Validation and Classification of the 9-Item Voice Handicap Index (VHI-9i)

The international nine-item Voice Handicap Index (VHI-9i) is a clinically established short-scale version of the original VHI, quantifying the patients’ self-assessed vocal handicap. However, the current vocal impairment classification is based on percentiles. The main goals of this study were to establish test–retest reliability and a sound statistical basis for VHI-9i severity levels. Between 2009 and 2021, 17,660 consecutive cases were documented. A total of 416 test–retest pairs and 3661 unique cases with complete multidimensional voice diagnostics were statistically analyzed. Classification candidates were the overall self-assessed vocal impairment (VHIs) on a four-point Likert scale, the dysphonia severity index (DSI), the vocal extent measure (VEM), and the auditory–perceptual evaluation (GRB scale). The test–retest correlation of VHI-9i total scores was very high (r = 0.919, p < 0.01). Reliability was excellent regardless of gender or professional voice use, with negligible dependency on age. The VHIs correlated best with the VHI-9i, whereas statistical calculations proved that DSI, VEM, and GRB are unsuitable classification criteria. Based on ROC analysis, we suggest modifying the former VHI-9i severity categories as follows: 0 (healthy): 0 ≤ 7; 1 (mild): 8 ≤ 16; 2 (moderate): 17 ≤ 26; and 3 (severe): 27 ≤ 36

Pathology-Related Influences on the VEM: Three Years’ Experience since Implementation of a New Parameter in Phoniatric Voice Diagnostics

The vocal extent measure (VEM) represents a new diagnostic tool to express vocal capacity by quantifying the dynamic performance and frequency range of voice range profiles (VRPs). For VEM calculation, the VRP area is multiplied by the quotient of the theoretical perimeter of a circle with equal VRP area and the actual VRP perimeter. Since different diseases affect voice function to varying degrees, pathology-related influences on the VEM should be investigated more detailed in this retrospective study, three years after VEM implementation. Data was obtained in a standardized voice assessment comprising videolaryngostroboscopy, voice handicap index (VHI-9i), and acoustic-aerodynamic analysis with automatic calculation of VEM and dysphonia severity index (DSI). The complete dataset comprised 1030 subjects, from which 994 adults (376 male, 618 female; 18-86 years) were analyzed more detailed. The VEM differed significantly between pathology subgroups (p<0.001) and correlated with the corresponding DSI values. Regarding VHI-9i, the VEM reflected the subjective impairment better than the DSI. We conclude that the VEM proved to be a comprehensible and easy-to-use interval-scaled parameter for objective VRP evaluation in all pathology subgroups. As expected, exclusive consideration of the measured pathology-related influences on the VEM does not allow conclusions regarding the specific underlying diagnosis

Evaluation of vardenafil for the treatment of subjective tinnitus: a controlled pilot study

<p>Abstract</p> <p>Background</p> <p>Vardenafil (Levitra^®) represents a potent and highly selective phosphodiesterase type 5 (PDE5) inhibitor, which is established for treatment of various diseases. There are several unpublished reports from patients stating that vardenafil has a considerable therapeutic effect on their concomitant tinnitus. This pilot study was conducted to specifically assess the effect of vardenafil in patients with chronic tinnitus.</p> <p>Methods</p> <p>This trial was based on a prospective, randomized, double-blind, placebo-controlled, parallel group design. Fourty-two consecutive subjects with mon- or binaural chronic tinnitus received 10 mg vardenafil (N = 21) or matching placebo tablets (N = 21) administered orally twice a day over a period of 12 weeks. Clinical examination and data acquisition took place at each visit: at baseline, after 4 weeks, after 12 weeks (end of treatment with study medication), and at non-medicated follow-up after 16 weeks. Assessment of clinical effectiveness was based on a standardized tinnitus questionnaire (TQ), the Short Form 36 health survey (SF-36), audiometric measurements (mode, pitch and loudness of tinnitus; auditory thresholds) and biomarkers of oxidative stress in patients' blood (malondialdehyde, protein carbonyl, homocysteine and total antioxidative status). Therapeutic efficacy was evaluated by comparison of subjective and objective parameters with baseline data between both treatment groups (ANCOVA).</p> <p>Results</p> <p>Vardenafil had no superior efficacy over placebo in the treatment of chronic tinnitus during this study. The primary efficacy criterion 'TQ total score' failed to demonstrate significant improvement compared to placebo. Subjective reports of TQ subscales and general quality of life areas (SF-36), objective audiometric examinations as well as investigated biomarkers for oxidative stress did not reveal any significant treatment effects. The safety profile was favorable and consistent with that in other vardenafil studies.</p> <p>Conclusion</p> <p>Although hypoxia and ischemia play a special role in the pathogenesis of tinnitus, the PDE5-inhibitor-induced increase of nitric oxide-mediated vasodilatation exerted no specific influence on tinnitus symptomatology. Considering the unclear risk of rarely associated hearing impairment, systemic application of vardenafil or other PDE5 inhibitors prove to be not appropriate for therapy of chronic tinnitus.</p

