced CS approximating 3 seconds was identified. Perceptual evaluations of the overall voice quality were performed by three expert voice clinicians using the G score of the GRBAS scale. AVQIs were calculated using a 3 seconds mid-vowel selection of the SV [a:] and the standardized syllable number of the CS. Finally, concurrent validity and diagnostic accuracy of AVQIv3-IT were analysed. RESULTS: The most appropriate syllable number for a standardized CS approximating 3 seconds in Italian was identified as 25. The perceptual ratings showed robust intra- and inter-rater reliability. A strong correlation was found between AVQI scores and overall voice quality perceptual evaluations (r = 0.81, P < 0.001). The best diagnostic outcome for AVQIv3-IT was found for a threshold of 2.35 (sensitivity of 90% and specificity of 92%). CONCLUSIONS: AVQIv3-IT was demonstrated to be a valid and robust tool for quantifying overall acoustic voice quality in the Italian speaking population.

Reliability and efficacy of a new CO2 laser hollow fiber: a prospective study of 39 patients.

We present the first series of patients treated by transoral laser surgery (TLS) using the new AcuPulse 40WG CO(2) laser with the FiberLase flexible waveguide (CO(2) LWG) (Lumenis, Santa Clara, CA) with the objective to test its reliability and efficacy. Patients older than 18 years, with oral, pharyngo-laryngeal or tracheal benign or premalignant lesions were enrolled after signing an informed consent. This prospective study was conducted between October 2010 and May 2011 in two tertiary care university hospitals. Thirty-nine patients were enrolled in the study. The mean age was 47.9 years (range 18-86 years). There were 21 women and 18 men. Thirteen patients had hypertrophy of lymphoid tissue (palatine and or lingual), nine patients had granulomas, four patients had an exudative glottic lesion, three patients had severe dysplasia (glottic and supraglottic), three patients had leukoplakia, two patients had glottal cysts, two patients had laryngeal papilloma, two patients had bilateral paralysis of the vocal folds and one patient suffered from spasmodic dysphonia. Eighty-two percent of the procedures were performed under general anesthesia with laryngo-tracheal intubation. The CO(2) fiber passed through a handpiece was used with a microscope in the majority of the procedures. The laser delivery mode parameter used was: SuperPulse or Continuous Wave. Power levels were 3-15 Watts (W), continuous delivery. Each procedure utilized one CO(2) fiber which performed adequately throughout the procedure. No complications were noted with the use of this technology. A bipolar cautery was needed to control bleeding in eight procedures; all these procedures were tonsillectomies. The CO(2) LWG is a safe and reliable tool for TLS. It is durable enough to last through the entire surgical procedure without the need for replacement. Its use must be tailored depending on the type and location of the lesion, the CO(2) lasers tissue effects as well as the surgeon's experience.

Phonosurgical Injection Approaches for Voice Restoration After Open Partial Horizontal Laryngectomies: A Pilot Study.

OBJECTIVE: The aim of the present study is to evaluate the efficacy of phonosurgical corrective approaches based on injection laryngoplasties and pharyngoplasties followed by speech therapy for voice restoration after unsatisfactory phonatory results of open partial horizontal laryngectomies. METHODS: Ten patients with not satisfying phonatory results despite speech therapy after type II or type III open partial horizontal laryngectomies (OPHLs) were included. Each patient underwent a voice restoration program based on phonosurgery (injection laryngoplasty and/or injection pharyngoplasty) with hyaluronic acid and/or calcium hydroxyapatite, followed by post-surgical voice rehabilitation. Voices were recorded and analysed through spectrographic, aerodynamic, perceptual, laryngoscopic and self-assessment evaluations before the treatment (T0), after 1 month (T1) and after three months (T2). RESULTS: Significant improvements in the patients voices were found between T0, T1 and T2 concerning acoustic, perceptual, aerodynamic, laryngoscopic and self assessment evaluations. CONCLUSIONS: The results of the present study support phonosurgical injection procedures followed by speech therapy as an effective strategy for voice restoration after type II or type III OPHLs in selected patients.

Substitution Voice Rehabilitation After Open Partial Horizontal Laryngectomy Through the Proprioceptive Elastic Method (PROEL): A Preliminary Study.

