Voice rest and sick leave after phonosurgical procedures : surveys among European laryngologists and phoniatricians

PurposeAfter surgery of vocal folds, almost every patient will need some voice rest. It is common to recommend total silence for some days, followed by less restricted voice use for variable periods. By now, we do not know how voice rest affects the healing process or the current practise in Europe.MethodsMembers of the European Laryngological Society (2012) and the Union of European Phoniatrics (2018) were sent a web-based questionnaire which included two patient cases with a short history and a still picture. The respondents were asked about the postoperative recommendation of absolute voice rest and sick leave.ResultsOver 90% of the respondents would recommend absolute voice rest after removing a polyp or after mucosal repair of Reinke's oedema. For both cases, the mean length of recommended absolute voice rest among UEP members was 4days (range 0-10days) and among ELS members was 5days (range 0-14days). The recommended sick leave ranged from 0 to 35days. The mean figures suggested by ELS members for the receptionist with Reinke's oedema were 12days and for the teacher with a polyp 13days. On average, UEP members recommended 14days of sick leave for both cases.ConclusionThe present scientific evidence is scant, but does not support for prolonged (over 3days) absolute voice rest after simple phonosurgery. So far, there are no studies that could show absolute voice rest to be superior over relative voice rest. According to the present survey, there is considerable variation in recommending voice rest and sick leave after the removal of benign mucosal lesions. Many European laryngologists suggest voice rest that is longer and stricter than the present scientific literature supports.Peer reviewe

Äänen arviointi uusien riskiryhmien keskuudessa : tutkimuskohteena orgaaniselle pölylle altistuvat työntekijät, lastentarhan opettajat sekä lapset, joille on tehty kurkunpään leikkauksia

