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Purpose This study (a) examined the effect of different levels of background noise on speech intelligibility and perceived listening effort in speakers with impaired and intact speech following treatment for head and neck cancer (HNC) and (b) determined the relative contribution of speech intelligibility, speaker group, and background noise to a measure of perceived listening effort. Method Ten speakers diagnosed with nasal, oral, or oropharyngeal HNC provided audio recordings of six sentences from the Sentence Intelligibility Test. All speakers were 100% intelligible in quiet: Five speakers with HNC exhibited mild speech imprecisions (speech impairment group), and five speakers with HNC demonstrated intact speech (HNC control group). Speech recordings were presented to 30 inexperienced listeners, who transcribed the sentences and rated perceived listening effort in quiet and two levels (+7 and +5 dB SNR) of background noise. Results Significant Group × Noise interactions were found for speech intelligibility and perceived listening effort. While no differences in speech intelligibility were found between the speaker groups in quiet, the results showed that, as the signal-to-noise ratio decreased, speakers with intact speech (HNC control) performed significantly better (greater intelligibility, less perceived listening effort) than those with speech imprecisions in the two noise conditions. Perceived listening effort was also shown to be associated with decreased speech intelligibility, imprecise speech, and increased background noise. Conclusions Speakers with HNC who are 100% intelligible in quiet but who exhibit some degree of imprecise speech are particularly vulnerable to the effects of increased background noise in comparison to those with intact speech. Results have implications for speech evaluations, counseling, and rehabilitation.

OBJECTIVE: To determine how communicative participation is affected in patients with oral and oropharyngeal head and neck cancers (HNC) pre-treatment, and whether communication function predicts HNC-specific quality of life (QOL) before treatment, beyond known demographic, medical, psychosocial, and swallowing predictors. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: Eighty-seven patients with primary oral (40.2%) or oropharyngeal (59.8%) HNC were recruited prior to treatment. T stage, tumor site, and p16 status were extracted from medical records. Demographic and patient-reported measures were obtained. Communicative participation was measured using the Communicative Participation Item Bank (CPIB) General short form. A hierarchical regression analysis included demographic, medical, psychosocial, and functional measures of swallowing and communication as predictors; the University of Washington Quality of Life (UW-QOL v4) composite score was the predicted variable. RESULTS: Median baseline CPIB scores were 71.0 (SD = 11.83); patients with oral cancers reported worse scores. A final sequential hierarchical regression model that included all variables explained 71% of variance in QOL scores. Tumor site, T stage, and p16 status accounted for 28% of variance (P < 0.001). Perceived depression predicted an additional 28% of the variance (P < 0.001). Swallowing and communicative participation together predicted an additional 12% of variance (P = 0.005). Tumor site, perceived depression, swallowing, and communication measures were unique predictors in the final model. Finally, communicative participation uniquely predicted QOL, above and beyond other predictors. CONCLUSION: Pre-treatment communication predicted QOL, and was negatively impacted in some oral and oropharyngeal HNC patients.

OBJECTIVE The primary aim of this study was to examine the effect of the videolaryngostroboscopic auditory signal on videolaryngostroboscopy (VLS) ratings and interpretation in normophonic and dysphonic speakers. STUDY DESIGN Prospective repeated measures design METHOD: Eight speech-language pathologists evaluated rigid VLS exams obtained from 12 dysphonic speakers with vocal fold pathology and 4 normophonic speakers with normal VLS exams. VLS exams were evaluated with the auditory signal present and absent with a washout period between rating sessions. VLS measures were obtained using the Voice-vibratory Assessment of Laryngeal Imaging (VALI) and a 100mm visual analog scale (VAS). The effects of the auditory signal and its interaction with voice quality severity on 9 VLS ratings, diagnostic billing codes, and treatment recommendations were examined. RESULTS There was no effect of auditory information on VLS measures or overall severity of laryngeal function evaluated using the VAS (ps > 0.05). There was a main effect of auditory information and a significant interaction with voice quality severity for only one VLS measure (non-vibrating portion-left) evaluated using the VALI (P = 0.05). Post-hoc analysis for this rating showed significant increases (t-test adjusted P < 0.05) when voice quality severity was moderate-severe (M = 4.8%; SD = 1.65%) and auditory information was present. Agreement in individual clinician's selection of diagnostic codes (73%) and treatment recommendations (65.6%) when auditory cues were present and absent was moderate to high. CONCLUSION The presence of the videolaryngostroboscopic auditory signal had a minimal effect on VLS ratings, treatment recommendations, or diagnostic billing codes.

Objective The purpose of this study was to examine the unique contribution of psychosocial factors, including perceived social support, depression, and resilience to communicative participation, among adult survivors of head and neck cancer (HNC). Study Design Cross-sectional. Setting University-based laboratory and speech clinic. Subjects and Methods Adult survivors of HNC who were at least 2 years posttreatment for HNC completed patient-reported outcome measures, including those related to communicative participation and psychosocial function. Multiple linear regression analysis was conducted to predict communicative participation. Self-rated speech severity, cognitive function, laryngectomy status, and time since diagnosis were entered first as a block of variables (block 1), and psychosocial factors were entered second (block 2). Results Eighty-eight adults who were on average 12.2 years post-HNC diagnosis participated. The final regression model predicted 58.2% of the variance in communicative participation (full model R2 = 0.58, P < .001). Self-rated speech severity, cognitive function, laryngectomy status, and time since diagnosis together significantly predicted 46.1% of the variance in block 1. Perceived social support, depression, resilience, and interactions significantly and uniquely predicted 12.1% of the additional variance in block 2. Conclusion For clinicians, psychosocial factors such as perceived depression warrant consideration when counseling patients with HNC about communication outcomes and when designing future studies related to rehabilitation.