New options for diode laser application in the treatment of therapy-refractory otorhinologic diseases

In experimentell-labortechnischen und klinisch-praktischen Anwendungen wurden neue Optionen zum Einsatz des Diodenlasers in der Behandlung anderweitig therapie-resistenter bzw. -refraktärer oto-rhinologischer Erkrankungen untersucht. Im Alltag des HNO-Arztes haben in diesem Bereich insbesondere die rezidivierende Otitis media chronica cholesteatomatosa (Cholesteatom), die Rhinitis medicamentosa, die rezidivierende Polyposis nasi, die therapie- resistente allergische Rhinitis, und die chronische Dysfunktion der Tuba auditiva (Eustachii) eine besondere Bedeutung. Beim Cholesteatom erwiesen sich die eingesetzten Laser und Absorptionsverstärker als potentiell geeignete Instrumente einer lasergestützten Cholesteatom-Chirurgie. Die dargestellten Verfahren führten in vitro zu einer Zerstörung von bis zu 92% aller gefärbten und bestrahlten Cholesteatom-Zellen, während ungefärbte bestrahlte Zellen nicht beeinträchtigt wurden. Mit den verwendeten Antikörpern war jedoch aufgrund von Kreuzreaktionen mit Mukosazellen keine selektive Zellmarkierung zu erzielen. Für eine zukünftige Realisierbarkeit einer postoperativ durchgeführten, selektiven Laserbestrahlung residualer Cholesteatomzellen zur Senkung der Rezidivrate bleibt es weiterführenden Untersuchungen vorbehalten, das Chromophor an einen spezifischen Antikörper zu koppeln, der ausschließlich an ein charakteristisches Cholesteatom-Oberflächenantigen bindet. Bei Patienten mit therapie-refraktärer Rhinitis medicamentosa führte die Diodenlaser-basierte Reduktion der infolge Tachyphylaxie und „rebound“-Schwellung hyperplastischen unteren Nasenmuscheln zu einer langfristigen Besserung der nasalen Obstruktion. Dank der optimierten Nasenatmung konnte in der großen Mehrzahl der Fälle die psychophysische Abhängigkeit von abschwellenden Nasentopika („Privinismus“) durchbrochen und eine dauerhafte Heilung vom schleimhautschädigenden topischen Vasokonstriktiva-Abusus erreicht werden. Bei rezidivierender Polyposis nasi erwies sich die Diodenlaser-Polypektomie als hilfreich, die Hauptsymptome Nasenatmungsbehinderung und Dys-/Anosmie durch eine optimierte Ventilation bzw. die Freilegung der Polypen-verlegten Rima olfactoria deutlich zu verbessern. In Kombination mit einer hochdosierten, topischen Beclometason- Dipropionat-Anwendung resultierte bei den meisten Patienten eine langfristige Stabilisierung des Lokalbefundes. Neben einer Steigerung der Lebensqualität besteht dank der problemlosen minimal-invasiven Re-Applikationsmöglichkeit dieser Behandlungsoption die Aussicht, „große“ NNH-Eingriffe in Vollnarkose herauszuzögern bzw. zu reduzieren. Bei Patienten mit schwerer saisonaler und perennialer allergischer Rhinitis ließen sich mittels endonasal- laserchirurgischer Abtragung hyperplastischer Nasenmuscheln und obstruierender Septumpathologien alle typischen Allergie-assoziierten nasalen Symptome bessern, insbesondere Obstruktion und Rhinorrhoe. Risikoreiche Daueranwendungen von topischen Vasokonstriktiva und systemischen Kortikosteroiden können vermieden werden, da mit dieser Therapieoption bei insuffizienter oder kontraindizierter antiallergischer Standardtherapie ein guter Behandlungserfolg zu erzielen ist. Bei therapie-resistenter chronischer Tubendysfunktion mit gestörtem tympanalen Druckausgleich ermöglichte die Laserablation am epipharyngealen Tubenostium eine dauerhafte Verbesserung der Mittelohrventilation, der assoziierten otologischen Symptome sowie der Lebensqualität. Bei Patienten mit Trommelfellperforation konnte aufgrund der präoperativen Lasertuboplastie die Erfolgsrate hörverbessernder Tympanoplastiken gesteigert werden. Mittels Diodenlaser-assistiertem Tubenshaping lassen sich in vielen Fällen die kausalen