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OBJECTIVES: Acting voice coaches (AVCs) and speech-language pathologists (SLPs) use dynamic teaching methods and intervene using motor learning principles. Both display instructional flexibility based on the actor/client's needs. With these criteria, we developed a virtual 3-hour professional voice lab to promote team-based learning between SLP graduate students and Master of Fine Arts (MFA) student actors. METHODS: The lab contained three phases: prebrief (50 minutes), case-study simulation (1.5 hours), and debrief (30 minutes). The students completed pre and postevaluation surveys to reflect on their learning experience. During the prebrief, the roles of AVCs and SLPs in actor's voice habilitation and rehabilitation, respectively, were discussed along with the special vocal needs of stage actors. The learners completed a comprehensive voice evaluation on "Maria Horseman," a 23-year-old professional actor with a voice disorder, in small interprofessional groups. The provided template offered a holistic approach to explore speaking-singing-acting vocal activities, vocal behaviors, physical demands/cardiorespiratory load, training/practice regimen, lifestyle changes including medication effect, and voice ergonomics. A customized client-centered voice intervention plan was developed by considering Maria's best interests and stimulability. RESULTS: Two different surveys, 15 items in Performance Voice Diagnostics for SLP students and Voice-Related Self-Perception for MFA students, and 20 items in modified Casey-Fink Readiness to Practice, were used to compare differences in self-confidence levels intervening professional voice disorders. Comparison of pre and postevaluation data revealed a statistically significant difference in learner self-confidence and readiness levels. CONCLUSIONS: A team-based, interprofessional learning approach on voice rehabilitation would help SLPs to consider special vocal demands of professional voice users in their evaluation methods. This may also lead to preventive early intervention by increasing vocal awareness and knowledge on phonatory function in professional actors from the beginning of their careers.

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OBJECTIVES: The purposes of this study were (1) to analyze the reliability of direct magnitude estimation (DME) in auditory perceptual assessments measuring dysphonia severity and (2) to analyze the relationship between DME and four acoustic parameters (cepstral peak prominence [CPP], cepstral peak prominence-smoothed [CPPs], Acoustic Voice Quality Index [AVQI], and Acoustic Breathiness Index [ABI]) and (3) to predict dysphonia severity based on DME using four acoustic parameters. STUDY DESIGN: One hundred and sixty-one voice samples for dysphonia patients were used. In this study, we combined sustained vowel samples and connected speech samples using the Praat software to make the concatenated samples for implementing acoustic analysis and auditory perceptual assessments. For acoustic analysis, we analyzed each value of CPP, CPPs, AVQI, and ABI. For auditory perceptual assessments, three speech-language pathologists evaluated dysphonia severity from the concatenated samples. Finally, we performed a stepwise multiple regression analysis to verify which combination of the four acoustic parameters could best predict perceived dysphonia severity based on the DME. RESULTS: DME was found to have high reliability for auditory perceptual assessments measuring dysphonia severity, and there was a significant correlation between DME and four acoustic parameters. Finally, a two-variable model (AVQI and ABI) was useful for predicting perceived dysphonia severity based on the DME. CONCLUSIONS: We verified the usefulness of DME scales in judging the dysphonia severity of dysphonic patients when used with acoustic analysis. Also, the two-variable model was useful to predict perceived dysphonia severity based on the DME.

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OBJECTIVE: The present study aims to examine subjectively and objectively the voice changes in bulimia nervosa (BN) patients at different stages of treatment. METHOD: The study was conducted with a study group including 10 patients followed up with a diagnosis of BN and a control group consisting of 10 healthy participants of a similar age group without eating disorders. The Reflux Symptom Index (RFS) was used for stroboscopic evaluation. The fundamental frequency (F0), jitter, shimmer, and noise-to-harmonics ratio were determined during acoustic voice analysis. Maximum phonation time was analyzed. A subjective evaluation was performed using the Voice Handicap Index-10 (VHI-10). RESULTS: Jitter, shimmer, VHI-10 score, and RFS values showed a statistically significant difference in the patient and control groups (P < 0.05). The mean values of jitter, shimmer, VHI-10 score, and RFS were higher in the patient group than in the control group. Maximum phonation time did not differ between groups (P > 0.05) Age and F0 (Hz) values showed no statistically significant difference in the patient and control groups (P > 0.05). CONCLUSIONS: In BN patients, the laryngopharyngeal reflux mechanism causes negative effects on vocal cord examination and acoustic sound analysis parameters, leading to subjective dissatisfaction.