Over the last decades, school teachers and singers have been more or less the focus of voice research, due to their specific occupational needs. Now, other population groups as well start to draw attention. These new groups include workers exposed to organic dusts in various workplaces with possible laryngeal reactions. The second group includes children operated on for subglottic stenosis with possible effects on voice and related quality of life. The third are nursery teachers insufficiently studied through field research for possible voice problems. This thesis aims to shed light on these newly emerging vulnerable groups in terms of assessing their voices through questionnaires, perceptual and acoustic voice assessment, and videolaryngoscopic examination. The thesis includes four studies. Nine subjects with suspected occupational rhinitis or asthma participated in Studies I and II. They had single blinded exposures to organic dust and placebo substances. Subjective and perceptual voice assessment was done in addition to acoustic analysis of 180 samples using glottal inverse filtering. In Study III, children s voices were perceptually assessed as well as their health- and voice-related quality of life. In Study IV, 119 female kindergarten teachers responded to a questionnaire on voice habits, voice symptoms, and impact of various working conditions on voice. In addition, videolaryngoscopy examinations took place in these teachers workplaces. Studies I and II showed that some self-assessed voice and throat symptoms changed significantly after organic dust exposure, although perceptual assessment failed to record these changes. However, inverse filtering analysis revealed changes that represent the ones reported by the subjects. In Study III, voice-related quality of life and perceptual assessment of the study group showed lower scores than the controls . Study IV showed that 71.5% of the teachers examined reported frequent strain on the voice. Organic findings were observed in 10.9% of the subjects and did not correlate with subjective voice symptoms. The thesis added new information on these high-risk groups, identifying an occupational voice-disorder risk group related to laryngeal reactions rather than voice abuse. It also added information on the long-term effects of surgery for subglottic stenosis in early infancy. Nevertheless, field videolaryngoscopy was quite accurate in determining the percentage of organic findings among nursery teachers.Ääni on ihmiskunnan tärkein kommunikaatioväline, jota käytetään jatkuvasti aamusta iltaan. Ääniammateissa toimii jopa kolmannes yhteiskunnan työvoimasta, kuten opettajat, laulajat ja lakimiehet. Viime vuosikymmeninä opettajat ja laulajat ovat olleet äänitutkimusten keskiössä, mutta on myös muita väestöryhmiä, jotka alkavat herättää tutkijoiden huomiota mahdollisista ääniongelmista kärsiessään. Tämän tutkimuksen lähtökohtana oli kiinnostus näitä uusia riskiryhmiä sekä heidän ääniongelmiensa arviointia kohtaan. Väitöskirjaa varten tutkittiin kolmea uutta riskiryhmää, jotka ovat: 1) työntekijät, joille orgaanisen pölyn altistus aiheuttaa ääniongelmia, 2) lapset, joille on tehty kurkunpään leikkauksia varhaislapsuudessa ääniraon alapuolisen ahtauman vuoksi, ja 3) lastentarhan opettajat, joita ei ole tutkittu riittävästi kenttätutkimuksessa eli heidän työpaikoillaan. Väitöskirjan tutkimuksissa käytettiin erilaisia äänen tutkimusmenetelmiä: tavallisia tutkimusmenetelmiä, kuten kyselylomakkeita, mutta myös harvinaisempia, osaltaan hyvin uusia tutkimusmenetelmiä, kuten akustista analyysia käänteissuodatuksella. Käänteissuodatuksessa mitattiin äänenmuodostumista äänihuulten tasolla. Kurkunpään tähystys tehtiin kannettavalla videojärjestelmällä lastentarhan opettajien työpaikoilla. Väitöskirja koostuu neljästä kansainvälisessä lehdessä julkaistusta artikkelista, joissa käsitellään kolmen aiemmin mainittujen riskiryhmien tutkimuksia. Orgaaniselle pölylle altistuvat työntekijät kärsivät mahdollisesti työpaikkaan liittyvästä äänihäiriöstä, joka johtuu kurkunpään reaktiosta, ei äänenkäytöstä. Työntekijät tiedostavat äänensä muuttuneen, mutta silti muutos jää huomaamatta kuulon aistivaraisessa tutkimuksessa eli lääkäreiden korvissa. Akustinen analyysi käänteissuodatuksen menetelmällä on todennut nämä muutokset. Korvakuulolla huomaamatta jäävien äänimuutosten toteaminen akustisesti on hyvin harvinainen ja lupaava tulos. Toinen tutkittu ryhmä olivat lapset, jotka on leikattu äänihuulten alapuolisen ahtauman vuoksi. Tutkimuksen tuloksena todettiin operatiivisen hoidon vaikuttavan pitkällä tähtäimellä äänen kuulon aistivaraiseen laatuun heikentävästi terveisiin lapsiin verrattuna. Tämän lisäksi ääneen liittyvä elämänlaatu on alhaisempi leikatuilla lapsilla. Kolmantena riskiryhmänä tutkimuksessa olivat lastentarhan opettajat. Tutkimus osoitti, että 71,5 % tutkituista opettajista ilmoitti kärsivänsä toistuvasta äänen rasituksesta. Tämän lisäksi äänihuulten orgaaniset muutokset todettiin 10.9 %:lla opettajista. Väitöskirjan tutkimus on tuottanut merkittävää tietoa uusista riskiryhmistä

Analysis of phonation onsets in vowel production, using information from glottal area and flow estimate

A multichannel dataset comprising high-speed videoendoscopy images, and electroglottography and free-field microphone signals, was used to investigate phonation onsets in vowel production. Use of the multichannel data enabled simultaneous analysis of the two main aspects of phonation, glottal area, extracted from the high-speed videoendoscopy images, and glottal flow, estimated from the microphone signal using glottal inverse filtering. Pulse-wise parameterization of the glottal area and glottal flow indicate that there is no single dominant way to initiate quasi-stable phonation. The trajectories of fundamental frequency and normalized amplitude quotient, extracted from glottal area and estimated flow, may differ markedly during onsets. The location and steepness of the amplitude envelopes of the two signals were observed to be closely related, and quantitative analysis supported the hypothesis that glottal area and flow do not carry essentially different amplitude information during vowel onsets. Linear models were used to predict the phonation onset times from the characteristics of the subsequent steady phonation. The phonation onset time of glottal area was found to have good predictability from a combination of the fundamental frequency and the normalized amplitude quotient of the glottal flow, as well as the gender of the speaker. For the phonation onset time of glottal flow, the best linear model was obtained using the fundamental frequency and the normalized amplitude quotient of the glottal flow as predictors.Peer reviewe

