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Aging & Voice

The aging adult voice

Advancing age produces physiologic changes that may alter voice. Some of these changes are inevitable; others may be avoidable or reversible. In addition, many treatable medical conditions may cause voice changes similar to those of aging.

It is essential that all voice care providers be familiar with the expected changes of aging, and be alert to reversible conditions that may adversely affect phonation and be mistaken for presbyphonia.

Sataloff RT et al., The aging adult voice. J Voice, 1997 Jun, 11:2, 156-60.

Alcohol & Voice

Acoustic analysis was performed of voice in individuals with alcohol addictions.

Analysis showed an increase in medium and maximum jitter values, weakening of signal harmonic structure and an increase in periodical course occurrence with noise.

All parameters were compared with those of the control group.

Niedzielska, G et al Acoustic evaluation of voice in individuals with alcohol addiction. Folia Phoniatr Logop 1994;46(3):115-22.

Allied Health & Voice

Allied health professionals in nutrition and medical dietetics, occupational therapy, physical therapy, and speech-language pathology and audiology play both unique and key cross-cutting roles in the furtherance of clinical research.

Clinical research in speech-language pathology and audiology is singular in its focus on deafness and hearing disorders, voice, speech, language and related disorders, and intersections among these and other neurological and physical conditions.

Possibly due to their professional maturation within multidisciplinary academic units, allied health professionals have demonstrated a level of comfort with multidisciplinary and interdisciplinary collaborations unique within many academic health science centers.

Selker-LG: Clinical research in allied health. J-Allied-Health. 1994 Fall; 23(4): 201-28.

Asthma & Voice

Susceptibility to voice reactions during a histamine provocation test was studied in 21 asthmatics and 21 healthy subjects.

Speech samples were recorded before, and 5 and 15 min after histamine inhalation, and the samples were rated by six speech pathologists.

Deterioration of voice quality occurred in 2/12 asthmatic men and in 3/9 asthmatic women within 5 min after histamine inhalation; no change was observed between 5 and 15 min.

Voice reactions were not related to the degree of bronchial obstruction: the subjects with the most pronounced decrease in peak expiratory flow (PEF) (60-61% in three subjects) did not develop voice reactions, and PEF did not decrease in one subject with voice reactions.

No voice reactions were observed in the healthy subjects.

Leinonen L & Poppius H: Voice reactions to histamine inhalation in asthma. Allergy, 1997 Jan, 52:1, 27-31.


Acoustic analysis of vocal instability during the production of isolated vowels, including computation of mean fundamental frequency (F0), period-to-period variability (jitter), pitch fluctuations, and between-trial variation of F0, was performed in patients (# 20) with cerebellar cortical dysfunction.

A subgroup of subjects presented with enlarged pitch fluctuations and/or increased jitter values. It is conceivable that asymmetrically distributed motor deficits at the laryngeal level and altered gain settings of laryngeal and/or respiratory reflexes account for the observed phonatory instability.

Moreover, 5 of the 20 cerebellar patients had a pitch level exceeding the upper limit of the normal range. Presumably, this deviation reflects increased vocal effort.

Ackermann, H &; Ziegler, W: Acoustic analysis of vocal instability in cerebellar dysfunctions. Ann Otol Rhinol Laryngol 1994 Feb;103(2):98-104.

Hearing loss & Voice

This investigation studied the impact of hearing loss on phonatory, velopharyngeal, and articulatory functioning using a comprehensive physiological approach.

Electroglottograph (EGG), nasal/oral air flow, and intraoral air pressure signals were recorded simultaneously from adults with impaired and normal hearing as they produced syllables and words of varying physiological difficulty. Intraoral pressure, nasal air flow, durations of lip, velum, and vocal fold articulations, estimated subglottal pressure, mean phonatory air flow, fundamental frequency, and EGG abduction quotient were compared.

The individuals with moderate-to-profound hearing loss had good to excellent oral communication skills.

The speakers with hearing loss had significantly higher intraoral pressures, subglottal pressures, laryngeal resistances, and fundamental frequencies than those with normal hearing.