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OBJECTIVES/HYPOTHESIS: The purpose of this study is to elucidate factors associated with voice therapy attendance within the interdisciplinary care model. STUDY DESIGN: This was a retrospective review. METHODS: Patients referred for voice therapy following interdisciplinary evaluation involving speech language pathology and laryngology were included. Independent variables were (1) duration between interdisciplinary voice evaluation and first voice therapy session, (2) plan of care determined at the time of evaluation, (3) mode of voice therapy delivery, and (4) stimulability for improvement during evaluation. Voice therapy attendance was measured as (1) attendance to the first voice therapy session and (2) overall voice therapy attendance. RESULTS: Of 272 patients referred for voice therapy, 69.12% attended the first session, 17.28% canceled/no-showed (C/NS), and 13.6% did not schedule the first session. Of 235 patients who scheduled voice therapy, 48.94% attended all their scheduled sessions, and 51.06% C/NS at least one session. Patients with a plan of care including voice therapy + surgery were 86% less likely (risk ratio [RR] = 0.14, P = 0.0014) to C/NS any of their voice therapy sessions. In contrast, patients with plan of care including voice therapy + medication were more likely to C/NS at least one voice therapy session (RR = 1.27, P = 0.1419), although this finding was not significant. No other covariates had a significant impact on voice therapy initiation or overall attendance. CONCLUSIONS: This study provides further support for the positive impact of interdisciplinary evaluation on voice therapy initiation. However, once voice therapy is initiated, overall C/NS rates are persistently high, consistent with previous investigations of voice therapy dropout. Our findings suggest that plan of care determined at the time of evaluation may have an impact on voice therapy attendance.

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OBJECTIVES: Auditory-perceptual assessments are the gold standard for assessing voice quality. This project aims to develop a machine-learning model for measuring perceptual dysphonia severity of audio samples consistent with assessments by expert raters. METHODS: The Perceptual Voice Qualities Database samples were used, including sustained vowel and Consensus Auditory-Perceptual Evaluation of Voice sentences, which were previously expertly rated on a 0-100 scale. The OpenSMILE (audEERING GmbH, Gilching, Germany) toolkit was used to extract acoustic (Mel-Frequency Cepstral Coefficient-based, n = 1428) and prosodic (n = 152) features, pitch onsets, and recording duration. We utilized a support vector machine and these features (n = 1582) for automated assessment of dysphonia severity. Recordings were separated into vowels (V) and sentences (S) and features were extracted separately from each. Final voice quality predictions were made by combining the features extracted from the individual components with the whole audio (WA) sample (three file sets: S, V, WA). RESULTS: This algorithm has a high correlation (r = 0.847) with estimates of expert raters. The root mean square error was 13.36. Increasing signal complexity resulted in better estimation of dysphonia, whereby combining the features outperformed WA, S, and V sets individually. CONCLUSION: A novel machine-learning algorithm was able to perform perceptual estimates of dysphonia severity using standardized audio samples on a 100-point scale. This was highly correlated to expert raters. This suggests that ML algorithms could offer an objective method for evaluating voice samples for dysphonia severity.

