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PURPOSE: Swimmers present a unique challenge for the clinician when presenting with a diagnosis of exercise-induced laryngeal obstruction (EILO). The purpose of this tutorial was to query competitive swimmers about commonly used breathing strategies and then use that information as a basis from which to provide speech-language pathologists who treat EILO in swimmers with a clinical perspective for treatment planning and implementation. METHODS: A survey of competitive female and male swimmers aged 18 and over was conducted to inquire about swim breathing techniques used in the context of swim distance(s), training versus competition, bilateral versus unilateral head turn, and stroke-to-breath ratio. Questions regarding experience with EILO and asthma were also included. RESULTS: Following receipt of consent, 62 competitive swimmers completed the survey. The survey results indicated a preference for trickle breathing; however, many volunteers described different breathing strategies for training versus competition. Breath-to-stroke ratios differed widely, often based on swim distance as a means to have competitive advantage. Thirteen volunteers reported difficulty inhaling while swimming, two of whom reported a diagnosis of EILO and one who reported a diagnosis of asthma. CONCLUSIONS: Swimmers with EILO present with unique challenges for clinicians, given the various breathing techniques used and the idiosyncratic nature of breathing strategies for each swimmer. A one-size-fits-all approach is insufficient for this population and clinicians interested in treating swimmers with EILO will need to employ optimal critical thinking skills for intervention success-a true merger of art and deep understanding of respiratory and laryngeal physiology.

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PURPOSE: The primary goal of this investigation was to characterize the effect of the first-generation, over-the-counter antihistamine Chlor-Trimeton on laryngeal structure and function in a previously unstudied population - individuals diagnosed with allergic rhinitis who routinely take over-the-counter antihistamines and deny the experience or diagnosis of voice disorder. STUDY DESIGN: Prospective within-participant multimodality repeated measures design. METHODS: Eight consented participants (seven females, one male) previously diagnosed with allergic rhinitis and without history of voice disorder who routinely took over-the-counter antihistamines completed the study. Volunteers completed the following measures before and 2hours after antihistamine administration: perceptual vocal function measures, phonation threshold pressure (PTP), acoustic measures, and laryngeal imaging. All pre- and post-administration data were descriptively analyzed for clinically significant change. RESULTS: No clinically significant differences were identified for any acoustic or aerodynamic measures taken. Analyses of laryngeal imaging data indicated that all participants had evidence of mucosal changes in one or more of the following parameters: increased vascularity, mucus in the anterior commissure, and vocal fold color changes, all of which are consistent with prior descriptions of allergy larynx. CONCLUSIONS: Empirical study of laryngeal appearance in individuals diagnosed with allergic rhinitis, affirmed clinical observations of laryngeal tissue changes consistent with allergy larynx. Stable PTP suggests potential vocal fold cover adaptations from routine use of over-the-counter antihistamines that may buffer the typical desiccating effect on voice function observed in prior studies of healthy individuals.

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The primary aim of this investigation was to evaluate listener auditory-perceptual assessment of employability for individuals with hypernasal speech. Using an online survey platform, listeners with managerial experience evaluated speech samples from individuals with varying hypernasal resonance disorder severity to determine auditory-perceptual judgements regarding intelligence and employability. Speech samples of individuals with hypernasal speech were rated lower on scales of intelligence and employability, and more likely to be selected for jobs with infrequent rates of communication and lower levels of responsibility. Additionally, males with hypernasal speech were perceived as less intelligent, less employable, and more likely to be selected for a job with infrequent communication in comparison to females with hypernasal speech. Results of this preliminary investigation suggest that individuals with hypernasal speech may face employment barriers. The conclusions collected from this initial investigation open the doors for further research addressing linguistic considerations and aspects of employability. This is an important consideration for individuals with either acquired or congenitally related hypernasal resonance disorder.