All of the individuals with profound hearing loss had at least one speech/voice physiology measure that fell outside of the normal range, and most of the subjects demonstrated unique clusters of abnormal behaviors.

Physiological assessments provide important information about the speech/voice production abilities of individuals with moderate-to-profound hearing loss and are a valuable addition to standard assessment batteries.

Higgins, MB et al: Physiological assessment of speech and voice production of adults with hearing loss. J Speech Hear Res 1994 Jun;37(3):510-21.

Husky Voice

Disorders of voice are a common problem in general practice.

This article details the pathophysiology of voice production and how to assess the patient with hoarseness. Contemporary management of vocal disorders is described with reference to some newer surgical and investigative techniques.

Lyons, BM: 'Doctor, my voice seems husky'. Aust Fam Physician 1994 Nov;23(11):2111-9.

Hydration & Voice

Assessed the effectiveness of hydration treatments in the clinical management of selected voice disorders.

Improvements in voice and in laryngeal appearance followed both placebo/control and hydration treatments. However, the greatest improvements were obtained following the hydration treatment.

Preliminary evidence of a therapeutic benefit from hydration treatments in patients with nodules or polyps. Based on previous theoretical work, hydration effects may be related to reductions in the viscosity of vocal fold tissue, although other explanations are also possible.

Verdolini-Marston, K et al: Effect of hydration treatments on laryngeal nodules and polyps and related voice measures. J Voice 1994 Mar;8(1):30-47.

Malignancy of Voice

Voice frequency & malignancy

Performing systematically acoustical objective voice analysis in patients with chronic chorditis and glottic cancer a certain number of cases with exceptional acoustical pattern were detected.

In 7 of 50 patients with chronic chorditis.

In 31 of 50 patients with glottic cancer the same phenomenon was recorded.

Histology revealed in 6 of those 7 patients with clinical diagnosis of chronic chorditis invasive cancer of the vocal fold.

This acoustical sign may be a useful diagnostical parameter for very early diagnosis of glottic cancer. This is possible because of the great sensitivity and complexity of phonatory function.

Vecerina Volic S et al., Correlation between instability of fundamental voice frequency and malignant infiltration of vocal fold nerve endings. Acta Otolaryngol Suppl (Stockh), 1997, 527:, 131-3.

Fatigue & Voice

Measurement of fatigue

Laryngeal fatigue affects the physical sensations, effort, and perceptual quality of voice production. The underlying physiology of fatigue is not well understood.

Acoustic, aerodynamic, and videostroboscopic data were measured in normal speakers (# 10) before and after prolonged voice use.

Significant changes were found in the fundamental frequency of connected speech. Anterior glottal chinks were induced in a majority of subjects.

Implications are discussed.

Stemple, JC et al: Objective measures of voice production in normal subjects following prolonged voice use. J Voice 1995 Jun;9(2):127-33.

Muscle misuse & Voice

It is apparent that voice disorders frequently labelled "functional" are associated with laryngeal muscle misuse.

The word "functional" is, however, intrinsically ambiguous, and so we propose an alternative term based on descriptive features of dysfunction: "muscle misuse voice disorders".

Persistent phonation with an abnormal laryngeal posture can lead to organic changes such as nodules or polyps, particularly in females with posterior glottic chink.

Hypothesized that the chink was related to an overall increase in laryngeal muscle tension, and more directly due to inadequate relaxation of the posterior crico-arytenoid muscle during phonation.

The "working title": "muscular tension dysphonia" (MTD) was used but the term "laryngeal isometric" may be superior because of other misuses of the larynx that are manifestations of abnormal muscular tension.

A new classification evolved based on the laryngeal isometric, glottic and supraglottic lateral contraction states, antero-posterior contraction states, conversion aphonia, psychogenic bowing, and adolescent transitional dysphonia.

Morrison, MD & Rammage, LA: Muscle misuse voice disorders: description and classification. Acta Otolaryngol (Stockh) 1993 May;113(3):428-34.