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PURPOSE: The purpose of this study was to assess the relationship and comparability of cepstral and spectral measures of voice obtained from a high-cost "flat" microphone and precision sound level meter (SLM) vs. high-end and entry level models of commonly and currently used smartphones (iPhone i12 and iSE; Samsung s21 and s9 smartphones). Device comparisons were also conducted in different settings (sound-treated booth vs. typical "quiet" office room) and at different mouth-to-microphone distances (15 and 30 cm). METHODS: The SLM and smartphone devices were used to record a series of speech and vowel samples from a prerecorded diverse set of 24 speakers representing a wide range of sex, age, fundamental frequency (F0), and voice quality types. Recordings were analyzed for the following measures: smoothed cepstral peak prominence (CPP in dB); the low vs high spectral ratio (L/H Ratio in dB); and the Cepstral Spectral Index of Dysphonia (CSID). RESULTS: A strong device effect was observed for L/H Ratio (dB) in both vowel and sentence contexts and for CSID in the sentence context. In contrast, device had a weak effect on CPP (dB), regardless of context. Recording distance was observed to have a small-to-moderate effect on measures of CPP and CSID but had a negligible effect on L/H Ratio. With the exception of L/H Ratio in the vowel context, setting was observed to have a strong effect on all three measures. While these aforementioned effects resulted in significant differences between measures obtained with SLM vs. smartphone devices, the intercorrelations of the measurements were extremely strong (r's > 0.90), indicating that all devices were able to capture the range of voice characteristics represented in the voice sample corpus. Regression modeling showed that acoustic measurements obtained from smartphone recordings could be successfully converted to comparable measurements obtained by a "gold standard" (precision SLM recordings conducted in a sound-treated booth at 15 cm) with small degrees of error. CONCLUSIONS: These findings indicate that a variety of commonly available modern smartphones can be used to collect high quality voice recordings usable for informative acoustic analysis. While device, setting, and distance can have significant effects on acoustic measurements, these effects are predictable and can be accounted for using regression modeling.

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PURPOSE: Stimulability assessment is a common part of the voice evaluation, but little information exists about what is involved in the process, how it is measured, and how it impacts therapeutic decisions. The aim of this study was to establish the frequency, circumstances, techniques, and rationale for stimulability assessment among voice-specialized speech-language pathologists (SLPs). METHOD: An anonymized online survey was distributed to voice-specialized SLPs through email lists, online communities, and professional networks. Surveys queried clinical demographic information, respondents' definition of stimulability, importance of stimulability assessment, frequency with which stimulability assessment is performed for various patient populations, preferred facilitating techniques, importance of stimulability assessment for a variety of clinical goals, and methods of measuring voice stimulability. RESULTS: Eighty-eight responses were analyzed. All respondents perform voice stimulability assessment, with 97% considering the practice important. Stimulability assessment is completed with all voice disorders and is consistently completed with muscle tension dysphonia, phonotraumatic disorders, vocal fold mobility disorders, and presbyphonia. Ninety-one percent of the sample does not use a structured stimulability assessment protocol. All respondents felt that stimulability is, to some degree, predictive of successful voice therapy outcomes. Resonance modifications and semi-occluded vocal tract techniques were the most commonly used facilitating strategies. Respondents felt that stimulability assessment was very important for assessing patient awareness, estimating prognosis, and identifying training gestures. CONCLUSIONS: Responding voice clinicians felt that stimulability assessment is an important part of the voice evaluation. This study provides information on how stimulability assessment is being used and outlines what is needed to study its impact.

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OBJECTIVES: The purpose of this study was to the usefulness of a five-variable model predicting perceived voice severity and incorporating acoustic analysis based on cepstral analysis and self-reported questionnaires, for measuring voice recovery after endolaryngeal phonomicrosurgery in patients with vocal fold polyps. METHODS: In this study, 72 patients with vocal fold polyps were included. Two voice evaluations, including acoustic analysis, self-reported questionnaires, and auditory perceptual assessments for each patient, were implemented before and after endolaryngeal phonomicrosurgery. Using these evaluations, we compared the mean values of the perceptual evaluation of voice, acoustic analysis parameters, self-reported questionnaires, and the five-variable model estimated severity pre- and post-endolaryngeal phonomicrosurgery. RESULTS: Various parameters related to acoustic analysis, self-reported questionnaires, and auditory perceptual assessments were useful for measuring voice recovery after endolaryngeal phonomicrosurgery. In particular, a five-variable model incorporating spectral/cepstral analyses and self-reported questionnaires was able to effectively track voice changes after endolaryngeal phonomicrosurgery. CONCLUSION: We verified that most of the variables and the five-variable model were useful for measuring voice recovery in patients with vocal polyps after endolaryngeal phonomicrosurgery.

