Alison Behrman

Factors Predicting Patient Perception of Dysphonia Caused by Benign Vocal Fold Lesions

Objectives/Hypothesis: To assess factors that may be predictive of patient perception of dysphonia severity, as quantified by the Voice Handicap Index (VHI) score. We hypothesize that 1) level of vocal demand; 2) auditory‐perceptual evaluation of dysphonia severity; and 3) vocal function, as defined by phonatory glottal closure and mucosal wave vibration, are the most significant predictors of VHI score.

Management of Benign Vocal Fold Lesions: A Survey of Current Opinion and Practice

Empirical data are often not available to guide clinical practices in the treatment of benign mucosal lesions of the vocal folds. The purpose of this report is to describe opinions and practices in order to identify areas of consensus and discrepancy and thus guide future inquiry. A 16-item survey mailed to all active US members of the American Academy of Otolaryngology—Head and Neck Surgery (n = 7,321) included questions on the use of voice therapy; diagnostic testing; perioperative use of steroids, antibiotics, and antireflux medications; and use of lasers. Responses used a Likert 5-point scale with end anchors of 1 equaling “never” and 5 equaling “always” and were stratified according to lesion (nodules, polyps, cysts). A 16.5% response rate (n = 1,208) was obtained. A lack of consensus was most evident in the use of voice therapy for lesions other than nodules; antireflux medication; and intravenous steroids. Disagreement was also noted regarding the use of lasers, oral steroids, and antibiotics. Other than voice therapy as initial intervention for nodules, no statistically significant differences by lesion type exist regarding use of voice therapy, laser, or any medication. Prospective clinical trials addressing voice therapy, antireflux medications, steroids, and antibiotics are needed to inform clinical practice. Furthermore, treatment practices appear to be largely independent of lesion type. Therefore, traditional diagnostic categories do not seem to be useful guides to treatment, and may need to be reevaluated in light of improvements in diagnostic technology and surgical technique.

Quantitative analysis of videostroboscopic images in presbylarynges

Objective/Hypothesis Age‐related dysphonia, or presbylarynges, is often identified as the cause of voice disorders in older individuals. It is a diagnosis of exclusion that typically includes the subjective videostroboscopic findings of vocal fold bowing or atrophy and incomplete glottal closure. We hypothesize that vocal fold bowing correlates directly with glottal gap in patients with presbylarynges and that these characteristics may be quantified objectively using measures obtained from videostroboscopic images.

Anterior-Posterior and Medial Compression of the Supraglottis: Signs of Nonorganic Dysphonia or Normal Postures?

Two vocal tract postures commonly identified as hallmarks of nonorganic dysphonia are anterior-posterior and medial compression of the supraglottis. However, insufficient data exist to support their diagnostic utility. The purpose of this study was to compare these two postures in patients with nonorganic dysphonia and normal controls using interval data derived from quantitative measures of videostroboscopic images obtained with an oral endoscope. Retrospectively, 40 patients with nonorganic dysphonia and 40 normal controls were selected. Relative anterior-posterior compression (LO(AP)) was calculated as the laryngeal outlet (LO) (the view of the true vocal folds during phonation) normalized to the anterior-posterior dimension in pixels. Relative ventricular fold medial compression (LO(w)) was calculated as the laryngeal outlet normalized to the medial dimension in pixels. Results were as follows: (1) LO(AP) was significantly greater for the dysphonic group, (2) the range of LO(AP) values between the two groups overlapped considerably, (3) no significant difference was found between groups for LO(w), (4) the correlation between LO(AP) and LO(w) within each subject yielded r values of 0.71 and 0.67 for the nonorganic dysphonia and normal control groups, respectively. It is concluded that medial compression of the ventricular folds can be a normal laryngeal posture, and that although anterior-posterior compression is present in greater degree in dysphonics, it is sufficiently common in normals to question its utility as a diagnostic sign of phonatory dysfunction.

Voice Rest after Microlaryngoscopy: Current Opinion and Practice

Objective Although voice rest is often recommended after excision of benign mucosal vocal fold lesions, no standard of care exists regarding the use, duration, or extent of vocal restrictions. This prospective study is intended to explore current opinions and practices of otolaryngologists regarding the use of complete and relative voice rest.

The effect of upper airway surgery on voice.

OBJECTIVE: Our goal was to assess patient perception and acoustic characteristics of voice before and after upper airway surgery. STUDY DESIGN AND SETTING: We conducted a prospective assessment of 44 surgical patients preoperatively and postoperatively at a tertiary care, academic hospital. Operations included septoplasty and turbinectomy (n = 28) and septoplasty, turbinectomy, uvulopalatopharyngoplasty, and tonsillectomy (n = 16). Patient opinion measures included Voice Handicap Index score, perception of vocal resonance, and change in voice. Acoustic measures included assessment of the relative amplitude of selected formants (resonances) of the vocal tract. RESULTS: Mean Voice Handicap Index scores were unchanged after surgery. Nine patients (20%) perceived their voice to be improved after surgery. None perceived the voice to be worse. Postoperative changes in relative formant amplitudes were statistically significant. These changes caused the acoustic features to become more representative of normative data than the preoperative values. CONCLUSION: Upper airway oeprations can affect acoustics and perception of voice. SIGNIFICANCE: Patients are unlikely to perceive a change in voice as a result of upper airway surgeries, but in those cases where a difference is perceived, it is likely to be a positive change.

