Journal of Voice最新文献

Transcranial direct current stimulation (tDCS) can be used to temporarily and reversibly modulate brain functions and is an increasingly utilized tool to investigate the relationships between brain and behavior. This study aimed to identify the brain area where tDCS has the greatest effect on vocal quality, vocal range, neuromotor functioning of the larynx, and self-reported vocal effort in vocally healthy individuals. Sixteen adults, non-singers, with a mean age of 22.5 (±1.9) years and no vocal symptoms or brain dysfunction, participated in this double-blinded randomized crossover clinical trial. The participants underwent four anodal tDCS session (20 minutes; 2 mA) in targeting different areas-cerebellum, primary motor cortex (M1), primary somatosensory cortex (S1), and dorsolateral prefrontal cortex (DLPFC)-with a 7-day washout period between sessions. Volunteers were evaluated for vocal performance before and after each tDCS session. Voice recordings were taken to assess the following vocal parameters: vocal range profile (VRP) at weak and strong intensities; vocal quality (jitter, shimmer, irregularity, glottal-to-noise excitation ratio, and dysphonia acoustic index) at weak, habitual, and strong intensities; laryngeal diadochokinesis, and self-reported vocal effort using the adapted Borg CR10 scale. M1 stimulation enhanced the VRP by increasing maximum intensity and improving vocal quality, particularly at habitual and strong intensities. Similarly, S1 stimulation improved vocal quality at strong intensities but reduced the VRP by lowering the maximum fundamental frequency. Cerebellum stimulation enhanced neuromuscular control and coordination of the larynx without affecting vocal quality. Additionally, self-reported vocal effort decreased across all stimulated areas following tDCS. Our findings indicate that tDCS applied to different brain areas produces varying effects on vocal parameters.

Objective: Despite anecdotal evidence highlighting the benefits of singing teacher involvement in voice rehabilitation for effective and sustainable biopsychosocial treatment of vocal injury, singing teachers working as singing voice rehabilitation specialists (SVRS) in the United Kingdom (UK) have often been criticized for working beyond their scope of practice. With limited empirical research into the role, concern and confusion has fueled challenges to its legitimacy. The lack of regulation raises questions around safeguarding, skills, and demarcation of roles within the multidiscipline team. Previous research into patient experiences in the voice clinic has suggested hierarchy and power imbalances between patients and clinicians are impeding development of rehabilitation practices and outcomes. The aim of this pilot study is to explore whether similar socioeconomic and epistemological structures are perceived as contributing to critique of SVRS involvement in rehabilitation and whether formal professionalization of the role may provide a solution to the debate.

Methods: To systematically explore the views and experiences of professionals working in the multidisciplinary voice clinic team in the UK, a deductive, qualitative methodology was adopted. Recognizing the majority female workforce in this context, MFST was applied to semistructured interviews with nine female-identifying participants: three Otolaryngologists, three SLTs, and three SVRS. Data were analyzed according to the themes and concepts of materialist feminism, using in vivo and embodied facial coding to capture verbal and non-verbal communication.

Results: Participants viewed the SVRS role as a positive addition to clinical practice. They indicate that in their experiences, some of the concepts found in materialist femininist analysis of organizations and women's role in the workplace hold true, and may be reasonably said to contribute to skepticism surrounding the SVRS role. They suggest there are challenges and benefits to professionaling the role. These relate to relationships, management and oversight; navigating and respecting professional identity; individual scope of practice, skills, and qualifications; establishing and managing shared ethical and economic values.

Conclusion: Overall, professionalization for SVRS was viewed positively, to enhance integration into existing workplace structures. Professional training, certification, and regulation was felt to be important for creating a shared language between clinicians and nonclinicians. It was noted, however, that there are challenges within the current medical paradigm, which would be less advantageous to pursue. The requirements of professionalization should be carefully negotiated alongside the current freedoms and creative practices employed by SVRSs.