Ursachen direkt an der Tuba auditiva, und nicht mehr nur die Folgen der sekundär resultierenden Mittelohrerkrankungen beheben. Der Diodenlaser erwies sich insgesamt als überaus geeignete, sichere und gut tolerierte Behandlungsoption bei den verschiedenen dargestellten, anderweitig therapie-resistenten bzw. -refraktären oto-rhinologischen Erkrankungen.New options for diode laser treatment of otherwise therapy-resistant or -refractory otorhinologic diseases were investigated in experimental laboratory settings and in clinical practice. In the everyday work of ENT physicians, recurrent cholesteatoma, rhinitis medicamentosa, recurrent nasal polyposis, therapy-resistant allergic rhinitis, and chronic Eustachian tube dysfunction are of particular importance within this area. In cholesteatoma, the applied lasers and absorption enhancers proved as potentially suitable instruments of a laser-assisted cholesteatoma surgery. The presented procedures resulted in vitro in a destruction of up to 92% of all stained and irradiated cholesteatoma cells, while unstained irradiated cells were not impaired. However, selective antibody-mediated staining was not achieved due to cross reactions with middle ear mucosa cells. To reduce cholesteatoma recurrence rate and to realize selective postoperative photodynamic therapy of residual cholesteatoma cells, the chromophore has to be coupled to a particular antibody that binds exclusively to an easily accessible specific cholesteatoma surface antigen. In patients with therapy-refractory rhinitis medicamentosa, the diode laser based reduction of hyperplastic inferior turbinates resulted in a long-term improvement of nasal obstruction. Due to the enhanced nasal airflow, the psycho-physical addiction to topical decongestants („privinism“) was broken in the large majority of patients followed by complete stop of drug abuse and sustained recovery of damaged nasal mucosa. In chronic rhinosinusitis with recurrent nasal polyposis, the diode laser polypectomy effectively improved the major clinical symptoms nasal obstruction and dys-/anosmia because of an optimized ventilation and reopened polyp-obstructed olfactory clefts. Combination with a high dosed, topical beclomethasone dipropionate aerosol spray application caused in most affected patients a long-lasting stabilization of the local endonasal condition. This minimally invasive, easily reapplicable treatment option increases the patients quality of life and seems to reduce or delay the need for major paranasal sinus surgery under general anaesthesia. In patients with severe seasonal and perennial allergic rhinitis, endonasal laser ablation of hypertrophic turbinates and obstructing septal pathologies resulted in improvement of all typical allergy-associated nasal symptoms, especially obstruction and rhinorrhea. Dangerous long-term application of topical decongestants and systemic corticosteroids can be avoided, especially in cases of insufficient or contraindicated antiallergic standard therapy. In therapy- resistant chronic tube dysfunction with disturbed equalization of middle ear pressure, laser ablation at the epipharyngeal dorsal ostium of the Eustachian tube realized a durable improvement of middle ear ventilation, associated otological symptoms, and quality of life. The success rate of tympanoplasties in patients with eardrum perforation was increased when a preoperative laser tuboplasty was performed. Diode laser assisted tubal shaping treats not only the consequences of secondarily resulting middle ear diseases, but enables causal treatment directly at the Eustachian tube. In summary, the diode laser proved to be a very suitable, safe and well-tolerated treatment option in the different investigated, otherwise therapy-resistant or -refractory otorhinologic diseases