OBJECTIVE: The aim was to investigate the efficacy of the Proprioceptive Elastic Method (PROEL) in the rehabilitation of the substitution voice after open partial horizontal laryngectomy (OPHL). STUDY DESIGN: Prospective outcome study. METHODS: Fifteen patients surgically treated by OPHL type II or type III for laryngeal cancer were recruited (experimental group). Each patient underwent a specific program of voice rehabilitation based on the PROEL method with the same speech and language pathologist. Acoustic-aerodynamic analysis: maximum phonation time (MPT); spectrographic classification (Titze's modified classification), perceptual analysis (INFVo rating scale) and self-assessments (SECEL questionnaire) were performed before the treatment (T0), after 3 months of rehabilitation (T1), and at the end of the 6-month rehabilitation program (T2). A control sample of other 15 patients who underwent OPHL type II or type III and who underwent a standard perioperative rehabilitation was randomly extracted from an historical database and compared to the experimental group. RESULTS: Significative voice improvements between T0-T1 and T2 were found for acoustic, aerodynamic, perceptual, and self-assessments analysis in the experimental group. Significative differences were found between the experimental group at T2 and the control sample for aerodynamic, self-assessment, and perceptual analysis. CONCLUSIONS: The results of the present study support PROEL method as an effective approach for substitution voice rehabilitation after OPHL type II and III. Randomized controlled trials on larger groups of patients are needed in future in order to compare PROEL with other rehabilitative approaches.

Acoustic Analysis of Normal Voice Patterns in Italian Adults by Using Praat.

This study was designed to identify the physiological vocal parameters of Italian adult subjects by means of Praat software, differentiated by gender and age. The vocal parameters analyzed were mean pitch, Jitter local %, Jitter local absolute, Jitter rap, Jitter ppq5, Jitter ddp, Shimmer local %, Shimmer local dB, Shimmer apq3, Shimmer apq5, Shimmer apq11, Shimmer dda, Harmonicity Mean autocorrelation, Harmonicity Mean noise-to-harmonics ratio, Harmonicity Mean harmonics-to-noise ratio, and the maximum phonatory time. The volunteers were 123 (58 men and 65 women) and were recruited among students and employees of the University of Eastern Piedmont and of the University Hospital Maggiore della Carità Novara, among family members and researchers' acquaintances. The group of subjects was divided according to gender and age categories, ie, 18-30, 31-40, 41-50, 51-60, and 61-70 years. The voice samples were recorded in the same silent room to minimize the differences in background noise. The measurement was repeated twice on different days to evaluate the reproducibility of the vocal analysis with the Praat software. The comparisons of the vocal values obtained were carried out by stratifying the group of volunteers both by gender and age. After analyzing the variables for skewness, kurtosis, normality distribution through Shapiro-Wilk test, and the equality of variances by Levene test, parametric or nonparametric statistical tests were used when appropriated assuming a confidence level of 0.05. The Bland-Altman test has been used to evaluate the data reproducibility. The analysis of the stratified data for both gender and age showed a good repeatability of all the vocal parameters (except the maximum phonatory time in the age groups 18-30, 31-40, and 41-50 of the women where the Pvalue was less than 0.05). Gender differences were significant in all the vocal parameters, in particular, the variables related to the fundamental frequency and jitter local absolute were statistically significant in all categories. From the analysis of the data of the participants divided by age groups grouped there emerged a substantial difference among individuals belonging to different ages (with the exception of men aged between 18 and 50 years), thus making it impossible to compare and defining an important difference in vocal parameters throughout life.

Flexible endoscopic phonosurgery for treatment of functional sequelae after laryngeal oncologic surgery: a narrative review.

Flexible endoscopic phonosurgery (FEPS) is one of the most recent and constantly evolving operative techniques in the field of minimally invasive laryngeal surgery. Thanks in part to the possibility of using new technologies, such as digital endoscopes, laser fibres, and different laryngeal injection materials, its fields of application have rapidly expanded. This narrative review describes the current possible indications of FEPS ranging from injection laryngoplasties in cases of vocal cord paralysis or mass defect, to the correction of dysphagia after open partial horizontal laryngectomies. Use of microscissors, microforceps, and laser fibres also allows this technique to be applied for removal of superficial vocal cord lesions, avoiding general anaesthesia in an increasing number of patients.

"Before I die I want to ": An experience of death education among university students of social service and psychology.

The censorship of death and dying has removed the "memento mori" practices, and in order to reintroduce this practice, some "Before I die" projects have been increasingly implemented. Running in parallel, in the syllabi of social service and psychology students, some experiences of death education has commenced. This study illustrates the results of a qualitative research conducted on the "Before I die I want to …" Polaroid® Project (BIDIWT), which is divided into two phases. The first phase entails an analysis of the wishes collected from the United States, Japan, India, and Italy. The second phase refers to the analysis of the captions of the BIDIWT realized from two groups of undergraduates, with regard to the effect of such experience on their religiosity, representation of death, and fear of death.

Development and Validation of the Children's Voice Handicap Index-10 for Parents.

