Philippe H. Dejonckere

A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques

Abstract 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.

The effect of relative humidity of inhaled air onacoustic parameters of voice in normal subjects

The hypothesis that relative humidity (RH) of air exerts an effect on voice has been widely accepted. The aim of this study has been to assess whether this can be demonstrated. Eight healthy subjects inhaled during ten minutes three different air conditions: dry, standard room, and humidified air. After inhalation, the subjects produced repeatedly a sustained /a/ of controlled pitch and loudness, which was analyzed for perturbation and noise-to-harmonic parameters. Perturbation measures increased after inhalation of dry air. No significant differences existed between standard and humidified air. No significant difference in the noise-to-harmonic ratio was found among the three conditions. We conclude that the human voice is very sensitive to decreases in RH of inhaled air, because even after a short provocation with dry air, a significant increase in perturbation measures was found.

Efficacy and safety of oxandrolone in growth hormone-treated girls with turner syndrome.

CONTEXT AND OBJECTIVE GH therapy increases growth and adult height in Turner syndrome (TS). The benefit to risk ratio of adding the weak androgen oxandrolone (Ox) to GH is unclear. DESIGN AND PARTICIPANTS A randomized, placebo-controlled, double-blind, dose-response study was performed in 10 centers in The Netherlands. One hundred thirty-three patients with TS were included in age group 1 (2-7.99 yr), 2 (8-11.99 yr), or 3 (12-15.99 yr). Patients were treated with GH (1.33 mg/m(2) . d) from baseline, combined with placebo (Pl) or Ox in low (0.03 mg/kg . d) or conventional (0.06 mg/kg . d) dose from the age of 8 yr and estrogens from the age of 12 yr. Adult height gain (adult height minus predicted adult height) and safety parameters were systematically assessed. RESULTS Compared with GH+Pl, GH+Ox 0.03 increased adult height gain in the intention-to-treat analysis (mean +/- sd, 9.5 +/- 4.7 vs. 7.2 +/- 4.0 cm, P = 0.02) and per-protocol analysis (9.8 +/- 4.9 vs. 6.8 +/- 4.4 cm, P = 0.02). Partly due to accelerated bone maturation (P < 0.001), adult height gain on GH+Ox 0.06 was not significantly different from that on GH+Pl (8.3 +/- 4.7 vs. 7.2 +/- 4.0 cm, P = 0.3). Breast development was slower on GH+Ox (GH+Ox 0.03, P = 0.02; GH+Ox 0.06, P = 0.05), and more girls reported virilization on GH+Ox 0.06 than on GH+Pl (P < 0.001). CONCLUSIONS In GH-treated girls with TS, we discourage the use of the conventional Ox dosage (0.06 mg/kg . d) because of its low benefit to risk ratio. The addition of Ox 0.03 mg/kg . d modestly increases adult height gain and has a fairly good safety profile, except for some deceleration of breast development.

Voice problems in children: pathogenesis and diagnosis

Voice problems seem to concern more than one child out of twenty, and may concern quality (hoarseness), resonance (nasality), pitch (mutation) and loudness. The main etiological categories are defined as organic (congenital/acquired), functional/habitual (especially due to voice abuse and misuse), and psychogenic (especially mutation disorders). Flexible transnasal endoscopes of small diameter (2.3 mm) are optimally suited for accurate endoscopic diagnosis, especially if combined with video-recording and stroboscopy.

What determines the differences in perceptual rating of dysphonia between experienced raters

Although the perceptual GRBAS scale for pathological voice quality has been found to be sufficiently reliable in clinical practice, even experienced raters disagree to some extent, and the degree of disagreement depends on the perceptual characteristics. We looked for a possible link between the degree of disagreement (65 voices; 2 experienced raters) and objective acoustical measurements. No significant correlation appeared between any acoustical parameter and the degree of disagreement for G. By contrast, the difference in perceptual rating of R was related to the amount of shimmer, and the difference in perceptual rating of B was related to some extent to the amount of jitter. Thus the presence of a strong breathy component in a pathological voice disturbs the rating of the rough component, and reciprocally.

Pathogenesis of vocal fold nodules: new insights from a modelling approach.