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OBJECTIVE: Patients with ectodermal dysplasia (ED) suffer from an inherited disorder in the development of the ectodermal structures. Besides the main symptoms, i.e. significantly reduced formation/expression of teeth, hair and sweat glands, a decreased saliva production is objectively accounted. In addition to difficulties with chewing/swallowing, ED patients frequently report on the subjective impression of rough and hoarse voices. A correlation between the reduced production of saliva and an affliction of the voice has not yet been investigated objectively for this rare disease. METHODS: Following an established measurement protocol, a study has been conducted on 31 patients with ED and 47 controls (no ED, healthy voice). Additionally, the vocal fold oscillations were recorded by high-speed videoendoscopy (HSV@4 kHz). The glottal area waveform was determined by segmentation and objective glottal dynamic parameters were calculated. The generated acoustic signal was evaluated by objective and subjective measures. The individual impairment was documented by a standardized questionnaire (VHI). Additionally, the amount of generated saliva was measured for a defined period of time. RESULTS: ED patients displayed a significantly reduced saliva production compared to the control group. Furthermore, the auditory-perceptual evaluation yielded significantly higher ratings for breathiness and hoarseness in the voices of male ED patients compared to male controls. The majority of male ED patients (67%) indicated at least minor impairment in the self-evaluation. Objective acoustic measures like Jitter and Shimmer confirmed the decreased acoustic quality in male ED patients, whereas none of the investigated HSV parameters showed significant differences between the test groups. Statistical analysis did not confirm a statistically significant correlation between reduced voice quality and amount of saliva. CONCLUSIONS: An objective impairment of the acoustic outcome was demonstrated for male ED patients. However, the vocal folds dynamics in HSV recordings seem unaffected.

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OBJECTIVES: Voice change after uncomplicated thyroidectomy has been an important issue in the field of thyroid surgery. The aim of this study was to promote understanding of voice change after uncomplicated thyroidectomy by analysing the results for a large number of patients from a single institute. DESIGN: We retrospectively reviewed the medical records of 2879 consecutive patients who underwent thyroidectomy and voice evaluation between January 2014 and December 2019 in a single institute. All the patients had their vocal status assessed using videostroboscopy, acoustic voice analyses, aerodynamic study, and Thyroidectomy-related Voice and Symptom Questionnaire (TVSQ) scores preoperatively and at 1, 3, and 6 months postoperatively. We analysed the pattern of voice changes over time and differences in voice parameters based on clinical factors. To confirm the usefulness of the TVSQ, the correlation between TVSQ scores and objective parameters was analysed. Lastly, predictive factors for persistent voice symptoms were analysed. SETTING: Tertiary referral hospital. RESULTS: The frequency ranges and TVSQ scores exhibited significant deterioration until 6 months following surgery. Among clinical factors, the extents of thyroidectomy and neck dissection were associated with worse voice parameters. The TVSQ score was significantly correlated with objective voice parameters. The extents of thyroidectomy and neck dissection were predictive of persistent voice symptoms at 6 months after thyroidectomy. CONCLUSION: After uncomplicated thyroidectomy, most voice parameters tended to recover, but some parameters remained aggravated even at 6 months after surgery. With more extensive surgery, worse voice quality and the higher risk of persistent voice symptoms may be anticipated.