Many common voice disorders are associated with vocal hyperfunction (VH), with subtypes including phonotraumatic VH (leading to organic vocal fold lesions such as nodules and/or polyps) and nonphonotraumatic VH (often diagnosed as primary muscle tension dysphonia). VH has been hypothesized to influence baseline vocal fold tension during phonation, and the relative fundamental frequency (RFF) during onset and offset cycles of phonation has been related to vocal fold tension and has been shown to differentiate typical voices from patients with VH in laboratory settings. In this study, we investigated whether the laboratory sensitivity of RFF to the presence of VH found in the laboratory is preserved in naturalistic, in-field settings and whether ecological momentary assessment of RFF during daily life could be a correlate of self-reported vocal effort. RFF analysis was carried out after performing smartphone-based monitoring of anterior neck-surface vibration with accelerometer sensors in both laboratory and in-field settings. Supervised machine learning was applied to combine multiple RFF values to discriminate and classify patients with VH from vocally typical speakers. Results showed that RFF-based classification of VH can be preserved in the naturalistic environments for patients with phonotraumatic (81.3% accuracy) and nonphonotraumatic (62.5% accuracy) VH. Additionally, we used explainability techniques to understand which RFF features were clinically relevant in the classification tasks. No direct relationship was observed between RFF and self-reported vocal effort. Overall, this study advances our understanding about RFF as a potential biomarker of VH as individuals go about their daily life. Machine learning algorithms can be implemented within a monitoring device for proactive screening or in biofeedback-based voice therapy paradigms.

Objectives: To assess depression and perception of vocal handicap in individuals with and without early-stage Alzheimer's disease (AD) using a self-report method.

Methods: It was conducted between April 2024 and June 2024 with individuals who visited the Internal Medicine Clinics of Çankırı State Hospital, including those with AD (study group: n = 41) and those without AD (with normal cognitive levels) (control group: n = 50). 41.46% (n = 17) of the study group were female, 53.54% (n = 24) were male. 56% (n = 28) of the control group were female, 54% (n = 22) were male. The Personal and Medical Characteristics Information Form, The Standardized Mini-Mental State Examination, the Geriatric Depression Scale (GDS), and the Voice Handicap Index-10 (VHI-10) were used. For the perception of vocal handicap, participants were asked to respond to the question, "How do you describe your voice at the moment?" by choosing one of two options: good or bad, to express their opinion.

Results: The study group scored significantly higher on the GDS than did the control group (t = (89) = 3.043, P = 0.03). Similar results were obtained in the VHI-10 scores of the two groups (t = (89) = 0.892, P > 0.05). The study group reported a worse perception in their responses to the question regarding perceived of vocal handicap (χ²(1) = 28.145, P < 0.001). A significant relationship was found between the GDS results of the study group and the perceived vocal handicap (χ²(2) = 20.246, P < 0.001). A moderate positive correlation was found between VHI-10 and GDS (r = 0.508, P = 0.001).

Conclusion: The voice is an important tool that individuals use for communication with their environment. While individuals with AD are at risk for depression, the current impact of the disease also affects their perception of vocal handicap. It is thought that broad-spectrum evaluations could be guiding for healthcare professionals working in geriatrics to better understand AD.

Parkinson's disease (PD) is a neurodegenerative disorder affecting motor and non-motor functions, including speech. This study evaluates the effectiveness of the audio spectrogram transformer (AST) model in detecting PD through vocal biomarkers, hypothesizing that its self-attention mechanism would better capture PD related speech impairments compared to traditional deep learning approaches. Speech recordings from 150 participants (100 from PC-GITA: 50 PD, 50 healthy controls (HC); 50 from Italian Parkinson's voice and speech (ITA): 28 PD, 22 HC) were analyzed using the AST model and compared against established architectures including VGG16, VGG19, ResNet18, ResNet34, vision transformer, and swin transformer. Audio preprocessing included sampling rate standardization to 16 kHz and amplitude normalization. The AST model achieved superior classification performance across all datasets: 97.14% accuracy on ITA, 91.67% on Parkinson's Colombian - Grupo de Investigación en Telecomunicaciones Aplicadas (PC-GITA), and 92.73% on the combined dataset. Performance remained consistent across different speech tasks, with particularly strong results in sustained vowel analysis (precision: 0.97 ± 0.03, recall: 0.96 ± 0.03). The model demonstrated robust cross-lingual generalization, outperforming traditional architectures by 5%-10% in accuracy. These results suggest that the AST model provides a reliable, non-invasive method for PD detection through voice analysis, with strong performance across different languages and speech tasks. The model's success in cross-lingual generalization indicates potential for broader clinical application, though validation across more diverse populations is needed for clinical implementation.