Importance The Communicative Participation Item Bank (CPIB) is a patient-reported outcome measure assessing the association between communication disorders and participation in daily communication. To our knowledge, no prior research has examined whether CPIB scores change after treatment of unilateral vocal fold immobility (UVFI). Objective To compare CPIB scores before and after treatment of UVFI and with patient-defined target treatment outcomes and other common clinical outcomes after UVFI intervention. Design, setting, and participants This single-group case series recruited a convenience sample of community-dwelling patients aged 18 years or older from an urban academic medical center who had a diagnosis of UVFI and planned to receive intervention for UVFI. The study was conducted from March 2014 to March 2019. Exposures Intervention for UVFI according to clinicians' recommendations. The treatment type was not controlled for this study. Main outcomes and measures Patients' self-reported communicative participation was assessed by obtaining CPIB scores before and after treatment of UVFI, with scores calibrated to the standardized T scale. Pearson correlations between the CPIB general short form and computerized adaptive format, the Voice Handicap Index-10 (VHI-10), and self-rated and clinician-rated voice severity were also evaluated. Results The sample included 25 participants, of whom 17 (68%) were male, 8 (32%) were female, and the mean (SD) age was 54.9 (17.0) years. Significant changes after treatment were observed in all quantitative outcomes including the primary outcome of the CPIB; the mean T score before treatment was 40.95 (95% CI, 37.49-44.41) and after treatment was 53.23 (95% CI, 48.41-58.04) (mean difference, -13.04 [95% CI, -7.30 to -18.79]; Cohen d, 0.96). The Pearson correlation between the CPIB general short form and computerized adaptive testing scores at pretreatment was r = 0.93 and at posttreatment, r = 0.95. Computerized adaptive testing showed efficiency advantages, with typically 5 to 6 items required for administration compared with 10 items for the short form. The correlation between the CPIB and VHI-10 was moderate before treatment (r = -0.70) and strong after treatment (r = -0.91). Moderate correlations were observed between the CPIB and clinician-rated voice quality before (r = -0.52) and after (r = -0.46) treatment and between CPIB and self-rated voice quality before (r = -0.56) and after (r = -0.62) treatment. Conclusions and relevance The results of this case series suggest that the CPIB is relevant for clinical use to assess changes in communicative participation among patients with UVFI before and after they receive treatment.

Summary Objectives The purposes of this study were to (1) determine and compare the diagnostic accuracy of a single acoustic measure, smoothed cepstral peak prominence (CPPS), to predict voice disorder status from connected speech samples using two software systems: Analysis of Dysphonia in Speech and Voice ( ADSV ) and Praat ; and (2) to determine the relationship between measures of CPPS generated from these programs. Study Design This is a retrospective cross-sectional study. Methods Measures of CPPS were obtained from connected speech recordings of 100 subjects with voice disorders and 70 nondysphonic subjects without vocal complaints using commercially available ADSV and freely downloadable Praat software programs. Logistic regression and receiver operating characteristic (ROC) analyses were used to evaluate and compare the diagnostic accuracy of CPPS measures. Relationships between CPPS measures from the programs were determined. Results Results showed acceptable overall accuracy rates (75% accuracy, ADSV ; 82% accuracy, Praat ) and area under the ROC curves (area under the curve [AUC] = 0.81, ADSV ; AUC = 0.91, Praat ) for predicting voice disorder status, with slight differences in sensitivity and specificity. CPPS measures derived from Praat were uniquely predictive of disorder status above and beyond CPPS measures from ADSV ( χ 2 (1) = 40.71, P r = 0.88, P Conclusions A single acoustic measure of CPPS was highly predictive of voice disorder status using either program. Clinicians may consider using CPPS to complement clinical voice evaluation and screening protocols.

Purpose The purpose of this study was to examine the effect of severity of adductor spasmodic dysphonia (ADSD) and information about it on unfamiliar listeners' attitudes about speakers' personal characteristics, perceived vocal effort, and listener comfort on the basis of ratings of speech recordings. Method Fifteen women with ADSD and 5 controls provided speech samples. Forty-five unfamiliar listeners were randomized into 3 groups. Listeners in Group 1 received no information, listeners in Group 2 were told that some speakers had voice disorders or had no voice concerns, and listeners in Group 3 were provided diagnostic labels for each speaker and information about ADSD. Listeners then rated speech samples for attitudes, perceived vocal effort, and listener comfort. Results Speakers with ADSD were judged significantly worse than controls for attitudes related to “social desirability” and “intellect.” There was no effect of severity on “personality” attributes. However, provision of a diagnostic label resulted in significantly more favorable personality ratings than when no label was provided. Perceived vocal effort and comfort became significantly more negative as ADSD severity increased. Finally, most listener ratings were unaffected by provision of additional information about ADSD. Conclusions Listeners' perceptions about speakers with ADSD are difficult to change. Directions for counseling and public education need future study.