Parameterization of a computational physical model for glottal flow using inverse filtering and high-speed videoendoscopy

High-speed videoendoscopy, glottal inverse filtering, and physical modeling can be used to obtain complementary information about speech production. In this study, the three methodologies are combined to pursue a better understanding of the relationship between the glottal air flow and glottal area. Simultaneously acquired high-speed video and glottal inverse filtering data from three male and three female speakers were used. Significant correlations were found between the quasi-open and quasi-speed quotients of the glottal area (extracted from the high-speed videos) and glottal flow (estimated using glottal inverse filtering), but only the quasi-open quotient relationship could be represented as a linear model. A simple physical glottal flow model with three different glottal geometries was optimized to match the data. The results indicate that glottal flow skewing can be modeled using an inertial vocal/subglottal tract load and that estimated inertia within the glottis is sensitive to the quality of the data. Parameter optimisation also appears to favour combining the simplest glottal geometry with viscous losses and the more complex glottal geometries with entrance/exit effects in the glottis.Peer reviewe

Phoniatricians and otorhinolaryngologists approaching oropharyngeal dysphagia : an update on FEES

Purpose Oropharyngeal dysphagia (OD) is a common phenomenon in otorhinolaryngology and phoniatrics. As both sub-disciplines have a strong tradition and clinical experience in endoscopic assessment of the upper aerodigestive tract, the implementation of fiberoptic endoscopic evaluation of swallowing (FEES) was an almost self-evident evolution. This review aims to provide an update on FEES and the role of phoniatricians and otorhinolaryngologists using FEES in Europe. Methods A narrative review of the literature was performed by experts in the field of FEES both in the clinical context and in the field of scientific research. Results FEES is the first-choice OD assessment technique for both phoniatricians and otorhinolaryngologists. FEES is becoming increasingly popular because of its usefulness, safety, low costs, wide applicability, and feasibility in different clinical settings. FEES can be performed by health professionals of varying disciplines, once adequate knowledge and skills are acquired. FEES aims to determine OD nature and severity and can provide diagnostic information regarding the underlying etiology. The direct effect of therapeutic interventions can be evaluated using FEES, contributing to design the OD management plan. Standardization of FEES protocols and metrics is still lacking. Technological innovation regarding image resolution, frame rate frequency, endoscopic light source specifications, and endoscopic rotation range has contributed to an increased diagnostic accuracy. Conclusion The rising number of phoniatricians and otorhinolaryngologists performing FEES contributes to the early detection and treatment of OD in an aging European population. Nevertheless, a multidisciplinary approach together with other disciplines is crucial for the success of OD management.Peer reviewe

The Nasal Musculature as a Control Panel for Singing-Why Classical Singers Use a Special Facial Expression?

Objectives: This study aimed to explain the possible reason why classical singers seem to spread their nostrils and raise their cheeks before starting to sing. Study Design: This is an experimental study. Methods: Five subjects (three classical singers, two nonsingers) were investigated with nasofiberoscopy holding their breath after inhalation. The subjects were instructed to have a neutral expression first and then to take the singers' expression characterized by nostril flaring. In case of nonsingers, the special expression was rehearsed beforehand, guided by a classical singer. The following measurements were made: (1) height of soft palate, (2) area of the hypopharynx, (3) area of the epilaryngeal tube inlet (Aditus laryngis), and (4) dimensions of the (visible) glottis (length, width, and length-to-width ratio). Results: All subjects raised the palate and widened the pharyngeal inlet, epilaryngeal inlet, and the glottis during "singer's expression." Conclusions: The results suggest that classical singers may take advantage of breathing-and smelling-related connections between nasal and facial muscles and the larynx to avoid a hard glottal attack and pressed phonation and possibly also to assist the production of mixed register (head voice), characterized by a relatively low adduction between the vocal folds.Peer reviewe