Correlation dimension of electroglottographic data from healthy and pathologic subjects

This paper considers the effects of nonstationarity, noise, and finite data sets on the estimation of the correlation dimension of time-series data characterizing the vibratory behavior of the vocal folds. The electroglottographic signal of sustained /a/ phonations from 10 healthy subjects and 20 subjects with vocal fold pathologies were used to reconstruct the state space in successively higher embeddings using the method of lags. The dimension values were calculated from the scaling region (the level area of the slope plots) which did not increase for higher embeddings. Reasonably defined scaling regions were found in all of the data from the healthy subjects and from five of the pathologic subjects, with values saturating between the first and second embeddings. The EGG data from those five pathologic subjects were nearly periodic. From the remaining 15 subjects, the scaling regions were highly constricted with nonconstant slopes, so that dimension values could not be confidently estimated. The results suggest that the correlation dimension is a highly subjective measure which is not usefully applied to abnormal EGG data. It is recommended that, if used, correlation dimension statistics need to be presented cautiously, and graphical presentation of the data should be included.

Global and local dimensions of vocal dynamics.

The global embedding dimension (dE) and the local dynamical dimension (dL) are calculated from the microphone and electroglottographic (EGG) signals elicited from five healthy subjects and seven dysphonic subjects with laryngeal pathology during phonation of sustained/a/. The data from each pathologic subject contain at least one bifurcation and are divided into periodic and irregular segments for analysis. The dE values from both the microphone and EGG signals elicited from the healthy subjects indicate that a relatively small coordinate space can be used to reconstruct the attractor, with little residual noise. Consistent across all healthy subjects, three dominant degrees of freedom (dL) are found to govern local dynamics of the trajectories on the attractor. From the pathologic subjects, many of the dE values suggest the presence of a high-dimensional component in the signals. However, the noise does not completely obscure the deterministic dynamics of the source signal or prevent extraction of an optimal global embedding dimension. The data do not reveal consistent differences in degrees of freedom between healthy and pathologic phonation, or between different modes of pathologic phonation. However, the dL values suggest that the pathologic vocal fold vibration of these subjects, even highly irregular vibration, is governed locally by a low number of dominant degrees of freedom, sometimes no greater than those calculated from the signals of healthy subjects. Only in the cases of severe breathiness are the microphone and EGG signals sufficiently contaminated by noise to obscure any deterministic component.

A Comparison of Radiation-Induced and Presbylaryngeal Dysphonia

OBJECTIVE: The goal of this study was to assess voice after radiotherapy compared with patients with presbylaryngeal dysphonia. STUDY DESIGN AND SETTING: Prospective assessment of 20 patients aged 60+ years who remained free of disease longer than 1 year after radiotherapy for T1 squamous cell carcinoma and retrospective review of 46 patients aged 60+ with presbylaryngeal dysphonia, conducted at a tertiary care, academic hospital. Assessment data included videostroboscopy, spectrography, voice range profile, and Voice Handicap Index. RESULTS: Eighty percent of the radiotherapy patients reported a voice disorder. Acoustic data and functional measures reflected similar limitations and abnormalities for both groups. A high incidence of glottal gap in all patients may have been associated with increased mucosal stiffness in the radiotherapy group and vocal fold atrophy in the presbylaryngeal group. CONCLUSION: Patient perception and functional outcome of voice were similar for both groups, despite differences in etiology of abnormal vocal fold vibratory behavior. SIGNIFICANCE: Radiotherapy in older individuals may yield dysphonia that is no greater than that caused by normal aging.

Evidence-based treatment of paralytic dysphonia: making sense of outcomes and efficacy data

The criteria used to determine the success or failure of a given treatment for vocal fold paralysis are fundamental components of routine clinical practice and treatment outcomes research for the surgeon and voice therapist. The purpose of this article is to offer a guide to the critical interpretation of available measures of out-come and efficacy for this patient population. Such data form the basis for the practice of evidence-based medicine and voice therapy,essential if the standard of care is to evolve to the benefit of the patient. A better understanding of the potentials and limitations of each measure is important for treatment planning and patient counseling and, ultimately, for the conception of future well-designed clinical research. The complex issues regarding outcomes measurement are addressed here within the context of current treatment literature on vocal fold paralysis. Particular emphasis is placed on realistic data gathering within clinical practice.