Purpose The purpose of this study was to determine the influence of symptom severity and disclosure of adductor spasmodic dysphonia (ADSD) on the perceptions of human resource personnel members (HRPs) during a simulated phone interview. Method One female speaker with ADSD was recorded reading an interview script at two time points: (a) pre-BOTOX injection (severe), and (b) post-BOTOX injection (mild). Thirty-two HRPs evaluated the recording in one of the two conditions via a qualitative structured interview. HRPs gave their recommendations regarding when and how to disclose ADSD. Results In the mild condition, no HRP perceived that the applicant had a voice disorder. Disclosure was not recommended as often, as an impairment was not initially noticed. However, 15/16 HRPs commented on the applicant's voice in the severe condition, with most suspecting she was a smoker or had lung/throat cancer. Disclosure in the severe condition was recommended more often, as it clarified symptoms that were noted at the outset. Conclusions Symptom severity in ADSD influences employer perceptions during the phone interview process. Incorrect assumptions may be made about applicants with severe symptoms, and apparentness of symptoms influences whether or not disclosure is recommended. Results have implications for counseling individuals with ADSD who are navigating the job interview process.

Summary Objective/Hypothesis To determine whether the presence and accuracy of a laryngeal medical diagnosis affects novice listeners' judgments of dysphonia. Study Design Prospective, within subjects, modified factorial experimental design. Methods Twenty-six speakers with dysphonia and four normophonic speakers provided speech recordings. Forty novice clinicians evaluated speech samples for roughness and breathiness using 100-mm visual analog scales in two conditions. First, speech samples were presented without diagnostic information. In the second condition, 50% of the speech samples were presented with the accurate laryngeal medical diagnosis, while the other 50% of samples were presented with an inaccurate (alternative) diagnosis. Results Results showed that judgments of dysphonia were affected by the presence of both accurate and inaccurate diagnoses. As expected, when compared to no known diagnosis, judgments of roughness significantly increased in severity when an accurate diagnostic label of vocal fold lesions was presented. Likewise, in comparison to no known diagnosis, judgments of breathiness trended toward an increase in severity when an accurate diagnostic label of vocal fold paralysis/paresis was presented. Interestingly, increases in perceived severity of dysphonia were also observed with the presentation of inaccurate diagnoses, with the overall effect of inaccurate diagnostic information being greater than accurate diagnoses. Specifically, increases in perceived roughness and breathiness were observed when inaccurate diagnoses included benign vocal fold lesion(s) and vocal fold paralysis/paresis. In contrast, inaccurate diagnostic labels indicating “clear larynx” or diagnoses other than benign vocal fold lesion(s) or paralysis/paresis resulted in decreased perceived roughness and breathiness severity. The magnitude of the differences in perceived severity between conditions was overall reduced for breathiness compared to roughness. Conclusions Sources of bias such as knowledge and accuracy of medical diagnoses should be considered when novice clinicians use auditory-perceptual measures to evaluate dysphonia and measure treatment outcomes.

Background The purpose of this study was to examine relationships between communicative participation and postlaryngectomy speech outcomes, including listener-rated speech intelligibility and acceptability, and patient-rated speech acceptability and voice handicap. Methods Thirty-six laryngectomized individuals completed the Communicative Participation Item Bank (CPIB) short form and the Voice Handicap Index-10 (VHI-10). They provided recordings from the Sentence Intelligibility Test (SIT) and a reading passage, and rated their own speech acceptability. Forty-eight inexperienced listeners transcribed the SIT sentences to derive intelligibility scores. Eighteen additional listeners judged the speech acceptability using the rating scales. Results Listeners judged tracheoesophageal speakers as significantly more intelligible and acceptable than electrolaryngeal speakers (p < .05). Speech acceptability was significantly more acceptable to speakers than listeners (p < .05). Weak, nonsignificant relationships were found between communicative participation and listener-rated outcomes. Stronger, significant relationships were found between communicative participation and self-rated speech acceptability and voice handicap (p < .05). Conclusion Patient-reported communication outcomes are complementary to listener-rated outcomes. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Summary Objective To determine the effect of presence and location of severity labels for different types of visual analog scales (VAS) on overall severity (OS) ratings in dysphonic speech. Study Design Experimental, between group comparisons. Methods Dysphonic and normal voice samples from male and female speakers were presented to inexperienced listeners for judgments of OS. To rate samples, listeners used an undifferentiated 100-mm VAS labeled at the extremes, a VAS with nonlinearly distributed labels as in the “beta” version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), or a VAS with symmetrically distributed labels as in the “official” version of the CAPE-V. Results Overall, mean OS ratings did not differ significantly across scale types, although ratings using the nonlinearly marked VAS were generally lower than those from other scales. This effect was significant for female speakers whose samples tended toward moderate OS. The ratings distribution, when compiled into 10-mm bins, differed significantly by scale type, with users of the nonlinearly marked scales skewing their ratings toward normal. Conclusions The presence and placement of labels on VAS did not significantly affect OS ratings overall, but values were significantly lower when rating female voices with the nonlinearly labeled VAS. Results indicate that professionals should specify the scale type used for rating OS and use scales consistently when comparing voices.

Purpose To determine whether unfamiliar listeners' perceptions of speakers with adductor spasmodic dysphonia (ADSD) differ from control speakers on the parameters of relative age, confidence, tearfulness, and vocal effort and are related to speaker-rated vocal effort or voice-specific quality of life. Method Twenty speakers with ADSD (including 6 speakers with ADSD plus tremor) and 20 age- and sex-matched controls provided speech recordings, completed a voice-specific quality-of-life instrument (Voice Handicap Index; Jacobson et al., 1997), and rated their own vocal effort. Twenty listeners evaluated speech samples for relative age, confidence, tearfulness, and vocal effort using rating scales. Results Listeners judged speakers with ADSD as sounding significantly older, less confident, more tearful, and more effortful than control speakers ( p < .01). Increased vocal effort was strongly associated with decreased speaker confidence ( r s = .88–.89) and sounding more tearful ( r s = .83–.85). Self-rated speaker effort was moderately related ( r s = .45–.52) to listener impressions. Listeners' perceptions of confidence and tearfulness were also moderately associated with higher Voice Handicap Index scores ( r s = .65–.70). Conclusion Unfamiliar listeners judge speakers with ADSD more negatively than control speakers, with judgments extending beyond typical clinical measures. The results have implications for counseling and understanding the psychosocial effects of ADSD.