Objective: To give new insights into the pathogenesis of vocal fold nodules: (a) why the female/male ratio is so extreme, (b) how an hourglass-shaped vibration pattern – eliciting a localized microtrauma – originates, and (c) what the roles of muscular tension imbalance and of behavioral aspects are. Materials and Methods: Simulations with a 3-dimensional computer model of the vibrating vocal folds. Results and Conclusion: (1) A slightly incomplete dorsal vocal fold adduction is a first condition for inducing an hourglass vibration pattern. (2) A limited collision zone is only possible with a small degree of curving of the rest position of the vocal fold edges in their ventral portion. This is an anatomical characteristic of the adult female larynx. Muscular fatigue and resulting hypotonia seem to enhance this curving. (3) If both these conditions are fulfilled, a sufficient vibration amplitude is required to achieve a localized impact. (4) This third condition can be obtained by an increased subglottal pressure and/or by a decrease in active stress of the tension forces between the neighboring vocalis masses. These last aspects incorporate muscular tension imbalance (dyskinesia) and behavioral aspects in the modelling process. Decrease in active stress is a possible effect of fatigue, and increase in subglottal pressure a result of effort compensation.

Nonorganic Habitual Dysphonia and Autonomic Dysfunction

The present study was designed to test the hypothesis that there is a relation between nonorganic habitual dysphonia and subjective experience of dysfunction of the autonomic nervous system (neurovegetative lability). Eighty-three patients (65 women and 18 men) with a nonorganic voice disorder and a matched control group answered a questionnaire of 46 questions. One question replicated in different terms and six nonrelevant questions point out that the inquiry forms were answered in a consistent way. It appears that female patients in all age categories with a nonorganic habitual dysphonia report significantly more autonomic symptoms and complaints than healthy controls. This hypothesis cannot be confirmed for the male subgroup.

Plasticity of voice quality: a prognostic factor for outcome of voice therapy?

Plasticity of voice quality is defined here as the degree of improvement in deviant voice quality that can be achieved immediately or quasi-immediately by changing basic voicing conditions, posture, articulation or resonance, breathing mechanics, laryngeal position, or auditory feedback. Thirty-two adult patients with various benign organic voice pathologies, and who had a (preoperative) functional voice therapy, were scored before therapy using a weighted multidimensional Index of Voice Plasticity (IVP). The hypothesis is that IVP could be a predictor of the final outcome of functional voice therapy, and therefore a correlation with a comparable quantification of the actual results of the therapy was investigated. The IVP shows a satisfactory correlation (Spearmans rho = 0.68) with the efficacy of (preoperative) voice therapy. The IVP also significantly differs between diagnostic categories. Although its predictive value remains limited, the Index of Voice Plasticity seems helpful in decision making for indication of (presurgical) voice therapy.

Effect of louder voicing on acoustical measurements in dysphonic patients

Practically nothing is known about the possible effect of a slightly louder phonation (as reflected by the sound pressure level) on commonly used acoustical parameters for evaluation of pathological voice quality. In this experiment, 87 patients with various kinds of voice pathology produced a /a:/ firstly at comfortable pitch and loudness, and secondly a little louder (average SPL increase: 2,6 dB). In case of normal vocal fold anatomy or superficial vocal fold pathology (epithelium or Reinkes space), louder voicing significantly reduces the perturbation parameters (jitter and shimmer), and thus also the noise to harmonics ratio. This is probably due to the increase of the oscillating mass by larger involvement of normal deeper layers of the vocal fold. In case of cancer or vocal fold paralysis, both involving the deeper layers of the vocal fold, louder voicing significantly enhances the irregularity of vocal fold vibration (jitter). When a tremor component is present in a voice (without known primary n...

Correlation between the perceptual rating of speech in Dutch patients with velopharyngeal insufficiency and composite measures derived from mean nasalance scores

Objective: To evaluate the potential clinical use of composite measures derived from mean nasalance scores. Procedure: Speech samples with a normal distribution of phonemes (normal text, NT) and speech samples free of nasal consonants (denasal text, DT) of 43 patients with perceived hypernasality were used. The overall grade of severity, hyperrhinophonia, audible nasal emission, misarticulations associated with velopharyngeal insufficiency and intelligibility were perceptually rated on separate visual analog scales. Mean nasalance scores were computed by the Nasometer for the same speech samples on which the perceptual ratings were performed. From the mean nasalance scores computed for the NT and DT passages the difference and the quotient were calculated. The advantage could be that the derived measures provide some normalization with regard to the performance of the individual speaker. Spearman correlation coefficients were computed between these composite measures and the perceptually rated parameters. The results were compared with the correlation coefficients between the mean nasalance scores and the ratings. Setting: The Institute of Phoniatrics, Utrecht University Hospital, The Netherlands. Results: The correlations between the composite measures and the perceptual ratings were generally lower than the correlations between mean nasalance scores and the ratings. Conclusion: Normalization of the nasalance scores did not enhance the correlation with the perceptual ratings in this study.