Outcome & Voice

Outcome measurement

Examined the degree to which a standard voice assessment could discriminate between the potential benefits of 2 different voice therapy programs for individual patients.

The assessment discriminated well between patients requiring voice therapy to change physiological parameters of voice usage and patients able to self-adjust voice usage, and provided an objective means of measuring outcomes.

Gordon MT et al., Predictive assessment of vocal efficiency (PAVE). A method for voice therapy outcome measurement. J Laryngol Otol, 1997 Feb, 111:2, 129-33.

Parkinson's Voice

Parkinson’s (1)

To investigate and document the efficacy of intensive voice therapy to improve functional communication in patients with idiopathic Parkinson disease.

Of the 22 patients, 13 patients received intensive therapy aimed at increasing vocal and respiratory effort (VR), whereas nine received intensive therapy aimed at increasing respiratory effort (R) only. Laryngostroboscopy was again performed.

Differences in laryngeal function in these patients observed with fiberoptic laryngoscopy and rigid telescopic laryngoscopy are discussed.

The VR therapy group showed improvements on laryngostroboscopic variables: less glottal incompetence and no significant change in supraglottal hyperfunction after therapy. The mean intensity increase in the VR therapy group was 12.5 dB.

No differences were observed in the R-only group (decrease of 1.9 dB).

Findings suggest that in patients with Parkinson disease, intensive therapy focusing on phonatory effort improves adduction of the vocal folds as assessed by laryngostroboscopy.

Smith, ME et al: Intensive voice treatment in Parkinson disease. J Voice 1995 Dec;9(4):453-9.

Parkinson (2)

Changes in voice and speech production in a patient with Parkinson disease were examined as he increased vocal intensity following 1 month of intensive voice treatment.

Pre- to post-treatment increases were documented in sound pressure level in sustained phonation, syllable repetition, reading, and monologue. Corresponding improvements were measured in estimated subglottal pressure, maximum flow declination rate, laryngeal airway resistance, open quotient, EGGW-25, harmonic-spectral slope, and maximum vowel duration.

Measures of phonatory stability in sustained phonation and semitone standard deviation in reading and speaking showed changes accompanying increased vocal intensity. In addition, changes were measured in articulatory acoustic parameters (vowel and whole word duration, transition duration, extent and rate, and frication duration and rise time) in single-word productions.

Findings indicate that this patient increased his vocal intensity using phonatory mechanisms that have been associated with the nondisordered larynx. In addition, the increased vocal intensity led to changes in articulation that were not targeted in treatment.

Dromey, C et al: Phonatory and articulatory changes associated with increased vocal intensity in Parkinson disease. J Speech Hear Res. 1995 Aug;38(4):751-64.

Pediatric & Voice

Referrals are for: voice assessment (as part of the pre- or post-operative management of laryngeal disorders [e.g. cysts, webs, vocal fold palsies, laryngo-tracheal reconstruction]) and characterisation of voice abnormalities exist [e.g. mucopolysaccharidoses, functional dysphonias].

Electrolaryngography is used.

Guidelines for the establishment of a paediatric voice clinic are presented.

Papsin, BC et al: The developing role of a paediatric voice clinic: a review of our experience. J Laryngol Otol 1996 Nov;110(11):1022-

Prediction of Voice disorders

Prediction of severity

Investigated the relative effectiveness of three acoustic measures (jitter, shimmer, and harmonic/noise ratio) in predicting the dysphonic severity of a diverse clinical population singly and together.

Phonatory samples were recorded from normal subjects (# 20) and patients (# 60) representing 3 laryngeal groups (nodules, paralysis, and functional).

Findings indicated that:
(a) none of the variables was strongly correlated with dysphonia ratings, and
(b) a combination of acoustic predictors was no more successful than a single predictor of dysphonic severity, namely, shimmer.

Wolfe, V et al: Acoustic prediction of severity in commonly occurring voice problems. J Speech Hear Res 1995 Apr;38(2):273-9.