Objective: The purpose of this study was to determine how a new self-report outcome measure of communicative participation, the Communicative Participation Item Bank (CPIB), related to disease- and discipline-specific quality of life (QOL) outcomes in a head and neck cancer (HNC) population. Methods: One hundred ninety-five individuals treated for HNC completed the CPIB, the University of Washington Quality of Life questionnaire (UW-QOL), and the Voice Handicap Index–10 (VHI-10). Results: Results revealed moderate QOL scores across the UW-QOL (mean scores: global QOL = 66; physical subscale = 70; social-emotional subscale = 73) and VHI-10 (mean = 16). Correlations between the CPIB and the UW-QOL scores were statistically significant ( P < .001) but relatively weak ( r = .37–.38). As hypothesized, a stronger correlation was found between the CPIB and the VHI-10 ( r = −0.79; P < .001). Conclusion: Clinicians may consider adopting the CPIB to complement existing tools in assessing communication outcomes after HNC.

Purpose The aim of this study was to recommend protocols for instrumental assessment of voice production in the areas of laryngeal endoscopic imaging, acoustic analyses, and aerodynamic procedures, which will (a) improve the evidence for voice assessment measures, (b) enable valid comparisons of assessment results within and across clients and facilities, and (c) facilitate the evaluation of treatment efficacy. Method Existing evidence was combined with expert consensus in areas with a lack of evidence. In addition, a survey of clinicians and a peer review of an initial version of the protocol via VoiceServe and the American Speech-Language-Hearing Association's Special Interest Group 3 (Voice and Voice Disorders) Community were used to create the recommendations for the final protocols. Results The protocols include recommendations regarding technical specifications for data acquisition, voice and speech tasks, analysis methods, and reporting of results for instrumental evaluation of voice production in the areas of laryngeal endoscopic imaging, acoustics, and aerodynamics. Conclusion The recommended protocols for instrumental assessment of voice using laryngeal endoscopic imaging, acoustic, and aerodynamic methods will enable clinicians and researchers to collect a uniform set of valid and reliable measures that can be compared across assessments, clients, and facilities.

Purpose The purpose of this study was to examine how sentence intelligibility relates to self-reported communication in tracheoesophageal speakers when speech intelligibility is measured in quiet and noise. Method Twenty-four tracheoesophageal speakers who were at least 1 year postlaryngectomy provided audio recordings of 5 sentences from the Sentence Intelligibility Test. Speakers also completed self-reported measures of communication—the Voice Handicap Index-10 and the Communicative Participation Item Bank short form. Speech recordings were presented to 2 groups of inexperienced listeners who heard sentences in quiet or noise. Listeners transcribed the sentences to yield speech intelligibility scores. Results Very weak relationships were found between intelligibility in quiet and measures of voice handicap and communicative participation. Slightly stronger, but still weak and nonsignificant, relationships were observed between measures of intelligibility in noise and both self-reported measures. However, 12 speakers who were more than 65% intelligible in noise showed strong and statistically significant relationships with both self-reported measures ( R 2 = .76–.79). Conclusions Speech intelligibility in quiet is a weak predictor of self-reported communication measures in tracheoesophageal speakers. Speech intelligibility in noise may be a better metric of self-reported communicative function for speakers who demonstrate higher speech intelligibility in noise.

Purpose The purpose of this study was to examine the effects of an internally versus externally cued speech task on perceived understandability and naturalness in speakers with Parkinson's disease (PD) and cerebellar disease (CD). Method Sentences extracted from a covertly recorded conversation (internally cued) were compared to the same sentences read aloud (externally cued) by speakers with PD and a clinical comparison group of speakers with CD. Experienced listeners rated the speech samples using a visual analog scale for the perceptual dimensions of understandability and naturalness. Results Results suggest that experienced listeners rated the speech of participants with PD as significantly more natural and more understandable during the reading condition. Participants with CD were also rated as significantly more understandable during the reading condition, but ratings of naturalness did not differ between conversation and reading. Conclusions Speech tasks can have a pronounced impact on perceived speech patterns. For individuals with PD, both understandability and naturalness can improve during reading tasks versus conversational tasks. The speech benefits from reading may be attributed to several mechanisms, including possible improvement from an externally cued speech task. These findings have implications for speech task selection in evaluating individuals with dysarthria.

To determine how standard residency training and educational background affect otolaryngology resident auditory-perceptual judgments compared with inexperienced listeners. A secondary aim was to assess the impact of a brief training session on the reliability of judgments among otolaryngology residents.Mixed cross-sectional and cohort study.Twenty adult dysphonic and four normal speaker samples were selected from a database. Fifteen listeners at various stages of residency in otolaryngology judged all samples for breathiness and roughness using visual analog scales. Fifteen inexperienced listeners judged the same samples. Subsequently, 12 otolaryngology residents underwent a brief training session. During training, listeners were provided definitions of rating dimensions and accuracy feedback while rating 20 novel (training) stimuli. The feedback included averaged responses from experienced clinicians who had previously evaluated the same speech samples. The residents then completed posttraining evaluations.As a group, otolaryngology resident listeners had significantly better interrater agreement for judgments of roughness compared with inexperienced listeners (P0.05) and trended toward better interrater agreement for judgments of breathiness (P=0.058). Posttraining, no significant improvement in interrater agreement for judgments of roughness was observed; however, a significant improvement was found in interrater agreement of judgments of breathiness (P0.05).Compared with inexperienced (untrained) listeners, otolaryngology resident listeners had better interrater agreement overall for judgments of dysphonia. A short training module was associated with improved reliability in resident evaluation of breathiness. Results have implications for improving and standardizing resident evaluation of dysphonia.