Objectives/hypothesis: Assess the impact of the infraglottal medialization technique on acoustics and the vertical stiffness gradient of the vocal fold using excised canine larynges.

Methods: Seven ex vivo canine larynges were tested in three states: 1) no implant, 2) medialized using a glottal implant, and 3) medialized fold using an infraglottal implant. Outcome measures were vocal efficiency and stiffness of the fold. Stiffness was measured using the indentation technique in three height levels of the fold to assess the vertical stiffness gradient.

Results: Infraglottal medialization improved vocal efficiency in all larynges tested and was superior to the improved efficiency seen with glottal medialization. Infraglottal medialization increases the vertical stiffness gradient of the vocal fold. While glottal medialization increased overall vocal fold stiffness, it did not enhance the vertical stiffness gradient.

Conclusion: Infraglottal medialization improves vocal efficiency and vertical stiffness gradient. Stiffness gradient might be the mechanism behind the creation of the glottal divergent angle by infraglottal medialization, a finding that was observed in a previous study. These results provide valuable guidance to clinicians in selecting implant location and medialization techniques, offering the prospect of enhanced vocal outcomes. In addition, it sheds light on some principles in vocal fold vibration mechanics.

Level of evidence: NA.

Objective: To verify changes in acoustic parameters, namely jitter, shimmer, and standard deviation of the fundamental frequency (dp f_o), through the life span of vocally healthy Brazilian Portuguese speakers.

Method: In total, 526 voice recordings of subjects without complaints and without vocal disorders, aged between 5 and 93 years old, were included. The recordings were divided into 12 age groups (5 to 7, 8 to 9, 10 to 11, 12, 13 to 15, 16 to 18, 19 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, and 70 to 93 years old). Acoustic analysis was carried out, based on the sustained emission of the vowel /a/, extracting the parameters jitter, shimmer, and dp f_o, using the Multi-Dimensional Voice Program software. The two-way ANOVAtest was used to investigate possible differences between age groups, followed by the Sidak Post-Hoc test.

Results: Related to jitter, children present higher values compared with the elderly. In adults and the elderly, the jitter measurement does not reflect the changes resulting from aging in both sexes. Women have a higher jitter value compared with men. As for the shimmer, this measurement is high in the child population with stability during adulthood and, in the elderly, it was observed that the shimmer was sensitive to indicate vocal changes in the male population. In general, there are no sex differences on this measurement. Finally, for dp f_o, the study found higher values in the child population, with a reduction with aging until stabilizing in adults and the elderly. Higher values were observed for females compared with males.

Conclusion: Jitter, shimmer, and dp f_o changed through the life span, being elevated for the child population, remaining stable in the adult population, and with smaller changes during aging.

Objective: Serial intralesional steroid injections (SILSI) are increasingly used in the treatment of idiopathic subglottic stenosis (iSGS) and auto-immune related subglottic stenosis (SGS), which are both known for their high rate of recurrences. SILSI could potentially prolong the time to re-intervention. We evaluated the effects of adjuvant SILSI in iSGS and auto-immune related SGS-patients on time to reintervention and spirometry results.

Methods: A total of 16 consecutive subjects undergoing SILSI from 07/2018 were included in this consecutive case-series. All patients were treated with surgical endoscopic dilatation (ED) followed by SILSI (ED + SILSI). A subgroup of patients (no. 7/16) were previously also treated with solely ED. In this subgroup, outcome measures could be compared before and after adding SILSI within the same patient. Outcome measures included time to reintervention, side effects, and spirometry results expressed in Δarea under the curve_total/forced vital capicity (AUC).