Infection control, hand hygiene practice and PPE use among phoniatricians and ENT specialists during the COVID-19 pandemic, a UEP survey

Background: Caring for our patients while taking care of our own safety as well as theirs is a major concern during the current pandemic. Therefore, many societies developed guidance documents to educate clinicians about the required precautions. This study aims to assess personal protective equipment (PPE) usage, hand hygiene practice and infection control training among phoniatricians and otolaryngologists during the pandemic. An online survey was administered during the first wave of the COVID-19 pandemic in June 2020. Data collected included PPE availability, infection control training, adopted infection control precautions, hand hygiene practice, and use of different PPE elements as well as adherence to its use during potential aerosol generating procedures. Results: Based on their country of residences, eligible 154 participants were grouped into 4 groups and their responses were compared. Conclusion: Following the suggested recommendations, while adequate for some precautions, was still not satisfactory. Certain defects that are specific to particular groups had also been identified.Peer reviewe

Acoustic and videoendoscopic effects of temporary vocal fold augmentation in an office-based setting : a quasi-experimental study

Background: Vocal-fold augmentation is a continuously developing treatment modality for glottic insufficiency. Patients with glottic insufficiency attend the phoniatrics clinics with increasing frequency. Glottic insufficiency may be due to vocal-fold paralysis, paresis, atrophy, sulcus vocalis, scarring, and vocal-fold deficiency after laryngeal surgery. A variety of materials exist for injection augmentation. This follow-up study aimed to assess the short-term as well as long-term outcomes of vocal-fold injection with calcium hydroxyapatite (CaHA) in patients with glottic gap 1-3 mm. Method: This study included 25 patients with glottic insufficiency who underwent injection augmentation with CaHA. All patients were scheduled for voice evaluation using a comprehensive subjective and objective battery of assessments. Assessments were performed before the procedure and after the procedure at 2 months and at 1 year. Results: Perceptual voice quality assessed with the GRBAS scale improved and the results were stable after 1 year. Shimmer and HNR improved continuously through the follow-up sessions, while jitter and f0 showed slight improvement after CaHA injection. Conclusion: Voice improvement after injection of CaHA requires a minimum of 2 months to develop and may last for a long period.Peer reviewe

Measurement and mathematical simulation of acoustic characteristics of an artificially lengthened vocal tract

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Long-term outcome of endoscopic shortening and stiffening of the vocal folds to raise the pitch

In this study, we aimed to assess the long-term effects of the mucosal layer plastic surgery of the vocal folds performed on the voices of male-to-female transgenders. This retrospective cohort study enrolled 22 patients who were operated during 2004-2010 by a combined technique of transmucosal anterior suturing and stiffening of the vocal folds through a longitudinal cordotomy incision using CO2 laser. Long-term effects were assessed based on completed questionnaires on four different categories including subjective evaluation of patient's own voice perception and a standardized voice inventory (VHI), as well as an acoustic assessment and videolaryngoscopic examination. Out of the 22 patients contacted, 16 returned the questionnaires, and 13 of them participated in the subsequent acoustic analysis and videolaryngoscopic assessment. Results of the study were as follows: The total VHI score, after the procedure, was 32. F0 increased significantly for both the vowel/a/ and text from 157 to 207 Hz and 139 to 162 Hz, respectively. Perturbation measures did not show a significant change. F0 did not correlate with the VHI score. One patient had symptomatic anterior perforation that needed re-operation. The combination of transmucosal anterior suturing and stiffening of the vocal folds by laser cordectomy results in significant elevation of the F0 in the long term and in acceptable levels of VHI score compared to other reports. In conclusion, the results of the procedures show that it is enough to get the mucosal edges sutured together without the need to suture either the ligaments or the muscle of the vocal folds. The need for revision is minimal with this procedure.Peer reviewe