Harnessing Machine Learning in Vocal Arts Medicine: A Random Forest Application for “Fach” Classification in Opera

Vocal arts medicine provides care and prevention strategies for professional voice disorders in performing artists. The issue of correct “Fach” determination depending on the presence of a lyric or dramatic voice structure is of crucial importance for opera singers, as chronic overuse often leads to vocal fold damage. To avoid phonomicrosurgery or prevent a premature career end, our aim is to offer singers an improved, objective fach counseling using digital sound analyses and machine learning procedures. For this purpose, a large database of 2004 sound samples from professional opera singers was compiled. Building on this dataset, we employed a classic ensemble learning method, namely the Random Forest algorithm, to construct an efficient fach classifier. This model was trained to learn from features embedded within the sound samples, subsequently enabling voice classification as either lyric or dramatic. As a result, the developed system can decide with an accuracy of about 80% in most examined voice types whether a sound sample has a lyric or dramatic character. To advance diagnostic tools and health in vocal arts medicine and singing voice pedagogy, further machine learning methods will be applied to find the best and most efficient classification method based on artificial intelligence approaches

T1a Glottic Cancer: Advances in Vocal Outcome Assessment after Transoral CO2-Laser Microsurgery Using the VEM

Patients with unilateral vocal fold cancer (T1a) have a favorable prognosis. In addition to the oncological results of CO2 transoral laser microsurgery (TOLMS), voice function is among the outcome measures. Previous early glottic cancer studies have reported voice function in patients grouped into combined T stages (Tis, T1, T2) and merged cordectomy types (lesser- vs. larger-extent cordectomies). Some authors have questioned the value of objective vocal parameters. Therefore, the purpose of this exploratory prospective study was to investigate TOLMS-associated oncological and vocal outcomes in 60 T1a patients, applying the ELS protocols for cordectomy classification and voice assessment. Pre- and postoperative voice function analysis included: Vocal Extent Measure (VEM), Dysphonia Severity Index (DSI), auditory-perceptual assessment (GRB), and 9-item Voice Handicap Index (VHI-9i). Altogether, 51 subjects (43 male, eight female, mean age 65 years) completed the study. The 5-year recurrence-free, overall, and disease-specific survival rates (Kaplan-Meier method) were 71.4%, 94.4%, and 100.0%. Voice function was preserved; the objective parameter VEM (64 ± 33 vs. 83 ± 31; mean ± SD) and subjective vocal measures (G: 1.9 ± 0.7 vs. 1.3 ± 0.7; VHI-9i: 18 ± 8 vs. 9 ± 9) even improved significantly (p < 0.001). The VEM best reflected self-perceived voice impairment. It represents a sensitive measure of voice function for quantification of vocal performance

T1a Glottic Cancer: Advances in Vocal Outcome Assessment after Transoral CO2-Laser Microsurgery Using the VEM

Patients with unilateral vocal fold cancer (T1a) have a favorable prognosis. In addition to the oncological results of CO2 transoral laser microsurgery (TOLMS), voice function is among the outcome measures. Previous early glottic cancer studies have reported voice function in patients grouped into combined T stages (Tis, T1, T2) and merged cordectomy types (lesser- vs. larger-extent cordectomies). Some authors have questioned the value of objective vocal parameters. Therefore, the purpose of this exploratory prospective study was to investigate TOLMS-associated oncological and vocal outcomes in 60 T1a patients, applying the ELS protocols for cordectomy classification and voice assessment. Pre- and postoperative voice function analysis included: Vocal Extent Measure (VEM), Dysphonia Severity Index (DSI), auditory-perceptual assessment (GRB), and 9-item Voice Handicap Index (VHI-9i). Altogether, 51 subjects (43 male, eight female, mean age 65 years) completed the study. The 5-year recurrence-free, overall, and disease-specific survival rates (Kaplan–Meier method) were 71.4%, 94.4%, and 100.0%. Voice function was preserved; the objective parameter VEM (64 ± 33 vs. 83 ± 31; mean ± SD) and subjective vocal measures (G: 1.9 ± 0.7 vs. 1.3 ± 0.7; VHI-9i: 18 ± 8 vs. 9 ± 9) even improved significantly (p &lt; 0.001). The VEM best reflected self-perceived voice impairment. It represents a sensitive measure of voice function for quantification of vocal performance

The Vocal Extent Measure: Development of a Novel Parameter in Voice Diagnostics and Initial Clinical Experience

Voice range profile (VRP) and evaluation using the dysphonia severity index (DSI) represent essentials of instrument-based objective voice diagnostics and are implemented in different standardized registration programs. The respective measurement results, however, show differences. The aim of the study was to prove these differences statistically and to develop a new parameter, the Vocal Extent Measure (VEM), which is not influenced by the measurement program. VRPs of 97 subjects were recorded by two examiners using the established registration programs DiVAS (XION medical) and LingWAVES (WEVOSYS) simultaneously. The VEM was developed on the basis of VRP area and perimeter. All 194 VRP files were analyzed for various parameters and gender independence. The registration programs exhibited significant differences in several vocal parameters. A significant gender influence for DSI was found with DiVAS (p<0.01), but not with LingWAVES. The VEM quantified the dynamic performance and frequency range by a unidimensional, interval-scaled value without unit, mostly between 0 and 120. This novel parameter represents an intelligible and user-friendly positive measure of vocal function, allows simple and stable VRP description, and seems to be suitable for quantification of vocal capacity. In contrast to DSI, the VEM proved to be less susceptible to registration program and gender