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Objectives: The paralaryngeal muscles are thought to be hyperfunctional with phonation in patients with primary muscle tension dysphonia (pMTD). However, objective, quantitative tools to assess paralaryngeal movement patterns lack. The objectives of this study were to (1) validate the use of optical flow to characterize paralaryngeal movement patterns with phonation, (2) characterize phonatory optical flow velocities and variability of the paralaryngeal muscles before and after a vocal load challenge, and (3) compare phonatory optical flow measures to standard laryngoscopic, acoustic, and self-perceptual assessments., Methods: Phonatory movement velocities and variability of the paralaryngeal muscles at vocal onsets and offsets were quantified from ultrasound videos and optical flow methods across 42 subjects with and without a diagnosis of pMTD, before and after a vocal load challenge. Severity of laryngoscopic mediolateral supraglottic compression, acoustic perturbation, and ratings of vocal effort and discomfort were also obtained at both time points., Results: There were no significant differences in optical flow measures of the paralaryngeal muscles with phonation between patients with pMTD and controls. Patients with pMTD had significantly more supraglottic compression, higher acoustic perturbations, and higher vocal effort and vocal tract discomfort ratings. Vocal load had a significant effect on vocal effort and discomfort but not on supraglottic compression, acoustics, or optical flow measures of the paralaryngeal muscles., Conclusion: Optical flow methods can be used to study paralaryngeal muscle movement velocity and variability patterns during vocal productions, although the role of the paralaryngeal in pMTD diagnostics (e.g., vocal hyperfunction) remains suspect., Level of Evidence: 2 Laryngoscope, 134:1792-1801, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: It has been assumed that patients with primary muscle tension dysphonia (pMTD) have more extrinsic laryngeal muscle (ELM) tension, but tools to study this phenomenon lack. Shear wave elastography (SWE) is a potential method to address these shortcomings. The objectives of this study were to apply SWE to the ELMs, compare SWE measures to standard clinical metrics, and determine group differences in pMTD and typical voice users before and after vocal load., Methods: SWE measurements of the ELMs from ultrasound examinations of the anterior neck, supraglottic compression severities from laryngoscopic images, cepstral peak prominences (CPP) from voice recordings, and self-perceptual ratings of vocal effort and discomfort were obtained in voice users with (N = 30) and without (N = 35) pMTD, before and after a vocal load challenge., Results: ELM tension significantly increased from rest-to-voiced conditions in both groups. However, the groups were similar in their ELM stiffness levels at SWE at baseline, during vocalization, and post-vocal load. Levels of vocal effort and discomfort and supraglottic compression were significantly higher and CPP was significantly lower in the pMTD group. Vocal load had a significant effect on vocal effort and discomfort but not on laryngeal or acoustic patterns., Conclusion: SWE can be used to quantify ELM tension with voicing. Although the pMTD group reported significantly higher levels of vocal effort and vocal tract discomfort and, on average, exhibited significantly more severe supraglottic compression and lower CPP values, there were no group differences in levels of ELM tension using SWE., Level of Evidence: 2 Laryngoscope, 133:3482-3491, 2023., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background/objectives: False vocal fold (FVF) hyperfunction during phonation is thought to be a diagnostic sign of primary muscle tension dysphonia (pMTD). However, hyperfunctional patterns with phonation are also observed in typical speakers. This study tested the hypothesis that FVF posturing during quiet breathing, as measured by the curvature of FVF, could differentiate patients with pMTD from typical speakers., Methods: Laryngoscopic images were collected prospectively in 30 subjects with pMTD and 33 typical speakers. Images were acquired at the end of expiration and maximal inspiration during quiet breathing, during sustained /i/, and during loud phonation before and after a 30-min vocal loading task. The FVF curvature (degree of concavity/convexity) was quantified using a novel curvature index (CI, >0 for hyperfunctional/convex, <0 for "relaxed"/concave) and compared between the two groups., Results: At end-expiration, the pMTD group adopted a convex FVF contour, whereas the control group adopted a concave FVF contour (mean CI 0.123 [SEM 0.046] vs. -0.093 [SEM 0.030], p = 0.0002) before vocal loading. At maximal inspiration, the pMTD group had a neutral/straight FVF contour, whereas the control group had a concave FVF contour (mean CI 0.012 [SEM 0.038] vs. -0.155 [SEM 0.018], p = 0.0002). There were no statistically significant differences in FVF curvature between groups in either the sustained voiced or loud conditions. Vocal loading did not change any of these relationships., Conclusions: A hyperfunctional posture of the FVFs during quiet breathing especially at end-expiration may be more indicative of a hyperfunctional voice disorder than supraglottic constriction during voicing., Level of Evidence: 3 Laryngoscope, 133:3449-3454, 2023., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose The aim of this study was to test the hypothesis that stretch-and-flow voice therapy (SnF) is noninferior to resonant voice therapy (RVT) for speakers with muscle tension dysphonia. Method Participants with primary muscle tension dysphonia were randomly assigned to 1 