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PURPOSE: The ongoing literature suggests that COVID-19 may have a potential impact on voice characteristics during the infection period. In the current study, we explored how the disease deteriorates different vocal parameters in patients who recovered from COVID-19. METHODS: A total of 80 participants, 40 patients with a prior history of COVID-19 (20 male, 20 female) with a mean age of 39.9 ± 8.8 (range, 21-53) and 40 gender and age-matched healthy individuals (mean age, 37.3 ± 8.8; range, 21-54) were included to this study. The data of acoustic voice analyses, durational measurements, patient-reported outcomes, and auditory-perceptual evaluations were compared between the study group and the control group. Correlation analyses were conducted to examine the association between the clinical characteristics of the recovering patients and measured outcomes. RESULTS: Maximum phonation time (MPT) and the scores of both Voice Handicap Index-10 (VHI-10) and Voice-Related Quality of Life (V-RQOL) questionnaires significantly differed between the groups, which was more evident in female participants. The overall severity score of dysphonia was found to be higher in the study group than the control group (p = 0.023), but gender-based comparisons reached significance only in males (p = 0.032). VHI-10 and V-RQOL revealed significant correlations with the symptom scores of the disease. CONCLUSIONS: Patients with a prior history of COVID-19 had significantly lower MPT, increased VHI-10 scores, decreased voice-related quality of life based on the V-RQOL questionnaire, and higher overall severity scores in the auditory-perceptual evaluation. Self-reported voice complaints disclosed close relationships with the symptom scores of COVID-19 disease.

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BACKGROUND: Acoustic Breathiness Index (ABI) is an acoustic model which equates to the auditory-perceptual (A-P) measure of breathiness. Globally, ABI has been validated in multiple languages. To date, empirical studies validating ABI in the South Indian population have not been carried out. Moreover, there is only minimal evidence on the impact of language and gender on ABI. OBJECTIVES: This study attempted to validate ABI in languages of Malayalam and Kannada with "B" and "G" of GRBAS. The authors also examined the influence of language and gender on ABI. METHODS: The authors retrospectively analyzed a dataset consisting of 160 voice samples (91 normophonic and 69 dysphonic). Five speech-language pathologists perceptually evaluated these samples on the GRBAS scale. PRAAT software was used to calculate ABI for each voice sample. The authors also determined the effects of language and gender on ABI. Following this, ABI's concurrent validity and diagnostic accuracy were examined relating to "B" and "G" of the GRBAS scale. RESULTS: The judges reached a moderate agreement on the perceptual evaluation of voice quality. The authors observed neither language nor gender differences in ABI. The concurrent validity of ABI was strong (r = 0.761) when correlated against "B". Further, evaluations revealed that an ABI value of >3.66 could distinguish between breathy and non-breathy voice samples with an area under the curve of 0.816 (Sensitivity = 61.73%; Specificity = 94.93%). On the other hand, the concurrent validity of ABI in correlation with "G" did not yield the optimal result. CONCLUSIONS: ABI is a valid acoustic tool for identifying breathiness in the languages of Malayalam and Kannada. ABI correlates better with "B" than "G" on the GRBAS scale. ABI is independent of language and gender.

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OBJECTIVES: This study investigates vocal outcome after cordectomy by transoral CO2 laser microsurgery (TLM-cordectomy) in patients with laryngeal intra-epithelial neoplasia (LIN) or non-neoplastic lesions (NNL), for improved individual patient advice and potential adjustment of national treatment strategy by which patients suspected to have glottic LIN or T1a cancer are offered TLM-cordectomy, without prior biopsy. STUDY DESIGN: Prospective, longitudinal, quasi-experimental time series. METHODS: Consecutively included patients (n = 155) with LIN (n = 84) or NNL (n = 71) who underwent voice assessments before and after TLM-cordectomy. The multi-dimensional voice assessment protocol comprised voice and speech range profiles, aerodynamics, acoustic analysis, self-evaluated voice handicap, and perceptual auditory voice ratings. RESULTS: Median follow-up time was 195 (range 50-1121) days for patients with LIN and 193 (range 69-1294) days for patients with NNL. Statistically significant changes, LIN: in voice handicap index (VHI) and breathiness after TLM-cordectomy. Statistically significant changes, NNL: voice range profile (voice range area, intensity range, and frequency range) and VHI after TLM-cordectomy. All group-wise changes were to less disordered voices. Previous smokers had the largest decreases in VHI and breathiness. Patients with baseline VHI scores >65 had smaller increases in VHI, however 13-19% of the patients had increases in VHI above the clinically relevant threshold after TLM-cordectomy. CONCLUSION: Overall, TLM-cordectomy in patients with LIN and NNL improved vocal outcome and our study thus supports the current Danish treatment strategy and improves the basis for proper patient advice. Multi-dimensional voice assessment is suggested preoperatively and six-nine months postoperatively, with focus on individual vocal differences and voice demands.

