Journal of Voice

Reply to Functional Dysphonia: A Clear Need for Differential Diagnosis Publication date: Available online 18 July 2019 Source: Journal of Voice Author(s): Tamonud Modak

Factor Analysis of the Persian Version of the Voice Disability Coping Questionnaire Publication date: Available online 16 July 2019 Source: Journal of Voice Author(s): Farzaneh Salehimanesh, Majid Soltani, Maryam Dastoorpoor, Negin Moradi Abstract Introduction Voice disorders can affect the quality of life and coping mechanisms and also coping mechanisms can affect the way in which patients deal with their voice problems. People with voice disorders need to use coping strategies to deal with the problems caused by their voice disorder. The purpose of this study was to examine the psychometric properties and cultural adaptation of the Voice Disability Coping Questionnaire in the Iranian population. Methods The translation and cross-cultural adaptation procedures were performed according to the basic rules and instructions set by the International Quality of Life Assessment Project. Two hundred and forty-eight adults (218 patients with voice disorder and 30 healthy controls) were participated in the study. Face and content validity, clinical validity, and construct validity of the questionnaire were investigated by modern psychometric methods. Results Quantitative methods were used to measure content validity and all items were detected applicable. This means that the final version was clear and easy to answer. Clinical validity shows that the Persian version of VDCQ can distinguish between patients and healthy controls (P < 0.001). The construct validity of the VDCQ was tested in a cross-sectional study. The questionnaire was analyzed by exploratory and confirmatory factor analyses. Investigation of initial communality and after extraction of factors by Varimax rotation method showed that the share of items for all items in the questionnaire except item 12, is higher than 0.5. Therefore, item 12 should be removed from the questionnaire (Table 3). Based on the confirmatory factor analysis model, items 2 and 10, whose factor load were less than 0.4, were excluded from the questionnaire (Fig. 1). For reliability the Cronbach's alpha coefficient and ICC were obtained as 0.82 and 0.99, respectively. The results of studying the role of items in the reliability of the VDCQ showed that all items increase internal consistency. Conclusion Based on modern statistical analysis conducted in this study, the original 15 item questionnaire was reduced to 12 item. The 12 item questionnaire is a valid and reliable tool for quantifying coping strategies in people with voice disorder.

Vocal Fold "Paralysis": An Early Sign in Multiple System Atrophy Publication date: Available online 16 July 2019 Source: Journal of Voice Author(s): Philip W. Tipton, Dale C. Ekbom, Amy L. Rutt, Jay A. van Gerpen Summary Multiple system atrophy (MSA) is a neurodegenerative disease characterized by a cerebellar syndrome, autonomic dysfunction, and extrapyramidal signs. Extrapyramidal signs may manifest as parkinsonism as well as dystonia, which is the involuntary contraction of a muscle(s) resulting in an abnormal posture. MSA belongs to a family of diseases known as α-synucleinopathies which are associated with dream enactment reflecting REM sleep behavior disorder (RBD). In patients with MSA, dystonia or paresis may involve the laryngeal muscles resulting in vocal fold hypomobility. We identified four individuals presenting with vocal complaints and subsequently diagnosed with vocal fold "paralysis." Within one year, each patient developed neurologic symptoms and upon evaluation by a movement disorders specialist was diagnosed with probable MSA. Our findings highlight the importance of screening by otolaryngologists when patients are diagnosed with vocal fold hypomobility. Specifically, patients should be assessed for RBD by questioning others if he/she acts out their dreams. The presence of RBD raises clinical suspicion for a synucleinopathy such as MSA. Untreated patients with MSA experiencing nocturnal stridor and breathing disorders have an increased risk for sudden death. Therefore, early evaluation by a movement disorders specialist to promptly diagnose MSA may have a substantial effect on morbidity and mortality in this high-risk patient population.

Book Review of Janet Baker's book, "Psychosocial Perspectives on the Management of Voice Disorders: Implications for Client, Options and Strategies for Clinicians." Publication date: Available online 15 July 2019 Source: Journal of Voice Author(s): Miriam van Mersbergen

