The proposal of this basic protocol is an attempt to reach better agreement and uniformity concerning the methodology for functional assessment of pathologic voices. The purpose is to allow relevant comparisons with the literature when presenting / publishing the results of voice treatment, e.g. a phonosurgical technique, or a new / improved instrument or procedure for investigating the pathological voice. Meta-analyses of the results of voice treatments are generally limited and may even be impossible owing to the major diversity in the ways functional outcomes are assessed. A multidimensional set of minimal basic measurements suitable for all “common” dysphonias is proposed. It includes five different approaches: perception (grade, roughness, breathiness), videostroboscopy (closure, regularity, mucosal wave and symmetry), acoustics (jitter, shimmer, Fo-range and softest intensity), aerodynamics (phonation quotient), and subjective rating by the patient. The protocol is elaborated on the basis of an exhaustive review of the literature, of the experience of the Committee members, and of plenary discussions within the European Laryngological Society. Instrumentation is kept to a minimum, but it is considered essential for professionals performing phonosurgery.

/pdf/a-basic-protocol-for-functional-assessment-of-voice-27a8zvmdvj.pdf

A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. Guideline elaborated by the Committee on Phoniatrics of the European Laryngological Society (ELS).

http://linguistics.berkeley.edu/~kjohnson/ling210/sociophonetics/Foulkes_Docherty_06.pdf

The social life of phonetics and phonology

The maximum performance tests of speech production are those tests that examine the upper limits of performance for selected speech tasks. Among the most commonly used maximum performance tests are the following: maximum duration of phonation, maximum fricative duration, maximum phonation volume, maximum expiratory pressure, fundamental frequency range, maximum sound pressure level, maximum occluding force of the articulators, and diadochokinetic (maximum repetition) rate. Many clinicians use at least some of these tasks as part of an assessment protocol. These tests are analogous to strength, range, or speed tests in clinical neurology. Given the widespread use of these tests and a rather scattered literature on normative values obtained for them, a survey of the data base seemed in order. This paper summarizes the published normative data, discusses the adequacy of these data for clinical application, and recommends interpretive guidelines to enhance the usefulness of maximum performance tests.

Maximum performance tests of speech production

OBJECTIVE: This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness. PURPOSE: The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology‐ head and neck surgery, pediatrics, and consumers. RESULTS: The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The

/pdf/clinical-practice-guideline-hoarseness-dysphonia-4e0nnc9o4c.pdf

Clinical practice guideline: Hoarseness (Dysphonia)

A digital technique for high-speed visualization of vibration, called videokymography, was developed and applied to the vocal folds. The system uses a modified video camera able to work in two modes : high-speed (nearly 8000 images/s) and standard (50 images/s in CCIR norm). In the high-speed mode, the camera selects one active horizontal line (transverse to the glottis) from the whole laryngeal image. The successive line images are presented in real time o a commercial TV monitor, filling each video frame from top to bottom. The system makes it possible to observe left-right asymetries, open quotient, propagation of mucosal waves, movement of the upper and, in the closing phase, the lower margins of the vocal folds, etc... The technique is suitable for further processing and quantification of recorded vibration.

Videokymography : High-speed line scanning of vocal fold vibration

This paper is a sequel to a study which showed that the dominant dimension for perceptual discrimination among normal voices was the male-female categorization and which also suggested that discrimination within the male-female categories utilized distinct dimenisons. The present study eliminates the male-female axis by treating the gender groups separately and making the within-category dimensions available for more sensitive analysis. The purpose was to determine the number and nature of perceptual parameters needed to explain judgments of voice similarity depending on talker sex and whether the stimulus sample was a sustained vowel or a short phrase. The similarity judgments were submitted to multidimensional analysis via INDSCAL and the resulting dimenisons were interpreted in terms of available acoustic measures and unidimensional voice-quality ratings of pitch, breathiness, hoarseness, nasality, and effort. The decisions of the listerners appeared to be influenced by both the sex of the speaker and the stimulus sample, although fundamental frequency (fo), was important for all judgments. Aside from the fo dimensions, judgments concerning male voices were related to vocal tract parameters, while similarity judgments of female voices were related to perceived glottal/vocal tranct differences. Formant structure was apparently important in judging the similarity of vowels for both sexes while perceptual glottal/temporal attributes may have been used as cues in the judgments of phrases.

Multidimensional analysis of male and female voices

This study investigates and acoustically defines some of the perceptual parameters used to distinguish among normal male and female voices. Twenty normal speaking subjects, ten male and ten female, produced speech segments which were paired, randomized, and presented to ten listener judges. The judges rated the similarity of all combinations of voices on a seven-point scale, and these similarities were analyzed by a multidimensional analysis technique, INDSCAL. For each speaker, eight acoustical measures were obtained, and psychophysical ratings of four commonly used descriptive terms were made by ten speech pathologists. These measurements and ratings provided the interpretation of the INDSCAL solution and were also submitted to correlational analyses. The results indicate that, when distinguishing among the voices, the judges gave the greatest weight to the male versus female dimension and its acoustical correlates. The results of both the INDSCAL analysis and the correlational analyses suggest that listeners may use different perceptual strategies to classify male voices than they use to classify females ones.