Results: Of all patients, 8/16 (50%) underwent at least one reintervention post ED + SILSI after a mean time of 14 months. In the subgroup, the median of the mean time to reintervention improved from 12 (interquartile range = 6) months post ED to 18 months (IQR = 8) post ED + SILSI. The median difference in AUC was 1.27 (P = 0.022; 95% CI: 0.51-3.05). No patients developed serious side effects during SILSI.

Conclusion: Adjuvant SILSI after ED potentially prolongs time to reintervention in iSGS and auto-immune SGS patients. It is, however, still unclear which patients benefit most. The decision to incorporate this adjuvant treatment should be made in shared decision making between surgeon and patient.

Level of evidence: 4:

Objectives: In voice production, interactions occur between the oscillating vocal folds, the respiratory system, and the vocal tract. However, it is not yet sufficiently understood how the respiratory system could affect the vocal tract configuration. It is hypothesized that a reduction in tracheal pull, caused by decreasing lung volume, along with shifts in dominant exhalation forces (from inspiratory to expiratory muscles), leads to a larynx elevation with shortening of the vocal tract tube, and consecutively, articulatory adjustments to preserve consistent sound quality.

Methods: Seventeen professional operatic singers performed a maximum phonation time task on comfortable pitch while being recorded with dynamic 2D-magnetic resonance imaging (MRI) (25 fps, pixel resolution of 1.6 x 1.6 mm²) including simultaneous audio recording. From the MRI footage, articulatory movements were calculated for vertical larynx position, pharynx width at the narrowest point, lip opening, jaw opening, and jaw protrusion. Spectral data were extracted from the audio signals after noise reduction.

Results: The larynx moved in cranial direction in 5 of 9 female and 3 of 8 male participants during the phonatory exhalation. Such movement was directly counteracted by other articulators in four cases. In 12 of the subjects, articulatory and/or spectral events in the form of adaptions or twitches occurred around and after 50% of the phonation time. Most subjects exhibited changes in articulator positioning as well as adjustments to the subsequently sustained fundamental frequency during the first and last 10% of the sustained phonation.

Conclusions: The articulatory movements during the task were non-systematic. Sudden events/adaptations in the second half of the phonatory exhalation could potentially mark a passage of the REL. The cranial movement of the larynx could be attributed to the decreasing tracheal pull; however, this was not evident in all subjects, suggesting a high degree of individuality in the regulation of respiratory movement in relation to vertical larynx position. Overall, the data indicate that it is important to consider continuous and sudden articulatory movements during sustained measurements.

Objective: To investigate the laryngopharyngeal reflux disease (LPRD) features in singers.

Methods: According to the PRISMA statements, two investigators searched the literature related to the prevalence of symptoms, findings, and clinical therapeutic outcomes of reflux in singers through a PubMed, Scopus, and Cochrane Library systematic review.

Results: Of the 91 identified studies, 18 publications met the inclusion criteria, accounting for 2288 singers and 1398 controls, respectively. There were 1243 (54.3%) professional singers, 450 (19.7%) amateurs, 329 (14.4%) singing students, and 102 (4.5%) singing teachers. The LPRD diagnosis and findings were based on objective evaluations in 2/18 studies. According to validated and unvalidated patient-reported outcome questionnaires, reflux symptoms have been found in 25.0% to 65% of singers, with a RSI > 13 in 25.0%-33.9% of cases. The prevalence of LPRD signs ranged from 18.1% to 73.4% of singers without voice complaints and 18.1%-73.4% of singers with voice complaints at the time of the evaluation. No study investigated the pretreatment to post treatment changes in symptoms, findings, and voice outcome. Substantial heterogeneity was found between studies for reflux diagnosis, symptom and sign evaluations, singer profiles (musical styles, voice range), and association outcomes.

Conclusion: The prevalence of symptoms and findings attributed to LPRD can be high in singer populations. However, the nonspecificity of symptoms and findings, the lack of objective reflux testing, and the heterogeneity in the singer profile limit the drawing of valid conclusions for the prevalence of LPRD. Based on the findings collected in this systematic review, the authors proposed a semistructured questionnaire, including key points for primary singer evaluation.