Strobovideolaryngoscopy has proven essential to accurate diagnosis of voice disorders. Clinical interpretation of stroboscopic images usually follows a standard assessment protocol.

Features analyzed typically include symmetry of amplitude, symmetry of phase, regularity of periodicity, amplitudes and wave forms of individual vocal folds, presence or absence of adynamic segments, and other features. Speed and smoothness of abduction and adduction are also assessed.

In order for stroboscopic data to be used meaningfully in a clinical setting, it is essential for the laryngologist to recognize the range of normal variability of these parameters. This may be particularly important when trying to establish diagnoses for subtle voice disorders in professional voice users.

Investigated strobovideolaryngoscopic findings in a population of normal professional singers without voice complaints.

"Abnormal" strobovideolaryngoscopic findings occured in (58% of) this asymptomatic population of "volunteers." They might have been misinterpreted as causing voice complaints if seen for the first time when the singer sought medical care for a voice problem.

Physicians must be aware of the range of laryngeal behavior that may be found among normal subjects and must be cautious when interpreting strobovideolaryngoscopic findings.

Elias ME et al.: Normal strobovideolaryngoscopy: variability in healthy singers. J Voice, 1997 Mar, 11:1, 104-7.

Teachers & Voice

Compared the frequency and effects of voice symptoms in teachers to a group of individuals employed in other occupations. Teachers were more likely to report having a voice problem (15 vs. 6%), having 10 specific voice symptoms, and having 5 symptoms of physical discomfort. They averaged almost 2 symptoms compared with none for nonteachers. Likewise, teachers were more likely to perceive that a voice problem would adversely affect their future career options, had done so in the past, and was limiting their current job performance.

Over 20% of teachers but none of the nonteachers had missed any days of work due to a voice problem.

Findings suggest that teaching is a high-risk occupation for voice disorders and that this health problem may have significant work-related and economic effects.

Smith E et al., Frequency and effects of teachers' voice problems. J Voice, 1997 Mar, 11:1, 81-7.

Young adults & Voice

The young adult voice

Young adulthood is notable for rapid physical changes and psychosocial instability. Care of the young adult professional voice requires knowledge of the specific anatomic and physiologic changes associated with the mutational voice, as well as the effects of general growth and maturation on the vocal mechanism. The effects of psychological stresses common to young adulthood, such as educational commitments and early career choices, must also be understood.

Upper respiratory infection and allergies are common in this age group. Treatment of these conditions must be tailored in the professional voice user because of the potential side effects of some medications and the performance imperatives of the patient.

Surgical indications for tonsillectomy in the young voice patient are discussed.

Spiegel JR et al., The young adult voice. J Voice, 1997 Jun, 11:2, 138-43.

Professional Voices

As the modulating and power source for the voice, the upper and lower respiratory tracts play a key role in management of voice production. Allergic respiratory disease can impair vocalization, which can be a particular problem in the professional voice user.

To facilitate the evaluation and management of professional voice users who have allergic respiratory problems contributing to their vocal dysfunction.

The anatomy and physiology of voice production, laryngeal pathology, and special diagnostic and therapeutic considerations relative to the allergist's role in treatment of these patients are discussed.

Mechanisms of voice production are reviewed, as well as common laryngeal pathology effecting voice production. Allergic respiratory diseases are summarized, with particular attention to those aspects of management that are altered in professional voice users.

Professional voice users require modification in their management to optimize vocal function and minimize abnormalities of the vocal tract.

This includes avoidance of medications that produce drying of the airway, as well as avoidance of inhaled corticosteroids. Subtle changes in respiratory function, which may be of no consequence to other individuals, may adversely affect performance ability, and need aggressive management.

Allergen immunotherapy, because of its lack of adverse effects on the vocal apparatus, is particularly well suited for treatment of professional voice users.

Cohn, JR et al: Vocal disorders and the professional voice user: the allergist's role. Ann Allergy Asthma Immunol 1995 May;74(5):363-73; quiz 373-6.