of 2 treatment groups. Participants received 6 sessions of either SnF or RVT for 6 weeks (1 session per week). Pretreatment and posttreatment audio recordings of sustained vowels and connected speech were acquired. Response to treatment was assessed using the voice handicap index (VHI) as the primary outcome measure. Secondary outcome measures included the acoustic voice quality index, the smoothed cepstral peak prominence, and scales from the Consensus Auditory-Perceptual Evaluation of Voice instrument. Data were analyzed for 21 participants who completed the study (12 in the SnF group, 9 in the RVT group). Results Direction of change for the primary outcome measure and all 3 secondary outcome measures at posttreatment was in the direction of improvement for both SnF and RVT. Confidence intervals for VHI measures did not cross the null effect line on forest plots, suggesting significant effects for both treatments on the primary outcome measure. The effect sizes for pretreatment to posttreatment changes in VHI were large for both treatment groups. Similar results were found for the secondary acoustic outcome measures. There were statistically significant pretreatment to posttreatment changes in the primary and secondary outcome measures for patients receiving both treatments, indicating significant improvement in response to both RVT and SnF. There were no statistically significant differences in pretreatment to posttreatment changes in the primary outcome measure or any secondary outcome measure between the two groups. The within-group pretreatment to posttreatment changes in Consensus Auditory-Perceptual Evaluation of Voice scales did not reach statistical significance for either RVT or SnF. Conclusions Both SnF and RVT produced positive treatment response in speakers with muscle tension dysphonia, with no statistically significant difference in the outcome measures between the two treatments. This suggests that SnF is noninferior to RVT and that both are effective options for treating vocal hyperfunction. Results from this study also support previous findings documenting the sensitivity of multidimensional acoustic measurements to treatment response.

Objectives: (1) To develop an automated algorithm to analyze electroglottographic (EGG) signal in continuous dysphonic speech, and (2) to identify EGG waveform parameters that correlate with the auditory-perceptual quality of strain in the speech of patients with adductor spasmodic dysphonia (ADSD)., Study Design: Software development with application in a prospective controlled study., Methods: EGG was recorded from 12 normal speakers and 12 subjects with ADSD reading excerpts from the Rainbow Passage. Data were processed by a new algorithm developed with the specific goal of analyzing continuous dysphonic speech. The contact quotient, pulse width, a new parameter peak skew, and various contact closing slope quotient and contact opening slope quotient measures were extracted. EGG parameters were compared between normal and ADSD speech. Within the ADSD group, intra-subject comparison was also made between perceptually strained syllables and unstrained syllables., Results: The opening slope quotient SO7525 distinguished strained syllables from unstrained syllables in continuous speech within individual subjects with ADSD. The standard deviations, but not the means, of contact quotient, EGGW50, peak skew, and SO7525 were different between normal and ADSD speakers. The strain-stress pattern in continuous speech can be visualized as color gradients based on the variation of EGG parameter values., Conclusions: EGG parameters may provide a within-subject measure of vocal strain and serve as a marker for treatment response. The addition of EGG to multidimensional assessment may lead to improved characterization of the voice disturbance in ADSD., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the effect of stretch-and-flow voice therapy on vocal function and handicap., Study Design: Randomized controlled trial., Methods: Participants with primary muscle tension dysphonia were randomly assigned to experimental or control groups. Experimental participants received vocal hygiene education followed by 6 weeks of stretch-and-flow voice therapy. Control participants received vocal hygiene education only. Outcome variables consisted of a measure of vocal handicap (Voice Handicap Index [VHI]), maximum phonation time, s/z ratio, and acoustic measures. All measures were obtained at baseline prior to treatment and within 2 weeks posttreatment or at the end of the control period. The pre- to posttreatment measurement change (delta Δ) was applied to statistical analyses., Results: A multivariate analysis of variance revealed significant group differences in pre-to-post changes on measures of VHI, maximum phonation time, and cepstral peak prominence (CPP) in connected speech and vowels (P = 0.003, 0.013, 0.025, and 0.017 respectively), with a significant reduction of VHI (Cohen's d = 1.6), increase in maximum phonation time (Cohen's d = 1.2), increase of CPP in connected speech (Cohen's d = 1.2), and increase of CPP in vowels (Cohen's d = 1.1) in the experimental group compared to the control group., Conclusions: This preliminary small sample randomized controlled trial found significantly greater improvement in vocal handicap, maximum phonation time, and acoustic measures of vocal function after participants received stretch-and-flow voice therapy compared to participants receiving vocal hygiene education alone. Additional research incorporating larger samples will be needed to confirm and further investigate these findings., Level of Evidence: 1b., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To investigate the efficacy of stretch-and-flow voice therapy as a primary