Purpose To determine (a) the effect of fundamental frequency (f 0 ) on speech intelligibility, acceptability, and perceived gender in electrolaryngeal (EL) speakers, and (b) the effect of known gender on speech acceptability in EL speakers. Method A 2-part study was conducted. In Part 1, 34 healthy adults provided speech recordings using electrolarynges set at 75 Hz, 130 Hz, and 175 Hz, and 36 listeners transcribed the recordings. In Part 2, 22 speech samples were presented to 16 listeners. First, listeners identified the gender of each speaker and judged his or her speech acceptability using rating scales. Second, listeners judged the same samples for speech acceptability when gender information was provided. Results In Part 1, speakers were significantly more intelligible when using 75-Hz devices. In Part 2, the f 0 of the speech signal significantly impacted listeners' accuracy in perceiving the speaker’s gender: In gender-incongruent conditions (males using 175-Hz devices, females using 75-Hz devices), listeners were unable to identify female speakers. Speech acceptability judgments were directly related to intelligibility. Finally, listeners differentially penalized female speakers who used 75-Hz devices when gender information was known. Conclusion Low f 0 facilitated speech intelligibility. However, at low f 0 , listeners were unable to identify females as female, and females were differentially penalized for speech acceptability. Results may have implications for rehabilitation.

To investigate how ways of coping and traditional factors (age, sex, time postlaryngectomy, stage of disease, radiation, alaryngeal speech method) predict global quality of life, head and neck cancer-specific quality of life, and voice-related quality-of-life outcomes after total laryngectomy.Cross-sectional survey.University-based laboratory and speech clinic.Sixty-seven individuals who underwent total laryngectomy secondary to cancer were recruited from support groups and professional contacts. Individuals were at minimum 9 months postlaryngectomy. All outcomes were patient reported and included demographic data as well as a number of validated questionnaires: the Ways of Coping-Cancer Version (WOC-CV) scale, the Voice-Related Quality of Life (V-RQOL) scale, and the University of Washington Quality of Life (UW-QOL) composite and global QOL scores.Fifty-three individuals identified a stressful aspect of their laryngectomy. As a set, traditional variables (age, time postlaryngectomy, alaryngeal speech method) accounted for only 5% of global QOL scores but between 25% and 30% of the variance of composite UW-QOL and V-RQOL scores. Time postlaryngectomy was the strongest traditional predictor. Ways of coping accounted for 23% to 32% of all QOL scores. Avoidant coping strategies (both cognitive and behavioral escape) were among the strongest predictors of poorer QOL. When traditional variables were combined with ways of coping, they together accounted for 26% to 46% of the variance of QOL outcomes.Coping is important to consider when evaluating postlaryngectomy outcomes, above and beyond traditionally investigated factors.

Objectives: Little is known about the function of the true vocal folds (TVFs) during cough. The objective of this study was to determine the reliability of measuring TVF movements during cough and to obtain preliminary normative data for these measures. Methods: Sequential glottal angles associated with TVF adduction and abduction across the phases of cough were analyzed from laryngeal videoendoscopy records of 38 young healthy individuals. Results: The intraobserver and interobserver reliability of 3 experienced measurers was high (intraclass correlation of at least 0.97) for measuring sequential and maximum glottal angles. The TVF abduction velocity during expulsion was significantly higher than the precompression adduction velocity (p = 0.002), but there were no significant differences in maximum angle. No statistically significant differences were seen in maximum TVF angle and velocity when they were compared between the sexes and between the levels of cough strength. True vocal fold closure following expulsion occurred in 42% of soft coughs and in 57% of moderate to hard coughs. Conclusions: The TVF abduction angles during cough can be reliably measured from laryngeal videoendoscopy in young healthy individuals. The TVF movements are faster for expulsion abduction than for precompression adduction, but the extents of abduction are similar. To validly determine the cough phase duration, simultaneous measures of airflow are needed.

The objectives of this study were to determine the effect of musical background on both pitch discrimination abilities and the reliability of judging voice quality in dysphonic speakers, and to determine the relationship between pitch discrimination abilities and the reliability of voice quality judgments. Twenty musicians and 20 nonmusicians performed pitch discrimination tests. They also made judgments of dysphonic vowels and speech samples for breathiness and roughness using 100-mm visual analog scales. Musicians demonstrated significantly smaller pitch discrimination thresholds than nonmusicians. For measures of intrarater agreement, musicians were significantly more consistent than nonmusicians for judgments of breathiness in both vowels and speech produced by dysphonic speakers. Musicians also showed significantly better interrater agreement for judgments of breathiness in vowels. Weak to moderate relationships were found between pitch discrimination abilities and agreement values for voice quality judgments. Results suggest that musical background may affect a listener's reliability in making judgments of dysphonia, particularly for judgments of breathiness. However, simple pitch discrimination skills of pure tones do not explain these differences. More complex stimuli should be used in future investigations to help determine the nature of underlying differences.