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PURPOSE: The purpose of this tutorial is threefold: (a) present relevant exercise science literature on skeletal muscle metabolism and synthesize the limited available research on metabolism of the adult human speech musculature in an effort to elucidate the role of metabolism in speech production; (b) introduce a well-studied metabolic serum biomarker in exercise science, lactate, and the potential usefulness of investigating this metabolite, through a well-established exercise science methodology, to better understand metabolism of the musculature involved in voice production; and (c) discuss exercise physiology considerations for future voice science research that seeks to investigate blood lactate and metabolism in voice physiology in an ecologically valid manner. METHOD: This tutorial begins with relevant exercise science literature on the basic cellular processes of muscle contraction that require energy and the metabolic mechanisms that regenerate the energy required for task execution. The tutorial next synthesizes the available research investigating metabolism of the adult human speech musculature. This is followed by the authors proposing a hypothesis of speech metabolism based on the voice science literature and the application of well-studied exercise science principles of muscle physiology. The tutorial concludes with a discussion and the potential usefulness of lactate in investigations to better understand the metabolism of the musculature involved in vocal demand tasks. CONCLUSION: The role of metabolism during speech (respiratory, laryngeal, and articulatory) is an understudied yet critical aspect of speech physiology that warrants further study to better understand the metabolic systems that are used to meet vocal demands.

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PURPOSE: Given the importance of inspiratory phonation for assessment of vocal fold structure, the aim of this investigation was to evaluate and describe the vocal fold vibratory characteristics of inspiratory phonation using high-speed videoendoscopy in healthy volunteers. The study also examined the empirical relationship between cepstral peak prominence (CPP) and glottal area waveform measurements derived from simultaneous high-speed videoendoscopy and audio recordings. METHOD: Vocally healthy adults (33 women, 28 men) volunteered for this investigation and completed high-speed videoendoscopic assessment of vocal fold function for two trials of an expiratory/inspiratory phonation task at normal pitch and normal loudness. Twelve glottal area waveform measures and acoustic CPP values were extracted for analyses. RESULTS: Inspiratory phonation resulted in shorter closing time, longer duration of the opening phase, and faster closing phase velocity compared to expiratory phonation. Sex differences were elucidated. CPP changes for inspiratory phonation were predicted by changes in the glottal area index and waveform symmetry index, whereas changes in CPP during expiratory phonation were predicted by changes in asymmetry quotient, glottal area index, and amplitude periodicity. CONCLUSIONS: Vocal fold vibratory differences were identified for inspiratory phonation when compared to expiratory phonation, the latter of which has been studied more extensively. This investigation provides important basic inspiratory phonation data to better understand laryngeal physiology in vivo and provides a basic model from which to further study inspiratory phonation in a larger population representing a broader age range. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22223812.

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OBJECTIVE: To assess the recent literature for voice acoustic data values reported for individuals without voice disorder through the lifespan as a means to develop an updated normative acoustic data resource for children and adults. METHODS: A scoping review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. English language, full-text publications were identified through Medline (EBSCO & OVID), PubMed, APA PsycINFO, Web of Science, Google Scholar, and ProQuest Theses and Dissertations Global. RESULTS: A total of 903 sources were retrieved; of these 510 were duplicates. Abstracts of 393 were screened, with 68 full-text review. From the eligible studies, citation review yielded 51 additional resources. Twenty-eight sources were included for data extraction. For the normative acoustic data extracted for males and females across the lifespan, lower fundamental frequency for adult females was observed and few studies collected semitone range, sound level range, or frequency range. Data extraction also indicated a predominately gender binary reporting of acoustic measures with few studies reporting gender identity, race, or ethnicity as variables of interest. CONCLUSIONS: The scoping review yielded updated acoustic normative data that is of value for clinicians and researchers who rely on this normative data to make determinations about vocal function. The limited availability of acoustic data by gender, race, and ethnicity creates barriers for generalization of these normative values across all patients, clients, and research volunteers.