physiological treatment for patients with hyperfunctional voice disorders., Study Design: Prospective case series., Methods: Participants with a diagnosis of primary muscle tension dysphonia or phonotraumatic lesions due to hyperfunctional vocal behaviors were included. Participants received stretch-and-flow voice therapy structured once weekly for 6 weeks. Outcome variables consisted of two physiologic measures (s/z ratio and maximum phonation time), an acoustic measure (cepstral peak prominence [CPP]), and a measure of vocal handicap (voice handicap index [VHI]). All measures were obtained at baseline before treatment and within 2 weeks posttreatment., Results: The s/z ratio, maximum phonation time, sentence CPP, and VHI showed statistically significant (P < 0.05) improvement through therapy. Effect sizes reflecting the magnitude of change were large for s/z ratio and VHI (d = 1.25 and 1.96 respectively), and moderate for maximum phonation time and sentence CPP (d = 0.79 and 0.74, respectively)., Conclusions: This study provides supporting evidence for preliminary efficacy of stretch-and-flow voice therapy in a small sample of patients. The treatment effect was large or moderate for multiple outcome measures. The data provide justification for larger, controlled clinical trials on the application of stretch-and-flow voice therapy in the treatment of hyperfunctional voice disorders., (Copyright © 2015 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Hoarseness is a common symptom that can result from a wide spectrum of underlying causes ranging from the common cold to a malignancy. A framework for diagnostic evaluation is presented based on categorizing the myriad of causes by how they interfere with the voice production mechanism. Triaging of cases by necessity or urgency of laryngoscopy is assisted by forming a global index of suspicion based on targeted history taking. Laryngoscopy is required in most cases to obtain a diagnosis for the hoarseness. Treatments commonly prescribed for hoarseness are critically examined in this article. To listen to audio clips of patients with different types of hoarseness, please visit our website, www.medical.theclinics.com., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objectives: To assess perspectives of patients with voice problems and identify factors associated with the likelihood of referral to voice therapy via the CHEER (Creating Healthcare Excellence through Education and Research) practice-based research network infrastructure.Study Design: Prospectively enrolled cross-sectional study of CHEER patients seen for a voice problem (dysphonia).Setting: The CHEER network of community and academic sites.Methods: Patient-reported demographic information, nature and severity of voice problems, clinical diagnoses, and proposed treatment plans were collected. The relationship between patient factors and voice therapy referral was investigated.Results: Patients (N = 249) were identified over 12 months from 10 sites comprising 30 otolaryngology physicians. The majority were women (68%) and white (82%). Most patients reported a recurrent voice problem (72%) and symptom duration >4 weeks (89%). The most commonly reported voice-related diagnoses were vocal strain, reflux, and benign vocal fold lesions. Sixty-seven percent of enrolled patients reported receiving a recommendation for voice therapy. After adjusting for sociodemographic and other factors, diagnoses including vocal strain/excessive tension and vocal fold paralysis and academic practice type were associated with increased likelihood of reporting a referral for voice therapy.Conclusions: The CHEER network successfully enrolled a representative sample of patients with dysphonia. Common diagnoses were vocal strain, reflux, and benign vocal fold lesions; commonly reported treatment recommendations included speech/voice therapy and antireflux medication. Recommendation for speech/voice therapy was associated with academic practice type. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis The relationship between patient-reported vocal handicap and clinician-rated measures of vocal dysfunction is not understood. This study aimed to determine if a correlation exists between the Voice Handicap Index-10 (VHI-10) and the Voice Functional Communication Measure rating in the National Outcomes Measurement System (NOMS). Study Design Retrospective case series. Methods Four hundred and nine voice evaluations over 12 months at a tertiary voice center were reviewed. The VHI-10 and NOMS scores, diagnoses, and potential comorbid factors were collected and analyzed. Results For the study population as a whole, there was a moderate negative correlation between the NOMS rating and the VHI-10 (Pearson r = −0.57). However, for a given NOMS level, there could be considerable spread in the VHI-10. In addition, as the NOMS decreased stepwise below level 4, there was a corresponding increase in the VHI-10. However, a similar trend in VHI-10 was not observed for NOMS above level 4, indicating the NOMS versus VHI-10 correlation was not linear. Among diagnostic groups, the strongest correlation was found for subjects with functional dysphonia. The NOMS versus VHI-10 correlation was not affected by gender or the coexistence of a psychiatric diagnosis. Conclusions A simple relationship between VHI-10 and NOMS rating does not exist. Patients with mild vocal dysfunction have a less direct relationship between their NOMS ratings and the VHI-10. These findings provide insight into the interpretation of patient-perceived and clinician-rated measures of vocal function and may allow for better management of expectations and patient counseling in the treatment of voice disorders. Level of Evidence 4 Laryngoscope, 125:180-185, 2015 [ABSTRACT FROM AUTHOR]