Objectives: We performed a prospective, exploratory study 1) to determine differences in judgments of overall severity (OS) and vocal effort (VE) in adductor spasmodic dysphonia (ADSD) when judgments are made by experienced listeners, naive listeners, and speakers with ADSD; 2) to determine differences in judgments of listener comfort (LC) in ADSD when judgments are made by experienced and naive listeners; and 3) to determine relationships between auditory-perceptual ratings of voice and speakers' voice handicap. Methods: Twenty speakers with ADSD provided speech recordings. They judged their own speech samples for OS and VE and completed the Voice Handicap Index (VHI). Twenty naive and 8 experienced listeners evaluated speech samples for OS, VE, and LC using rating scales. Results: No differences were found for judgments of OS, VE, or LC across the groups. However, the strategies used by the speakers seemed to differ from those used by the other listeners in making OS and VE judgments. The speakers' self-judged VE correlated moderately with voice handicap; experienced and naive listeners' judgments were only weakly related to VHI scores. Conclusions: Speakers with ADSD and listeners appear to use auditory-perceptual dimensions differently. Voice handicap is best predicted by patient-perceived VE, and not by clinician or naive listeners' judgments.

Purpose To assess the adequacy of self-report instruments in speech-language pathology for measuring a construct called communicative participation. Method Six instruments were evaluated relative to (a) the construct measured, (b) the relevance of individual items to communicative participation, and (c) their psychometric properties. Results No instrument exclusively measured communicative participation. Twenty-six percent ( n = 34) of all items ( N = 132) across the reviewed instruments were consistent with communicative participation. The majority (76%) of the 34 items were associated with general communication, while the remaining 24% of the items were associated with communication at work, during leisure, or for establishing relationships. Instruments varied relative to psychometric properties. Conclusions No existing self-report instruments in speech-language pathology were found to be solely dedicated to measuring communicative participation. Developing an instrument for measuring communicative participation is essential for meeting the requirements of our scope of practice.

Summary Objective The Americans with Disabilities Act Amendments Act of 2008 (ADAAA) resulted in changes to the legal definition of disability and substantially affected how those with voice disorders may qualify for reasonable accommodations under the law. However, there has been little guidance and a lack of awareness about these changes within the voice literature. This article examines the Americans with Disabilities Act of 1990 (ADA), the changes made in 2008 (ADAAA), and how the law applies to individuals with voice disorders. Study Design This is a review article. Methods The ADA and ADAAA are summarized with a particular focus on individuals with voice disorders. Types of reasonable accommodations within the workplace are suggested, and online resources are provided which outline the disclosure and accommodation process. Practical examples are used to provide guidance for clinicians who may be involved in counseling this clinical population. Results/Conclusions Many individuals with voice disorders may not realize that their conditions can be classified as disabilities under the law, entitling them to workplace accommodations and time off to pursue medical treatment. However, disclosure laws such as the right to refrain from mentioning a disability during a job interview may not be protective of individuals with severe voice impairments, as symptoms are often difficult to conceal. Clinical implications and directions for future research are discussed.

Summary Objectives “Speech usage” refers to what people want or need to do with their speech to meet communication demands in life roles. The purpose of this study was to contribute to validation of the Levels of Speech Usage scale by providing descriptive data from a sample of adults without communication disorders, comparing this scale to a published Occupational Voice Demands scale and examining predictors of speech usage levels. Study design This is a survey design. Methods Adults aged ≥25 years without reported communication disorders were recruited nationally to complete an online questionnaire. The questionnaire included the Levels of Speech Usage scale, questions about relevant occupational and nonoccupational activities (eg, socializing, hobbies, childcare, and so forth), and demographic information. Participants were also categorized according to Koufman and Isaacson occupational voice demands scale. Results A total of 276 participants completed the questionnaires. People who worked for pay tended to report higher levels of speech usage than those who do not work for pay. Regression analyses showed employment to be the major contributor to speech usage; however, considerable variance left unaccounted for suggests that determinants of speech usage and the relationship between speech usage, employment, and other life activities are not yet fully defined. Conclusions The Levels of Speech Usage may be a viable instrument to systematically rate speech usage because it captures both occupational and nonoccupational speech demands. These data from a sample of typical adults may provide a reference to help in interpreting the impact of communication disorders on speech usage patterns.

Objectives: This study characterized the relationship between relative fundamental frequency (RFF) and listeners' perceptions of vocal effort and overall spasmodic dysphonia severity in the voices of 19 individuals with adductor spasmodic dysphonia. Methods: Twenty inexperienced listeners evaluated the vocal effort and overall severity of voices using visual analog scales. The squared correlation coefficients (R2) between average vocal effort and overall severity and RFF measures were calculated as a function of the number of acoustic instances used for the RFF estimate (from 1 to 9, of a total of 9 voiced-voiceless-voiced instances). Results: Increases in the number of acoustic instances used for the RFF average led to increases in the variance predicted by the RFF at the first cycle of voicing onset (onset RFF) in the perceptual measures; the use of 6 or more instances resulted in a stable estimate. The variance predicted by the onset RFF for vocal effort (R2 range, 0.06 to 0.43) was higher than that for overall severity (R2 range, 0.06 to 0.35). The offset RFF was not related to the perceptual measures, irrespective of the sample size. Conclusions: This study indicates that onset RFF measures are related to perceived vocal effort in patients with adductor spasmodic dysphonia. These results have implications for measuring outcomes in this population.