Long-Term Effects of a Voice Training Program to Prevent Voice Disorders in Teachers Publication date: Available online 13 July 2019 Source: Journal of Voice Author(s): Birte Meier, Ulla Beushausen Abstract Objectives Research findings about long-term effectiveness of voice training programs for teachers are limited. This study shows long-term evaluation results of a statewide voice training program for teachers in Lower Saxony/Germany. Method Twenty-seven voice training sessions with 286 participating teachers were evaluated with different questionnaire surveys on three different occasions (prior and after seminar, follow-up 3 months later). Prior the training and 3 months after completion of the training the validated self-assessment tool Voice Profile for Professional Voice users (VPPV) was used to measure subjective impact of voice problems on the participating teachers. In addition, questionnaires to evaluate benefits of the seminars for everyday working life, possible voice changes and satisfaction with the program were used. Results Prior the training 64.9% of the participating teachers were above the cut-off point of the VPPV that indicates a high subjective impact of voice problems. Three month after the training this number decreased by −14.9% down to 50% (P= 0.001, T = 3.437, df = 314). Ninety-three percent of the respondents implemented aspects of the voice training seminar in their occupational everyday life. Furthermore, teachers showed a slight or considerable improvement of their vocal resilience (72.2%) 3 months after the training. This included rarer clearing of the throat (80.6%) and/or a reduction of vocal tract discomfort symptoms (66%). Conclusion The results indicate that a vast majority of teachers implement contents of the voice training program in their occupational everyday life and that these changes in behavior lead to a better vocal capacity and vocal performance. Nevertheless, the number of teachers that have a mean value in the VPPV that can be regarded as very high self-perceived voice impact which indicates a risk for a voice disorder is still high after the voice training. Voice training sessions held so far proofed to be an important aspect to reduce self-perceived voice impact in teachers in Lower Saxony/Germany.

Intraglottal Pressure: A Comparison Between Male and Female Larynxes Publication date: Available online 13 July 2019 Source: Journal of Voice Author(s): Sheng Li, Ronald C. Scherer, MingXi Wan, SuPin Wang, Bo Song Summary Acoustic differences in the phonated sounds made by men and women are related to laryngeal and vocal tract structural differences. This model-based study explored how typical vocal fold differences between males and females affect intraglottal pressure distributions under conditions of different glottal angles and transglottal pressures, and thus how they may affect phonation. The computational code ANSYS Fluent 6.3 was used to obtain the pressure distributions and other aerodynamic parameters for laminar, incompressible flow. Typical values of the vocal fold length, the vertical glottal duct length, and the lateral vocal fold tissue depth were selected both for males and females under conditions of nine typical convergent/divergent glottal angles and three transglottal pressures. There was no coupling of the upstream or downstream vocal tracts, and also no vocal fold contact in these two-dimensional static glottal geometries. Results suggest that males tend to have greater intraglottal pressures for the convergent glottal shape that occurs during glottal opening, and the male glottis offers less flow resistance than the female glottis. These results suggest that the male vocal folds may vibrate more easily (ie, with lower transglottal pressure) but the tissue differences may nullify such an hypothesis. Also, the peak velocities in the glottis were dependent on the transglottal pressure driving the flow and the minimal glottal diameter, which were the same for both the male and female larynxes, rather than on the inferior-superior length of the glottis or the anterior-posterior glottal length. In addition, the tangential forces for larger glottal convergent angles was significantly greater in the female larynx. The entrance loss coefficients, however, were similar between the male and female larynxes, except for the uniform glottis for which the values were larger for the male larynx. The results suggest that the structural differences between male and female vocal folds should be well specified when building computational and physical models of the larynx.

Dehydration and Estrous Staging in the Rat Larynx: an in vivo Prospective Investigation Publication date: Available online 13 July 2019 Source: Journal of Voice Author(s): Abigail Cox, Naila Cannes do Nascimento, Andrea Pires dos Santos, M. Preeti Sivasankar Abstract Objective This novel study sought to untangle the association between hydration state and the estrous cycle in the vocal folds, since the voice is reported to negatively change in speakers during the estrous cycle and with dehydration. We hypothesized that there would be alterations in vocal fold tissue morphology depending on hydration state and that these changes would vary with the estrous cycle. Study Design Prospective, in vivo study design. Methods Female Sprague Dawley rats (n = 30) were used in this study. Sixteen rats were systemically dehydrated to an average of 10% reduction in body weight by withholding water (range of body weight loss: 8%–13%). Fourteen rats were assigned to euhydrated, control condition. Estrous stage of female Sprague Dawley rats (n = 30) was determined via cytological evaluation of vaginal smears. Following euthanization, larynges were prepared for histological staining with hematoxylin and eosin, Masson's trichrome and alcian blue (pH 2.5). To quantify hyaluronan, alcian blue staining was completed pre- and posthyaluronidase incubation. The change in staining percent was quantified with image analysis algorithms and reported as the hyaluronan quantity. Relative collagen distribution (index of dehydration), hyaluronan quantity, and tissue morphology were the outcome measures. Results Systemic dehydration was associated with changes in hyaluronan quantity in the rat vocal fold lamina propria. Dehydration did not significantly affect the collagen distribution nor the tissue morphology. Estrous stage alone does not impact the quantity of vocal fold hyaluronan, alter tissue morphology, or change collagen distribution. Conclusion Decreases in hyaluronan quantity in the lamina propria of the rat vocal fold may play a role in tissue fluid balance during systemic dehydration. Future studies will expand this work to investigate additional components of the vocal fold extracellular matrix to fully elucidate the impact of hydration state on the vocal fold.