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BACKGROUND: Acoustic Voice Quality Index (AVQI) has emerged in the recent past as a robust multiparametric voice quality evaluation tool. Two versions of AVQI derived using the program PRAAT have found extensive clinical and research applications. These versions have been validated in several languages around the world. However, no research reports are available on validation of AVQI in the South Indian population. Further, studies comparing the performance of the two versions of AVQI are limited in the literature. OBJECTIVES: This study was designed to validate and compare the two versions of AVQI (AVQIv02.02 and AVQIv03.01) in South Indian languages (Malayalam and Kannada). METHODS: A retrospective analysis of previously recorded voice samples was carried out on a total of 160 (91 normophonic and 69 dysphonic) voice samples. These samples were perceptually rated on a GRBAS scale by five experienced speech-language pathologists. Standardized Syllable Number (SSN) necessary to derive AVQIv03.01 was computed. Following this, these samples were analyzed to obtain the AVQIv02.02 and AVQIv03.01. The concurrent validity and diagnostic accuracy of these measures were then examined and compared. RESULTS: A moderate agreement was obtained across the judges on perceptual evaluation of voice quality. SSN in Malayalam and Kannada languages were identified to be 29 and 25 syllables respectively. Language differences were not observed on both versions of AVQI. The concurrent validity of AVQIv03.01 (r = 0.788) was superior to that of AVQIv02.02 (r = 0.655). Further, the threshold of differentiating normophonic and dysphonic samples were determined to be >3.45 for AVQIv02.02 and >2.45 for AVQIv03.01. CONCLUSIONS: AVQIv03.01 is superior to AVQIv02.02 in terms of its diagnostic accuracy and concurrent validity. Current findings also extend the application of AVQI as a robust tool for the evaluation of voice characteristics to the South Indian population.

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PURPOSE: The purpose of the study was to assess outcomes of injection laryngoplasty (IL) for treating glottal insufficiency in elderly patients with presbyphonia or unilateral vocal fold paralysis (UVFP). METHODS: A single-center retrospective study was performed. The study group consisted of 34 patients with glottal insufficiency aged between 60 and 82 years who had been treated with injection laryngoplasty. Of them, 16 patients were diagnosed with presbyphonia and 18 with UVFP. RESULTS: After IL, glottal closure improved in both groups. The change was statistically significant in the patients with presbyphonia (marginal homogeneity test MH = 3.80; p < 0.001) and in the UVFP patients (MH = 4.04; p < 0.001). Voice quality improved after IL and 12 months after surgical intervention remained significantly better compared to before augmentation (MH tests were statistically significant at p < 0.05 for R, B, A, and S parameters). In the patients with UVFP, significant improvement was observed in 7 of 12 evaluated parameters (Jitt, RAP, PPQ, Shim, APQ, sAPQ, and NHR) but in the patients with presbyphonia only average fundamental frequency (F0) improved significantly. Comparison of the Voice Handicap Index outcomes before and 12 months after surgery showed improvement of subjectively assessed voice quality in both groups; however, the change was statistically significant only in the UVFP patients. CONCLUSIONS: Injection laryngoplasty is a safe and effective treatment method for glottal insufficiency in the elderly. This study shows a significant and clinically relevant improvement to at least12 months, especially in patients with UVFP.