Purpose To determine what research evidence exists to support the use of voice measures in the clinical assessment of patients with voice disorders. Method The American Speech-Language-Hearing Association (ASHA) National Center for Evidence-Based Practice in Communication Disorders staff searched 29 databases for peer-reviewed English-language articles between January 1930 and April 2009 that included key words pertaining to objective and subjective voice measures, voice disorders, and diagnostic accuracy. The identified articles were systematically assessed by an ASHA-appointed committee employing a modification of the critical appraisal of diagnostic evidence rating system. Results One hundred articles met the search criteria. The majority of studies investigated acoustic measures (60%) and focused on how well a test method identified the presence or absence of a voice disorder (78%). Only 17 of the 100 articles were judged to contain adequate evidence for the measures studied to be formally considered for inclusion in clinical voice assessment. Conclusion Results provide evidence for selected acoustic, laryngeal imaging–based, auditory–perceptual, functional, and aerodynamic measures to be used as effective components in a clinical voice evaluation. However, there is clearly a pressing need for further high-quality research to produce sufficient evidence on which to recommend a comprehensive set of methods for a standard clinical voice evaluation.

Purpose To explore the similarities and differences in self-reported restrictions in communicative participation across different communication disorders in community-dwelling adults. Method Interviews were conducted with 44 adults representing 7 different medical conditions: spasmodic dysphonia, multiple sclerosis, stroke, stuttering, Parkinson’s disease, amyotrophic lateral sclerosis, and laryngectomy. This article represents a secondary analysis of qualitative data collected in cognitive interviews during development of the Communicative Participation Item Bank. The data were analyzed to identify themes in participants' experiences related to communicative participation. Results Participants described many situations in which they experienced interference in communicative participation. Two themes emerged from the data. The first theme was Interference is both “functional” and “emotional,” in which participants defined interference as limitations in accomplishing tasks and emotional consequences. The second theme was “It depends”—sources of interference, in which participants described many variables that contribute to interference in participation. Participants had limited control of some variables such as symptoms and environmental contexts, but personal decisions and priorities also influenced participation. Conclusions Despite different impairments and activity limitations, participants described similar communicative participation restrictions. These similarities may have theoretical and clinical implications in terms of how we assess, treat, and study the participation restrictions associated with communication disorders.

Summary Objective/Hypothesis To determine whether knowledge of medical diagnosis biases listeners with varied experience levels in their judgments of dysphonia. Study Design Prospective, mixed experimental and comparative design. Methods Twenty-six speakers with dysphonia and four normal controls provided speech recordings. Twenty novice and eight experienced clinicians evaluated speech samples for roughness and breathiness using 100-mm visual analog scales. In one condition, the speech samples were presented without diagnostic information; in the second condition, samples were presented in conjunction with the medical diagnosis. Results Regardless of experience level, listeners judged the samples as significantly more severe when the speakers' diagnoses were known. Specifically, novice listeners (NLs) significantly increased the severity of judgments for speakers who were mildly breathy or mildly or moderately rough when diagnostic information was known. In addition, listeners in both groups judged speakers with mass lesions to be significantly rougher when diagnosis was known; this bias was not observed for speakers with other diagnoses. NLs also trended toward increasing the severity of breathiness judgments for individuals with known vocal fold paralysis but not other diagnoses. Conclusions Sources of bias such as knowledge of medical diagnoses should be considered when listeners with varied experience levels use auditory-perceptual measures to evaluate dysphonia.

The objectives of this prospective and exploratory study are to determine: (1) naive listener preference for gender in tracheoesophageal (TE) speech when speech severity is controlled; (2) the accuracy of identifying TE speaker gender; (3) the effects of gender identification on judgments of speech acceptability (ACC) and naturalness (NAT); and (4) the acoustic basis of ACC and NAT judgments. Six male and six female adult TE speakers were matched for speech severity. Twenty naive listeners made auditory-perceptual judgments of speech samples in three listening sessions. First, listeners performed preference judgments using a paired comparison paradigm. Second, listeners made judgments of speaker gender, speech ACC, and NAT using rating scales. Last, listeners made ACC and NAT judgments when speaker gender was provided coincidentally. Duration, frequency, and spectral measures were performed. No significant differences were found for preference of male or female speakers. All male speakers were accurately identified, but only two of six female speakers were accurately identified. Significant interactions were found between gender and listening condition (gender known) for NAT and ACC judgments. Males were judged more natural when gender was known; female speakers were judged less natural and less acceptable when gender was known. Regression analyses revealed that judgments of female speakers were best predicted with duration measures when gender was unknown, but with spectral measures when gender was known; judgments of males were best predicted with spectral measures. Naive listeners have difficulty identifying the gender of female TE speakers. Listeners show no preference for speaker gender, but when gender is known, female speakers are least acceptable and natural. The nature of the perceptual task may affect the acoustic basis of listener judgments.

Summary Objectives/Hypothesis: The purpose of this study is to examine the psychosocial consequences of BOTOX® (Allergan, Inc. Irvine, CA) treatment for spasmodic dysphonia (SD). This article also explores how patients judge the success of treatment and make decisions about future treatment based on psychosocial issues relevant to them. Study Design: This study follows the phenomenological tradition of qualitative inquiry in which the objective is to explore the lived experiences of a group of persons who share a common phenomenon, in this case receiving BOTOX injections for SD. Methods: Six adults with SD who had been receiving BOTOX injections on a long-term basis participated in face-to-face interviews. The interviews were recorded, transcribed, and analyzed according to phenomenological guidelines to identify consistent themes as well as differences among participants' experiences. Results: The results are summarized in three primary themes that suggest (1) participants' experiences vary over time based on changes in factors such as lifestyle and personal priorities; (2) BOTOX has multidimensional psychosocial implications in physical, personal, and social domains; and (3) participants individualize their treatment regimens, taking into consideration the burden of treatment, scheduling priorities, and other strategies to maximize the benefits of BOTOX. Conclusions: Based on this study, suggestions are provided for future research into a psychosocial outcome measurement, including longitudinal evaluations that accommodate changing patient priorities over time; multidimensional evaluations that incorporate physical, personal, and social issues; evaluations that include a measure of the burden of treatment; and evaluations that support a shared decision-making model with the voice clinicians.

