Susan Baker Brehm

Perceptual Evaluation of Severe Pediatric Voice Disorders: Rater Reliability Using the Consensus Auditory Perceptual Evaluation of Voice

The purpose of this nonrandomized prospective study was to quantify the inter- and intrarater reliability of experienced speech-language pathologists perceptual ratings of voice in pediatric patients post-laryngotracheal reconstruction (LTR). Moderate to severe dysphonia is common in this population. Using the sentence portion of the Consensus Auditory Perceptual Evaluation-Voice (CAPE-V) rating scale, three experienced speech-language pathologists independently rated randomized voice samples of 50 participants ages 4-20 years, who had acquired or congenital airway conditions requiring at least one LTR on the six salient perceptual vocal attributes. Data collection and listening conditions were carefully controlled. Seventeen (34%) of the samples were randomly selected for rerating at a later time. Estimates of interrater reliability were strongest for perceptual ratings of breathiness (intraclass correlation coefficient [ICC]=71%), roughness (ICC=68%), pitch (ICC=68%), and overall severity (ICC=67%). Reliability was lower for ratings of loudness (ICC=57%) and strain (ICC=35%). For each rater, the intrarater reliability on all but one parameter (strain) was moderate to strong (ICC=63-93%). There was a strong interrater eliability for four of six vocal parameters rated using the CAPE-V in a population of children and adolescents with marked dysphonia. The parameter of strain, when rated by auditory sample alone and apart from the clinical context, was difficult to rate.

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.

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 Childrens 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.

Voice outcomes following adult cricotracheal resection.

Cricotracheal resection (CTR) is an effective treatment for moderate‐to‐severe laryngotracheal stenosis (LTS) in adults. However, one of the potentially significant sequela of this procedure is postoperative dysphonia and permanent voice alteration. The objective of this study is to characterize voice changes in adult patients with subglottic stenosis who have undergone CTR.

Aerodynamic and acoustic assessment in children following airway reconstruction: An assessment of feasibility

OBJECTIVE The purpose of this study was to examine the feasibility of conducting aerodynamic and acoustic assessment in children following airway reconstruction. Underlying etiologies, co-morbidities and age related factors can present challenges for meaningful instrumental data collection in this population. METHODS A chart review of 100 children who were seen for a complete voice evaluation at the Center for Pediatric Voice Disorders at the Cincinnati Childrens Hospital Medical Center was conducted. Children who completed full or partial aerodynamic and acoustic protocols were identified. Data regarding the ability to participate in the assessment was tabulated, and vowel samples taken from the acoustic data were subjected to signal type classifications (e.g., Type I, II, III). RESULTS Fifty-three children met the inclusion/exclusion criteria of the chart review. Of those children, 58% (n=31/53) were able to complete the full acoustic and aerodynamic protocols without any modification. In regards to the aerodynamic protocol alone, 64% (n=34/53) could complete protocol. In regards to the acoustic protocol alone, 75% (n=40/53) could complete the entire acoustic protocol without any modification. There were 32% (n=17) who provided a Type I acoustic signal which was appropriate for measurement of F(0). There was a significant correlation between age and ability to complete the protocol for both the aerodynamic (p=.007) and acoustic (p=.004) protocols. CONCLUSIONS This study demonstrated that a majority of children were capable of completing aerodynamic and acoustic protocols. A significant proportion of children in this study had severe dysphonia, precluding the ability to extract fundamental frequency. Although aerodynamic and acoustic measures are feasible for many patients in this population, the severity of dysphonias observed in these patients causes the use of these measures to be limited in some cases for documenting behavioral and surgical outcomes measures.

An Examination of Elicitation Method on Fundamental Frequency and Repeatability of Average Airflow Measures in Children Age 4:0–5:11 Years

OBJECTIVE The purpose of this study was to determine the effect of task type on fundamental frequency (F(0)) and the short-term repeatability of average airflow values in preschool/kindergarten-age children. STUDY DESIGN Prospective, experimental. METHODS Thirty healthy children (age 4.0-5.11 years) were included in this study. Participants completed three tasks (sustained vowel, counting, and storytelling) used to elicit measurements of F(0). With a 10-minute interval, participants also completed two trials of sustained /a/ at a comfortable pitch and loudness level for the measurement of average airflow rate. F(0) and intensity of the vowel production were recorded for both trials. RESULTS A repeated measures analysis of variance revealed a significant main effect for task type elicitation on F(0) values (P=0.0003). A significant difference between elicitation tasks for F(0) was observed in the comparison of the counting and storytelling task (P<0.0001). A paired t test revealed no significant difference in average airflow rate across two trials (P=0.872). The change in F(0) and intensity was measured across the trials, and separate analyses of covariance revealed that these changes did not significantly influence average airflow values, (P=0.809) and (P=0.365), respectively. CONCLUSIONS The results of this study demonstrated that F(0) may be influenced by task type in young children. Average airflow values appear to be stable over a short time period. This information is important in determining methods of evaluation and the reliability of instrumental measures in young children with voice disorders.

Update on pediatric voice and airway disorders: assessment and care.

Purpose of reviewTo investigate the status of the recent literature focused on studying the assessment and treatment of pediatric voice and airway disorders using both established and novel techniques. Recent findingsRecent research regarding voice assessment and treatment reveals the use of systematic and innovative approaches when collecting instrumental and perceptual voice data. There are recent advancements in certain surgical interventions designed to minimize complications. Wider use of functional endoscopic imaging of the pediatric larynx is improving our understanding of childhood voice production and airway management. There is also an important emerging focus on quantifying the impact of having a childhood voice disorder through the use of new tools. Although there is an increase in pediatric voice and airway research, many studies tend to be entirely descriptive rather than quantitative. There continues to be little specific research that uses prospective, longer-term and formal voice outcomes before and after behavioral and surgical interventions. SummaryPediatric voice and airway disorders are an important childhood health problem. Voice assessment in children should include formal perceptual and instrumental evaluations, including sophisticated acoustic, aerodynamic and imaging modalities. The care of these children requires a collaborative approach that includes systematic and innovative treatment methods.

Influence of preoperative voice assessment on treatment plan prior to airway surgery: Influence of Preoperative Voice Assessment

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.