OBJECTIVES/HYPOTHESIS: The Children's Voice Handicap Index-10 (CVHI-10) was introduced as a tool for self-assessment of children's dysphonia. However, in the management of children with voice disorders, both parents' and children's perspectives play an important role. Because a self-tool including both a children's and a parents' version does not exist yet, the aim of the study was to develop and validate an assessment tool which parallels the CVHI-10 for parents to assess the level of voice handicap in their child's voice. STUDY DESIGN: Observational, prospective, cross-sectional study. METHODS: To develop a CVHI-10 for parents, called "CVHI-10-P", the CVHI-10 items were adapted to reflect parents' responses about their child. Fifty-five children aged 7-12 years completed the CVHI-10, whereas their parents completed the CVHI-10-P. Each child's voice was also perceptually assessed by an otolaryngologist using the Grade Breathness Roughness (GRB) scale. Fifty-one of the 55 children underwent voice therapy (VT) and were assessed afterward using the GRB, CVHI-10, and CVHI-10-P. RESULTS: CVHI-10-P internal consistency was satisfactory (Cronbach alpha = .78). Correlation between CVHI-10-P and CVHI-10 was moderate (r = 0.37). CVHI-10-P total scores were lower than CVHI-10 scores in most of the cases. Single-item mean scores were always lower in CVHI-10-P compared with CVHI-10, with the exception of the only one item of the CVHI-10-P that directly involves the parent's experience (item 10). Data gained from one tool are not directly related to the other, suggesting that these two tools appraise the child's voice handicap from different perspectives. The overall perceptual assessment scores of the 51 children after VT significantly improved. There was a statistically significant reduction of the total scores and for each item in CVHI-10 and CVHI-10-P after VT. These data support the adoption of the CVHI-10-P as an assessment tool and an outcome measure for management of children's voice disorders. CONCLUSIONS: CVHI-10-P is a valid tool to appraise parents' perspective of their child's voice disorder. The use of the CVHI-10 and the CVHI-10-P is recommended for objectively determining the level of voice handicap in children by parents and child.

Development and validation of the children's voice handicap index-10 (CVHI-10).

OBJECTIVES/HYPOTHESIS: To develop and validate the self-administered Voice Handicap Index-10 for children (CVHI-10) in Italian and evaluate its internal consistency and reliability in normal and disordered children's voices. STUDY DESIGN: Cross-sectional survey study. METHODS: CVHI-10 was developed after a series of individual interviews with 20 children, aged 8-14 years to discuss the phrasing and wording of the original VHI-10. Subsequently, 66 dysphonic children (group 1) provided input to test internal consistency, external validity, and clinical validity. The voices of group 1 children were rated using the grade, roughness, and breathiness parameters of the grade, roughness, breathiness, asthenia, strain (GRBAS) scale. The test-retest results of 30 children (group 2) who successfully underwent voice treatment were also analyzed for test-retest reliability and responsiveness to treatment. Children of group 2 completed CVHI-10 twice, with an interval of 2 weeks. Additionally, 40 children without voice disorders (group 3) were included as a control group to obtain clinical validity. Each child included in the study completed CVHI-10 autonomously. RESULTS: Internal consistency measured with the Cronbach α coefficient was .85; test-retest reliability was 0.84. CVHI-10 positively correlated with G (r=0.62) and B (r=0.34) parameters of the GRBAS scale on Spearman rho test. The mean CVHI-10 score for group 2 was 12.4±2.8 before treatment and 3.6±1.6 after treatment; the difference was significant using the Wilcoxon sign test (P=0.0001). The difference between CVHI-10 scores in groups 1 and 3 was significant using the Mann-Whitney U test (P=0.0001). CONCLUSIONS: CVHI-10 is easily administered, highly reproducible, exhibits good clinical validity, and responsiveness to treatment.

Auto-crosslinked hyaluronan gel injections in phonosurgery.

OBJECTIVES: To evaluate the clinical performance of an auto-crosslinked gel obtained from hyaluronic acid (ACP-based gel) as an anti-adhesive agent and/or augmentative agent in vocal cord surgery for the treatment of vocal fold (VF) atrophy, sulcus vocalis, and postsurgery scarring as well as its tolerability at short- and long-term follow-up. STUDY DESIGN: This was a prospective multicenter trial conducted between 2007 and 2009. SETTING: Academic center. SUBJECTS AND METHODS: Inclusion criteria were patients with glottic gap due to previous endoscopic phonosurgery, VF scars, vocal cord atrophy, and sulcus vocalis. Forty patients who underwent endoscopic injection of hyaluronic acid under general anesthesia were enrolled. Two different injections sites were used: the thyroarytenoid muscle in cases of glottic gap for augmentative purposes, and the lamina propria for treatment of scars and sulcus vocalis. A voice-evaluation protocol was performed before surgery, at the first follow-up visit (3 mo), and at the final follow-up (12 mo). RESULTS: Follow-up data at three months were available for 38 patients, while data at 12 months follow-up were available for 27 patients. No side effects, hematoma, or infection and allergic reactions were reported in either the perioperative or postoperative period. Patients had statistically significant improvement in voice parameters compared with the baseline data at the first follow-up visit and at the 12-month follow-up. CONCLUSION: ACP-based gel seems to be a new tool in the challenging treatment of VF scarring, functioning as both an anti-adhesive product and an augmentation agent. Improvements in all glottal parameters and in both objective and subjective evaluation of voice performance were observed.