Multidimensional classification of normal voice qualities

Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) is a comprehensive endoscopic assessment of the sensory and motor components of a swallow. Previous studies addressing patient safety issues with respect to FEESST included relatively small numbers of patients and paid almost no attention to patient characteristics. The purpose of this study was to determine the incidence of FEESST-related complications in the outpatient and inpatient settings and to analyze patient diagnoses that led to the performance of FEESST. We performed a prospective study of FEESST complications in 1,340 consecutive evaluations performed over a 4 1/2-year period. The primary outcome variables were incidence of epistaxis and airway compromise. The secondary outcome variable was underlying patient diagnoses. The incidence of epistaxis was 1 in 1,340 (0.07%). There were no instances of airway compromise. Stroke was the most common reason for the performance of FEESST (343; 25.6%), followed by cardiac-related dysphagia (298; 22.2%) following open heart surgery (169/298; 56.7%), heart attack, congestive heart failure, or new arrhythmia. The remaining causes were head and neck cancer (207; 15.4%), pulmonary disease (141; 10.5%), chronic neurologic disease (124; 9.3%), and acid reflux disease (80; 6.0%). We conclude that FEESST is a relatively safe procedure for the sensory and motor assessment of dysphagia in a cohort of patients with a wide variety of underlying diagnoses. The emergence of cardiac surgery as a common cause of dysphagia warrants further study.

Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1,340 consecutive examinations.

Objectives/Hypothesis:

To analyze existing evidence regarding utility of laryngeal electromyography (LEMG) for prognosis in cases of vocal fold palsy (VFP).



Study Design:

Meta-analysis of studies reporting LEMG results and clinical outcomes in 503 patients with of VFP identified by literature search.



Methods:

Studies were identified by literature search. Method of diagnosis, interval to LEMG, criteria for prognostication, and outcome were assessed. Criteria for prognosis were standardized to the extent possible across all studies, and studies were checked for consistency in outcome measures and assessments. Pooled data were subjected to statistical analysis.



Results:

A total of 296/503 patients (58.8%) had findings predictive with poor prognosis, whereas 207/503 (41.2%) had findings of recovery. According to laryngoscopic examination, 269/296 patients with predicted poor recovery had poor recovery (positive predictive value = 90.9%), whereas 27/296 (9.1%) had good recovery. In patients with findings consistent with recovery, 115/207 (negative predictive value = 55.6%) noted return of motion, whereas 88/207 (44.4%) did not. The odds ratio was 11.56 with 95% confidence interval of 7.10-18.81.



Conclusions:

LEMG is a good predictor of poor recovery in patients with VFP and is clinically useful in identifying candidates for early definitive intervention.

Laryngeal electromyography for prognosis of vocal fold palsy: a meta-analysis.

Objectives/Hypothesis:

Although the diagnostic accuracy of paradoxical vocal fold movement disorder and chronic cough has improved, the underlying pathophysiology remains relatively unknown. We hypothesize that one potential etiological factor in these patients is an aberrant laryngeal sensory response and sought to determine if respiratory retraining in addition to antireflux therapy alters this aberrant response.



Study Design:

Retrospective, outcomes.



Methods:

Sixteen patients who had been on at least 3 months of twice-daily proton pump inhibitors with no subjective improvement in their primary complaint of cough, self-reported symptoms of gastroesophageal and laryngopharyngeal reflux, and concurrent paradoxical vocal fold movement (PVFM) were included in the current study. In addition to continuing twice daily pharmacological therapy, subjects underwent a course of respiratory retraining. Outcome measures including the Reflux Symptom Index (RSI), transnasal flexible laryngoscopy, and laryngopharyngeal sensory discrimination thresholds were obtained prior to and following a course of respiratory retraining.



Results:

Mean bilateral laryngeal sensory response improved significantly after combined respiratory retraining and aggressive proton pump inhibitor therapy (P = .01). In addition, mean RSI score decreased significantly following treatment (P = .02). Specifically, 13 of 16 patients experienced improved sensory response, corresponding with patient reports of improved PVFM symptoms following treatment.



Conclusions:

Aberrant laryngeal sensation was identified in patients with PVFM and chronic cough. This response, however, normalized following a limited course of respiratory retraining, corresponding with improved patient symptoms. Laryngoscope, 2010

Thomas Murry

Papers

Multidimensional analysis of male and female voices

Multidimensional classification of normal voice qualities

Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1,340 consecutive examinations.

Laryngeal electromyography for prognosis of vocal fold palsy: a meta-analysis.

Laryngeal sensory deficits in patients with chronic cough and paradoxical vocal fold movement disorder