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Inducible laryngeal obstruction (ILO), formerly referred to as paradoxical vocal fold motion and vocal cord dysfunction, is a complex disorder of the upper airway that requires skillful differential diagnosis. There are several medical conditions that may mimic ILO (or which ILO may mimic) that should be considered in the differential diagnosis before evidence-supported behavioral intervention is initiated to mitigate or eliminate this upper airway condition. A key in treatment planning is determination of an isolated presentation of ILO or ILO concurrent with other conditions that affect the upper airway. Accurate, timely differential diagnosis in the clinical assessment of this condition mitigates delay of targeted symptom relief and/or insufficient intervention. Accurate assessment and nuanced clinical counseling are necessary to untangle concurrent, competing conditions in a single patient. This tutorial describes the common and rare mimics that may be encountered by medical professionals who evaluate and treat ILO, with particular attention to the role of the speech-language pathologist. Speech-language pathologists receive referrals for ILO from several different medical specialists (allergy, pulmonology, and sports medicine), sometimes without a comprehensive team assessment. It is paramount that speech-language pathologists who assess and treat this disorder have a solid understanding of the conditions that may mimic ILO. Summary tables that delineate differential diagnosis considerations for airway noise, origin of noise, symptoms, triggers, role of the speech-language pathologist, and ß-agonist response are included for clinician reference. A clinical checklist is also provided to aid clinicians in the critical assessment process.

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PURPOSE: Rural-living residents of Alabama depend on rural hospitals and clinics staffed with physicians and allied health professionals including speech-language pathologists (SLPs). The purpose of the exploratory study was to examine the speech-language pathology workforce in health care facilities in nonmetropolitan Alabama counties to determine potential disparities in access and identify medical SLP deserts for rural Alabamians. METHOD: The hospitals, rural health clinics, nursing homes, and rehabilitation centers for each of the 37 nonmetropolitan counties were identified through the 2020 Alabama Department of Public Health directories, and phone surveys were completed to determine medical SLP staffing at each facility. Descriptive statistics and regression analysis were conducted. RESULTS: The initial review yielded 229 rural health care facilities with 223 ultimately included in the analysis and 176 facilities completing a phone inquiry (76.68%). Sixty-one (35.88%) reported employing at least one SLP and no facility stated staffing SLP assistants. Linear regression indicated a positive, yet moderate effect size between the reported number of SLPs staffed within each county and specific population of the county (r 2 = .519). Anecdotally, facilities reported difficulty in hiring and retaining SLPs due to rural geographical location. CONCLUSIONS: The exploratory findings suggest disparities in access to behavioral communication and swallowing care for rural residents in the state. The methodology employed for data collection and analysis may be applied to other states and U.S. territories, in an effort to frame the issue nationally and support rural health care policy across the United States. Further investigation regarding the cost effectiveness of telepractice, the availability of broadband Internet access, the efficacy of community-based service delivery, and the effectiveness of incentivized rural SLP graduate programs is warranted to mitigate the disparities in access.

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PURPOSE: The purpose of this meta-analysis was to assess the frequency of sex, race, and ethnicity reporting and proportional representation in funded, noncancerous voice clinical trials to determine the state of compliance with National Institutes of Health (NIH) guidelines for inclusivity in clinical research. METHOD: Clinical trials registered with the NIH/U.S. National Library of Medicine between January 1988 and September 2021 were analyzed. Primary reports of the trials were obtained from clinicaltrials.gov and PubMed. Outcomes included the proportion of trials reporting sex, race, and ethnicity and the proportion of participants by sex, race, and ethnicity in the trials. Descriptive statistics and chi-square tests were used to analyze the data with 95% confidence intervals (CIs) reported. RESULTS: The search yielded 46 research studies. After inclusion and exclusion criteria were applied and attempts to locate studies were conducted, 11 total articles were ultimately evaluated. Descriptively, there were more female subjects, yet overall, no significant difference in sex distribution (χ2 = 0.07, p = .75, 95% CI [-0.25, -0.19]). Race and ethnicity were only reported in two clinical trials. Black participants were underrepresented in one clinical trial (χ2 = 4.93, p = .02, 95% CI [-0.11, -0.02]), whereas Hispanic participants were underrepresented in a second trial (χ2 = 11.27, p < .00, 95% CI [-0.20, - 0.13]). CONCLUSIONS: This preliminary analysis highlights the disparities in race and ethnicity recruitment and reporting in noncancerous voice clinical trials. There is a need for strategic recruitment strategies and improved reporting practices to adhere to the NIH inclusivity directives.