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INTRODUCTION: The Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) scale is a modern, clinical-scientific approach to voice analysis. It has been translated and culturally adapted to Brazilian Portuguese, but it still lacks validation. OBJECTIVE: To validate the Brazilian Portuguese version of the CAPE-V scale using the previously translated and culturally adapted version. METHOD: Forty voice samples were selected (30 dysphonic, 10 nondysphonic), and the degree of vocal deviation was evaluated by a committee of three voice specialists. Nine voice specialists judged the 40 voice samples plus 20% repetition (total of 48 samples) using the CAPE-V. To ensure construct validity of the CAPE-V, its analysis was compared to the Grade-Roughness-Breathiness-Asthenia-Strain (GRBAS) scale that was performed 48-72 hours later. Finally, the intra- and inter-rater reliability values were verified and the correlation between the nine judges and the previously defined evaluation was analyzed. RESULTS: The Brazilian CAPE-V presented significant intra (0.860-0.997) and inter-rater reliability values (0.707-0.964) for the overall degree and strong correlation with GRBAS (above 0.828). Deviant voice quality had greater consensus among raters than normal voices. A strong correlation was observed between the analysis of the nine raters and that of the committee. CONCLUSION: CAPE-V is an important diagnostic instrument that contributes to the standardization of vocal quality evaluation in several languages, including Brazilian Portuguese. Thus, its usefulness is neither related to a single language nor to a single set of raters.

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OBJECTIVE: To clarify the relationship between voice and respiratory function, and to understand the role for airflow measures in the evaluation of voice patients. METHODS: Literature searches of MEDLINE (Ovid) and Web of Science were performed on April 6, 2020, to include articles written in English that both discussed voice in relation to lower respiratory function and reported evaluation of airflow. Search strategies included the keywords voice, respiratory, airflow, and aerodynamic measures. Data were extracted from articles that met inclusion criteria. RESULTS: Twenty studies were included for review. Fourteen (70%) studies evaluated at least 1 spirometric respiratory measure, including Forced Vital Capacity, Forced Expiratory Volume in 1 second, and Forced Expiratory Flow. Other measures assessed included mean flow rate, mean peak airflow, phonatory airflow, inspiratory airflow, expiratory airflow, and phonation quotient. Notably, four studies which included pulmonary function tests (PFTs) as part of voice evaluation discovered previously undiagnosed respiratory disease in their study populations. CONCLUSION: This review confirms that respiratory function contributes significantly to voice and reveals that few studies have explored the role for airflow measures in clarifying this relationship. Including airflow measures such as PFTs in standard voice evaluation may allow recognition of underlying respiratory disease contributing to voice dysfunction. Further research is recommended to establish indications and diagnostic criteria for the use of PFTs in voice patients.

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OBJECTIVES: Evaluation of trends and utilization of speech-language-pathology (SLP) services, including stroboscopy, before and after medialization laryngoplasty (ML) over 11 years. METHODS: Retrospective national US database study conducted using OptumLabs Data Warehouse. Study cohort included patients (age ≥18 years) who underwent ML between January 2007 and December 2016. Primary outcomes were rates of SLP visits in the 12 months before and 12 months after ML. Linear regression analysis was performed assessing for trends utilization across years. Secondary outcomes were predictors of utilization After-ML using multivariable logistic regression. RESULTS: 1114 patients met criteria. Services, including stroboscopy, were utilized by 774 (69%) Before-ML and 697 (63%) After-ML. SLP services, excluding stroboscopy, were utilized by 512 (46%) Before-ML and 478 (43%) After-ML. Vocal cord paralysis was the most common diagnosis, 945 (84.8%) patients. Other service billed were stroboscopy, [Before-ML 676 (60.7%); After-ML 567 (50.9%)], voice evaluation [Before-ML 431(38.7%); After-ML 366 (32.9%)], voice therapy [Before-ML 309 (27.7%); After-ML 339 (30.4%)], laryngeal function studies, [Before-ML 175 (15.7%); After-ML 164 (14.7%)], swallow evaluations [Before-ML 150 (13.5%); After-ML 90 (8.1%)], and swallow therapy [Before-ML 53 (4.8%); After-ML 47 (4.2%)]. SLP utilization Before-ML predicted SLP utilization After-ML [Odds Ratio (95% Confidence Interval): 9.31 (6.78, 12.77)]. Nearly half (49%) of visits occurred in the 6 months around ML. Of those who had voice therapy, the majority (73.7%) had a total of 1 to 5 sessions. CONCLUSION: Based on this retrospective US national database study, SLP services and stroboscopy are a complementary component of assessment and treatment of patients who undergo ML with the majority of services occurring in the 3 months before and after ML. Future work would benefit from outcome data.