Translation and Cross-Cultural Adaptation of the Newcastle Laryngeal Hypersensitivity Questionnaire to Brazilian Portuguese Publication date: Available online 13 July 2019 Source: Journal of Voice Author(s): Vanessa Veis Ribeiro, Anne Vertigan, Mara Behlau Abstract Objective To translate and cross-culturally adapt the Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ) to the Brazilian Portuguese language. Material and methods The translation and cross-cultural adaptation procedures were performed in five stages: translation, synthesis, back-translation, committee review, and pretest performance. Results At the end of the first four stages, a questionnaire was produced in Brazilian Portuguese, known as the Questionário Newcastle de Hipersensibilidade Laríngea (LHQ-Br). This version was given as a pretest to 31 participants with laryngeal hypersensitivity: 14 were in the muscle tension dysphonia clinical group, 10 in the refractory chronic cough group, and seven in the globus pharyngeus group. There was a difference in the frequency of occurrence choices in question five ("my throat is blocked"; P = 0.007) and question eight ("I have a sensation of something pushing on my chest"; P = 0.026), but in both questions, the frequency choice of "never" was significantly higher than the other options in all three clinical groups. The relative frequency of participants picking the 'nonapplicable' option in all clinical groups for all questions was zero. Conclusion This study showed satisfactory results for the translation and cross-cultural adaptation of the LHQ to Brazilian Portuguese (LHQ-Br).

Monitoring Breathing Muscle Performance During Singing Noninvasively Using Mechanomyography and Electromyography Publication date: Available online 9 July 2019 Source: Journal of Voice Author(s): Muhammad Imran Ramli, Nur Azah Hamzaid, Julia Patrick Engkasan Abstract Objectives The aim of this study was to investigate the performance of mechanomyography (MMG) and electromyography (EMG) in monitoring the sternocleidomastoid (SCM) as accessory respiratory muscles when breathing during singing. Methods MMG and EMG were used to record the activity of the SCM in 32 untrained singers reciting a monotonous text and a standard folk song. Their voices were recorded and their pitch, or fundamental frequency (FF), and intensity were derived using Praat software. Instants of inhale and exhales were identified during singing from their voice recordings and the corresponding SCM MMG and EMG activities were analysed. Results The SCM MMG, and EMG signals during breathing while singing were significantly different than breathing at rest (p < 0.001). On the other hand, MMG was relatively better correlated to voice intensity in both reading and singing than EMG. EMG was better, but not significantly, correlated with FF in both reading and singing as compared to MMG. Conclusions This study established MMG and EMG as the quantitative measurement tool to monitor breathing activities during singing. This is useful for applications related to singing therapy performance measure including potentially pathologically effected population. While the MMG and EMG could not distinguish FF and intensity significantly, it is useful to serve as a proxy of inhalation and exhalation levels throughout a particular singing session. Further studies are required to determine its efficacy in a therapeutic setting.

Laboratory Evaluation of Spasmodic Dysphonia Publication date: Available online 6 July 2019 Source: Journal of Voice Author(s): Sammy Othman, Srihari Daggumati, Rohan Patel, Justin Ross, Robert T. Sataloff Summary Objectives To evaluate the utility of comprehensive laboratory evaluation in patients with spasmodic dysphonia (SD). Study Design Retrospective chart review. Methods A review of the medical records of 40 patients diagnosed with spasmodic dysphonia from 2009-2018 was preformed to evaluate abnormal test results that were significant when compared with abnormal results of the general population and for any other clinically relevant pathology. Results Erythrocyte sedimentation rate, ceruloplasmin levels, and anti-AChR were found to be elevated at levels considered statistically significant (p <0.05). Furthermore, we found levels of cholesterol, thyroid-stimulating hormone (TSH), T3, fasting blood glucose, creatine kinase, immunoglobulin, antinuclear antibody (ANA), and alpha-fetoprotein (AFP) levels to be abnormal at a greater rate in our population, but these were not statistically significant. Workup revealed several underlying conditions including thyroid neoplasms, hypothyroidism, and laryngopharyngeal reflux. Additionally, brain MRI revealed age-related ischemic pathology in an elevated number of patients, but with no obvious clinical sequalae. Conclusion There is an association between serological values and spasmodic dysphonia that can aid in diagnosing pathology, as well as establishing a directed workup. Additionally, our study shows the utility of comprehensive evaluation in identifying undetected disease.

Alexandros Sfakianakis
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