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The purpose of this investigation was to observe laryngeal tissue and vocal function changes over the course of 28 days in a single participant diagnosed by a laryngologist with bilateral nodules. Laryngeal imaging, acoustic variables and perceptual assessments of voice quality, and perceived vocal effort were obtained every morning for 28 consecutive days. A daily journal of occupational and recreational voice use as well as menstruation and alcohol consumption was maintained each day. It was hypothesized that the laryngeal pathology would appear more extensive and the vocal function measures obtained would be worse following extensive voice use. Laryngeal imaging, acoustic variables, and perceptual measures quantified provided evidence to support the study hypotheses. The size, extent, and asymmetry of the bilateral vocal pathologies observed were more extensive on days following occupational and recreational vocal loading. Acoustic and perceptual measures obtained correlated with the laryngeal tissue changes observed. Study findings support a more holistic approach to laryngeal pathology diagnosis that is based on a more thorough understanding of vocal loading considerations up to 48 hours prior to laryngeal endoscopy to better understand the pathophysiology of the observed lesion(s) for most accurate clinical diagnosis.

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PURPOSE: Participation in sorority recruitment often results in acute vocal impairment. The purpose of this investigation was to characterize the extent to which voice function and laryngeal appearance may be altered by participation in this social phenomenon. METHODS: Using a within-participant repeated measures design, nine women participating as sorority recruiters completed the study protocol. The following data were collected at two time points, immediately before and after the completion of two weeks of sorority recruitment: stroboscopic laryngeal imaging, vocal acoustic measures, and perceptual measures of vocal effort and voice quality. RESULTS: Perceived phonatory effort and overall severity of voice quality were significantly impaired following sorority recruitment. All participants had evidence of mucosal changes in the form of one or more the following: observed edema, erythema, increased vascularity, glottic margin changes. No significant differences in acoustic measures were identified. CONCLUSIONS: Increased perceived vocal effort, increased overall severity ratings of voice quality, and deleterious vocal fold tissue changes observed support the hypothesis that the acute vocal loading that is characteristic of the sorority recruitment process contributes to a decline in voice function in the short term. Acoustic measures taken either lacked the sensitivity for the perceived decline in voice function or the participants, who were otherwise healthy, managed to adapt the acoustic signal to the tissue changes observed. The extent to which these acute changes may be mitigated with vocal hygiene and voice training is an area for future study.

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PURPOSE: To assess the potential epidemiological association between various possible risk factors and healthcare disparities specifically related to the access, use and/or quality of speech language pathology services for individuals with voice and upper airway disorders. METHOD: A systematic review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis. Full text journal articles were identified through PubMed, PsycINFO and Web of Science. The reference sections of included articles were also manually screened and identified four additional studies for consideration of inclusion. Included articles specifically addressed healthcare disparities in voice and upper airway disorders related to speech pathology care. International literature was excluded. Eligible studies were reviewed and data extracted. Risk of bias of each eligible study was performed using the quality assessment tool from National Institute of Health for observational cohort and cross-sectional studies. Data from eligible studies were synthesized thematically. RESULTS: A total of 1,101 resources were retrieved from the search; of these, 133 were duplicates. Titles and abstracts of 968 articles were screened, with 14 selected for full-text review. Eleven articles were considered eligible for inclusion. Voice disorders were the condition most frequently examined followed by only one article addressing upper airways disorders. There was considerable heterogeneity in the methodology and statistical analyses among the eligible papers. There was a lack of standard methodology for collecting and accurately determining patient characteristics as well as variability in measuring confounding variables and providing statistical analyses for such adjustments that may have impacted the findings. The information extracted from these articles revealed healthcare disparities related to sex/gender, age, insurance status/coverage, race/ethnicity, among others including etiology and preferred language. CONCLUSIONS: This systematic review highlights the limited research on speech language pathology-specific healthcare disparities for individuals with voice and upper airway disorders. There was significant clinical and methodological heterogeneity between studies which may have contributed to varied results between studies. There is a need for greater methodological rigor and prospectively designed studies to better characterize the impact of disparities in the access to, use of, and quality of speech pathology care for this patient population.