Summary Objectives/hypothesis: The purpose of this study was (1) to determine whether changes in intra- and interrater reliability occur for inexperienced listeners' judgments of overall severity, roughness, and breathiness in dysphonic and normal speakers after 2 hours of listener training; and (2) to determine the acoustic bases of inexperienced listeners' judgments before and after training. Study Design: Prospective, single group, pre- and postdesign. Methods: Thirty adult dysphonic and six normal speaker samples were selected from a database. Samples included 21 test stimuli and 15 training stimuli of both sustained vowels and connected speech. Sixteen inexperienced listeners judged all samples for overall severity, roughness, and breathiness using visual analog scales. Each listener provided pretraining ratings at baseline. Listeners were then trained using 15 anchor voice samples and 15 training stimuli. During training, listeners were provided with definitions of rating dimensions, accuracy feedback, and anchor samples. Listeners then judged test stimuli in a posttraining session. Speaker samples also were analyzed acoustically. Results: Intrarater reliability was least variable for judgments of overall severity, but improved further with training. Listener judgments of roughness and breathiness in vowels were least reliable at baseline, but they significantly improved between listeners after training. Finally, measures of cepstral peak prominence significantly predicted all voice quality judgments except roughness in vowels, which was predicted by shimmer. The acoustic bases of group perceptual judgments did not seem to change with training. Conclusions: These findings have implications for developing training programs in perceptual evaluation and mapping relationships between acoustic and perceptual characteristics of voice disorders.

Summary The purpose of this study was (1) to determine the psychophysical character of auditory-perceptual ratings of voice pleasantness (VP) and voice acceptability (VA) for tracheoesophageal (TE) speakers using direct magnitude estimation (DME) and equal-appearing interval (EAI) scaling procedures and (2) to determine the relationship between listeners' ratings of VP and VA. Ten adult listeners judged overall VP and VA from connected speech samples produced by 20 adult male TE speakers. Although results yielded a prothetic continuum for VP and a metathetic continuum for VA, the amount of variance accounted for by a curvilinear model of VP was minimally more than that accounted for by a linear model. Results also revealed a significant relationship between VP and VA ( r =0.939). Findings from this study do not suggest any greater validity associated with VP and VA ratings obtained by the DME than the EAI method. As a result of the significant relationship between these ratings and to the ease of applying EAI scales, it is recommended that VA be used as a current clinical outcome measure. These data illustrate the need to identify attributes that best describe TE speech that are measured appropriately and are clinically useful.

OBJECTIVES/HYPOTHESIS: The purposes of the study were to determine listeners' auditory-perceptual ratings of tracheoesophageal speakers, to determine quality of life in tracheoesophageal speakers, and to determine the potential relationship between listeners' ratings of speech and tracheoesophageal speakers' self-rated quality of life. STUDY DESIGN: Twenty-eight laryngectomized individuals who used tracheoesophageal speech as their primary mode of communication were studied. Fifteen naive listeners provided auditory-perceptual ratings. METHODS: Twenty-eight tracheoesophageal speakers (22 men and 6 women) completed a general information form, in addition to the University of Michigan Head and Neck Quality of Life (HNQOL) instrument; speakers also provided connected speech samples of a standard passage. Fifteen naive listeners evaluated the tracheoesophageal speech samples for overall speech severity, naturalness, acceptability, and pleasantness using direct magnitude estimation procedures. RESULTS: Listeners were able to discriminate among tracheoesophageal speech samples relative to the auditory-perceptual dimensions. Male tracheoesophageal speakers were judged as having significantly better, more acceptable, and more pleasant voices than women. Scores on the HNQOL instrument were determined to be higher among the group of tracheoesophageal speakers in the present study than those reported in previous studies. No significant differences were found among men and women for quality of life scores. Quality of life domains and auditory-perceptual judgments of tracheoesophageal speech were moderately correlated. CONCLUSION: Women who use tracheoesophageal speech may be differentially penalized for dimensions related to voice quality. Limitations in voice did not necessarily translate into worse overall quality of life, indicating that auditory-perceptual evaluation and quality of life questionnaires are evaluating different aspects of function after laryngectomy.

The purpose of this study was (1) to determine the relationship between acoustic measures and auditory-perceptual dimensions of overall voice severity and pleasantness and (2) to evaluate the ability of acoustic and auditory-perceptual measures to discriminate normal from dysphonic voices. Thirty adult dysphonic speakers and six, age-matched normal control speakers were asked to provide oral reading samples of the Rainbow Passage. Acoustic analysis of the speech samples was used to identify abnormal phonatory events associated with dysphonia. The acoustic program calculated long-term average spectral measures, glottal noise measures, and those measures based on linear prediction (LP) modeling. Twelve adult listeners judged overall voice severity and pleasantness from the connected speech samples using direct magnitude estimation (DME) procedures. The acoustic measures accounted for 48% of overall voice severity and 40% of voice pleasantness for dysphonic speakers. The classification performance of the acoustic measures and auditory-perceptual measures was quantified using logistic regression analysis. When acoustic measures or auditory-perceptual measures were considered in isolation, classification was generally accurate and similar across measures. Classification accuracy improved to 100% when acoustic and auditory-perceptual measures were combined. These data provide further support for use of both auditory-perceptual evaluation and acoustic analyses for classifying and evaluating dysphonia.