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AIM: Significant differences exist in anatomical, acoustic, and aerodynamic parameters for nonspeech tasks between culturally and linguistically diverse sample populations. There is a need for expansion of the normative acoustic data to include sociolinguistically diverse groups to ensure that clinical objective measurements are accurately classifying the voice quality of all individuals. This study examined objective measures of voice quality assessment of monolingual speakers of Standard American English (SAE) with sequential bilingual, native (L1) French and Spanish speakers on perturbation, noise, spectral/cepstral analyses, and compared ratings on auditory-perceptual assessment with acoustic data secondary to degree of accentedness. METHOD: Thirty speakers with normal voice quality were rated on the Consensus Auditory-Perceptual Evaluation of Voice scale. Voice quality measures were analyzed using the Multi-Dimensional Voice Program and Analysis of Dysphonia in Speech and Voice. A measure of accentedness of SAE was calculated using an informal task by two evaluators. RESULTS: Objective acoustic measures of jitter and all-voiced cepstral peak prominence were statistically significant between SAE speakers and L1 Spanish and French speakers. SAE speakers demonstrated significantly higher group mean cepstral peak prominence for the all-voiced sentence ("We were away a year ago.") than native French and Spanish speakers. There were no significant differences in perception of voice quality and acoustic measures secondary to degree of accentedness of the non-native SAE speakers. CONCLUSION: It is important to engage and strengthen voice diagnostic measures to support culturally competent service delivery for the diversifying clinical population. Normative databases established on SAE speakers should reflect the statistically significant differences evidenced between diverse sociolinguistic populations in anatomical, auditory-perceptual, aerodynamic, and acoustical parameters.

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OBJECTIVE: This integrative review aims to determine the quality level of evidence on using surface electromyography (sEMG) as a diagnostic tool in identifying muscle tension dysphonia. METHOD: Two independent reviewers used one search engine and five databases to identify sEMG studies published between January 1980 and December 2020, using a set of specified search terms related to muscle tension dysphonia. The selected articles were systematically evaluated by two independent raters using a modified critical appraisal of diagnostic evidence (m-CADE) form. RESULTS: Nine articles that satisfied the inclusion criteria were selected from among 576 studies for evaluation. These nine studies showed varied methodological approaches in sEMG measurements, including electrode configuration and position, tasks used in sEMG data collection, outcome measure, and normalization procedures. Five studies showed relatively high m-CADE scores, which were indicative of "suggestive validity and compelling importance". Two studies were rated as "suggestive validity and importance", while two remaining studies were rated as "less suggestive or equivocal validity and importance". CONCLUSIONS: The review found a moderate level of evidence that sEMG can be a potentially useful tool with diagnostic value in identifying muscle tension dysphonia. However, evidence is not yet available to determine the diagnostic accuracy of sEMG for muscle tension dysphonia. More studies are needed, and it is recommended that future studies involving sEMG and reference measurements should be undertaken using a blinding procedure in order to control any subjective biases. Details of the population that the sEMG has been tested on should be outlined clearly so that spectrum bias could be eliminated or minimized in the application process. Furthermore, it is suggested that a reliable and valid protocol in collecting sEMG data during speech should be developed to minimize the variability of sEMG measures in assessing muscle activities during speech.