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The increasing frequency of S. aureus antimicrobial resistance has spurred interest in identifying alternative therapeutants. We investigated the S. aureus-inhibitory capacity of B. velezensis strains in mouse and bovine models. Among multiple B. velezensis strains that inhibited S. aureus growth in vitro, B. velezensis AP183 provided the most potent inhibition of S. aureus proliferation and bioluminescence in a mouse cutaneous wound (P = 0.02). Histology revealed abundant Gram-positive cocci in control wounds that were reduced in B. velezensis AP183-treated tissues. Experiments were then conducted to evaluate the ability of B. velezensis AP183 to prevent S. aureus biofilm formation on a tracheostomy tube substrate. B. velezensis AP183 could form a biofilm on a tracheostomy tube inner cannula substrate, and that this biofilm was antagonistic to S. aureus colonization. B. velezensis AP183 was also observed to inhibit the growth of S. aureus isolates originated from bovine mastitis cases. To evaluate the inflammatory response of mammary tissue to intramammary inoculation with B. velezensis AP183, we used high dose and low dose inocula in dairy cows. At the high dose, a significant increase in somatic cell count (SCC) and clinical mastitis was observed at all post-inoculation time points (P < 0.01), which resolved quickly compared to S. aureus-induced mastitis; in contrast, the lower dose of B. velezensis AP183 resulted in a slight increase of SCC and no clinical mastitis. In a subsequent experiment, all mammary quarters in four cows were induced to have grade 1 clinical mastitis by intramammary inoculation of a S. aureus mastitis isolate; following mastitis induction, eight quarters were treated with B. velezensis AP183 and milk samples were collected from pretreatment and post-treatment samples for 9 days. In groups treated with B. velezensis AP183, SCC and abundance of S. aureus decreased with significant reductions in S. aureus after 3 days post-inoculation with AP183 (P = 0.04). A milk microbiome analysis revealed significant reductions in S. aureus relative abundance in the AP183-treated group by 8 days post-inoculation (P = 0.02). These data indicate that B. velezensis AP183 can inhibit S. aureus biofilm formation and its proliferation in murine and bovine disease models.

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The application of exercise science training knowledge has been of growing interest to voice professionals. This tutorial, derived from the authors' invited presentations from the "Exercise and the Voice" Special Session at the 2018 Voice Foundation Symposium, proposes a foundational theoretical structure based in exercise science, clarifies the wide range of variables that may influence voice training, and summarizes our present understanding of voice physiology from the perspective of muscle training. The body of literature on voice exercise was then analyzed from the perspective of this framework, identifying what we currently know and what we still have yet to learn.

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Purpose The primary aim of this review was to identify environmental irritants known to trigger chronic cough through the life span and develop a comprehensive clinically useful irritant checklist. Method A scoping review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews, checklist, and explanation. English-language, full-text resources were identified through Medline, PsycINFO, SPORTDiscus, Web of Science, and ProQuest Dissertations and Theses Global. Results A total of 1,072 sources were retrieved; of these, 109 were duplicates. Titles of abstracts of 963 articles were screened, with 295 selected for full-text review. Using the exclusion and inclusion criteria listed, 236 articles were considered eligible and 214 different triggers were identified. Triggers were identified from North America, Europe, Africa, Asia, and Australia. Occupational exposures were also delineated. Conclusions A clinically useful checklist of both frequently encountered triggers and idiosyncratic or rare triggers was developed. The clinical checklist provides a unique contribution to streamline and standardize clinical assessment of irritant-induced chronic cough. The international scope of this review extends the usefulness of the clinical checklist to clinicians on most continents.

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Purpose The aim of this study was to examine the influence of menstrual cycle phases (follicular, ovulatory, luteal, and ischemic) and hormone levels (estradiol, testosterone, progesterone, and neuropeptide Y) on vocal fold vibrations in reproductive and postmenopausal women. Method Glottal area waveforms were extracted from high-speed videoendoscopy during sustained phonation, inhalation phonation, and voice onset/offset in the reproductive (n = 15) and postmenopausal (n = 13) groups. Linear mixed-model analysis was conducted to evaluate hormone levels and high-speed videoendoscopy outcome variables between the reproductive and postmenopausal groups. In the reproductive group, simple linear regression and multiple regression were conducted to determine the effects of hormones on the dependent variables. Results Group differences between reproductive and postmenopausal women were identified for stiffness index, oscillatory onset time, and oscillatory offset time. Neuropeptide Y hormone in the ischemic phase significantly predicted changes in the reproductive group for some dependent variables; however, the relationship varied for sustained phonation and inhalation phonation. Conclusion These findings provide preliminary evidence that vocal fold vibrations in the reproductive group are different predominantly in the ischemic phase due to neuropeptide Y changes.

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Purpose The primary aim of this study was to investigate the extent to which individuals with facial and/or speech differences secondary to a craniofacial anomaly experienced bullying through social media platforms during late school age and adolescence. Method Using an online survey platform, a questionnaire was distributed via several public and private social media groups designated for individuals with craniofacial anomaly and their caregivers. Results The majority of participants (n = 38; 88.4%) indicated they had been bullied during late school-age and adolescence and that they believed this was due to their facial difference and/or speech disorder (n = 27; 71.1%). Almost one third indicated they had been victims of cyberbullying during this time (n = 12; 31.6%) with the most common venues being texting and Facebook. Despite the large percentage of participants who reported being bullied through social media, half (n = 6) indicated they did not often report these instances of cyberbullying. Conclusions As social media use continues to increase, it appears inevitable that cyberbullying will occur. Particularly vulnerable to both traditional and cyberbullying are individuals with craniofacial anomalies. Because of the specialized training of speech-language pathologists, school-based speech-language pathologists are in a unique position to play a key role in school-wide antibullying efforts and to educate school personnel on ways in which to support the needs of children with craniofacial anomalies both inside and outside of the classroom.

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The application of exercise science training knowledge has been of growing interest to voice professionals. This tutorial, derived from the authors' invited presentations from the "Exercise and the Voice" Special Session at the 2018 Voice Foundation Symposium, proposes a foundational theoretical structure based in exercise science, clarifies the wide range of variables that may influence voice training, and summarizes our present understanding of voice physiology from the perspective of muscle training. The body of literature on voice exercise was then analyzed from the perspective of this framework, identifying what we currently know and what we still have yet to learn.

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The primary aim of this research was to quantify the degree to which the upper airway temperature changes with singing warm-up. Based on prior upper airway thermoregulation research it was hypothesized that upper airway temperature would not significantly increase during singing warm up when compared to prewarm up and recovery phases. Ten participants completed a short singing warm-up of their choice until they felt sufficiently warmed up while upper airway temperature was measured at 1 second intervals via a transnasal thermistor placed against the posterior pharyngeal wall, just above the larynx. Descriptive statistics and statistical modeling were used for comparison of pre-warm-up, warm-up, and recovery phases of a short singing warm-up. Results indicated a physiologically-significant increase (≥0.5°C) of upper airway temperature during the singing warm-up when compared to the prewarm up average. Significant differences (P < 0.0001) were identified between all pairwise comparisons analyzed for the three phases of data collected (baseline, warm-up, and recovery). These findings support an upper airway tissue temperature increase in response to the singing warm-up. The extent to which these findings can be generalized to the intrinsic laryngeal muscles is still unknown given the technical difficulty of obtaining intramuscular laryngeal temperature measures.

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