BACKGROUND Injury to the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy results in a lowered fundamental frequency of the voice and deteriorated voice performance in producing high-frequency sounds. It remains unclear if the use of intraoperative nerve monitoring (IONM) can improve the clinical outcome of thyroidectomy in terms of preserved individual voice performance. This study was designed to test that hypothesis. METHODS A total of 210 consenting female patients planned for total thyroidectomy were randomly assigned to two groups equal in size (n = 105): visual inspection of the EBSLN and RLN vs. this plus additional EBSLN and RLN monitoring. The primary outcome was the identification rate of the EBSLN. The secondary outcomes included: anatomical variability of the EBSLN according to the Cernea classification and changes in postoperative voice performance. Voice assessment included pre- and postoperative videostrobolaryngoscopy and an analysis of maximum phonation time (MPT), voice level (VL), fundamental frequency (Fo), and voice quality rating on the GRBAS scale. RESULTS The following differences were found for operations without vs. with IONM: identification rate of the EBSLN was 34.3 % vs. 83.8 %(p < 0.001), whereas a 10 % or higher decrease in phonation parameters was found in 10 % vs. 2 % patients for MPT (p = 0.018), 13 % vs. 2 % for VL (p = 0.003), and 9 % vs. 1 % for Fo (p = 0.03), a change in the GRBAS scale > 4 points in 7 % vs. 1 %(p = 0.03), and temporary RLN injury was found in 2 % vs. 1 %(p = 0.56), respectively. CONCLUSIONS The use of IONM significantly improved the identification rate of the EBSLN during thyroidectomy, as well as reduced the risk of early phonation changes after thyroidectomy.

OBJECTIVES/HYPOTHESIS The purpose of this study was to compare the agreement among several groups of listeners with different types of experience in regard to classifying voice quality. STUDY DESIGN This is a retrospective cross-sectional quasi-experimental design. METHOD This study compared three groups: speech-language pathologists who specialize in voice, singing voice teachers, and inexperienced listeners. All groups were asked to classify voice samples as breathy, rough, or normal. RESULTS Results show a significant difference across all groups with speech-language pathologists demonstrating a substantial interrater agreement, κ=0.67, z=103.07 (P<0.01); singing voice teachers demonstrating a moderate interrater agreement, κ=0.53, z=79.10 (P<0.01); and inexperienced listeners demonstrating a fair interrater agreement, κ=0.24, z=35.82 (P<0.01). CONCLUSIONS Experienced listeners demonstrated a higher interrater agreement as compared with inexperienced listeners, with speech-language pathologists demonstrating a superior agreement as compared with all groups.

OBJECTIVES/HYPOTHESIS This study investigates the effect of consensus training of listeners on intrarater and interrater reliability and agreement of perceptual voice analysis. The use of such training, including a reference voice sample, could be assumed to make the internal standards held in memory common and more robust, which is of great importance to reduce the variability of auditory perceptual ratings. STUDY DESIGN A prospective design with testing before and after training. METHODS Thirteen students of audiologopedics served as listening subjects. The ratings were made using a multidimensional protocol with four-point equal-appearing interval scales. The stimuli consisted of text reading by authentic dysphonic patients. The consensus training for each perceptual voice parameter included (1) definition,(2) underlying physiology,(3) presentation of carefully selected sound examples representing the parameter in three different grades followed by group discussions of perceived characteristics, and (4) practical exercises including imitation to make use of the listeners' proprioception. RESULTS Intrarater reliability and agreement showed a marked improvement for intermittent aphonia but not for vocal fry. Interrater reliability was high for most parameters before training with a slight increase after training. Interrater agreement showed marked increases for most voice quality parameters as a result of the training. CONCLUSION The results support the recommendation of specific consensus training, including use of a reference voice sample material, to calibrate, equalize, and stabilize the internal standards held in memory by the listeners.

PURPOSE To evaluate the utility of a pitch elevation task in the assessment of oropharyngeal dysphagia. METHOD This study was a pilot prospective cohort study including 40 consecutive patients (16 male and 24 female) who were referred by their physician for a swallowing evaluation. Patients were evaluated with a noninstrumental clinical examination and a videofluoroscopic swallow study, and participated in a pitch elevation task during videofluoroscopic image acquisition. Relationships between pitch elevation measurements (acoustic and perceptual) and swallow parameters (penetration/aspiration and residue) were investigated. RESULTS Results of this pilot study revealed that both maximum fundamental frequency (F(0)) and perceptual evaluation of pitch elevation independently significantly predicted Penetration-Aspiration Scale scores for thin liquid swallows (p =.01 and .03, respectively). Vocal range (average pitch to falsetto) was not sensitive in predicting likelihood of oropharyngeal dysphagia. CONCLUSIONS Findings indicate that reduced pitch elevation can be indicative of reduced airway protection and swallowing impairment in some dysphagia patients and may be a useful supplement to dysphagia screening and diagnosis. Further investigation is warranted to determine the optimal utility of this procedure for different diagnostic categories of patients.

Functional magnetic resonance imaging (fMRI) was used to investigate cortical activity related to differential control of the human phonatory system during a sentence production task. Our focus in this report was on activation of the temporo-parietal (TP) junctional region, suggested by recent models in speech production/perception to play a critical role between self-generated acoustic and associated somatosensory inputs related to the consequences of speech. Thirteen healthy participants produced multiple trials of phonetically balanced sentences during each of three performance conditions:"covert","whisper" and "voice". An event-related, sparse sampling fMRI method was used to examine TP activity associated with sentence production during each condition. Results demonstrated differential responsiveness in the TP region bilaterally as a function of task conditions, with covert production generating the highest level of TP activation. These results suggest that the TP region is differentially responsive to phonation-specific production variables. Our finding that covert production instead of overt voicing resulted in the greatest activity in TP is consistent with recent reports demonstrating TP activation related to temporal ordering judgments and task-dependent memory use.

PURPOSE To determine whether experienced and inexperienced listeners rate postthyroidectomy voice samples similarly using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). METHOD Prospective observational study of voice quality ratings of randomized and blinded voice samples was performed. Twenty-one postthyroidectomy patients' voices, representing a wide range of severities, were rated using a custom-automated version of the CAPE-V. Ten male and 11 female voices were rated by 10 experienced and 10 inexperienced listeners. Experienced listeners consisted of 5 otolaryngologists (ENTs) and 5 speech-language pathologists (SLPs); inexperienced listeners were medical professionals with no formal training or experience in voice disorders. RESULTS Inexperienced listeners rated voices as more severely impaired than experienced listeners for all CAPE-V parameters (p < or =.003). Those without experience in voice disorders had lower intra- and interrater reliability (e.g., r =.838 and .528, respectively, for overall severity) than those with experience in voice disorders (e.g., r =.911 and .722, respectively, for overall severity) for all parameters. Among experienced listeners, ENTs and SLPs rated voices similarly for most parameters. CONCLUSIONS Experienced and inexperienced listeners judged voice quality differently given minimal training with the use of the CAPE-V. SLPs and ENTs rated postthyroidectomy voice quality similarly. These findings indicate that the CAPE-V can be used reliably and similarly by professionals who specialize in voice disorders.

Procedures used for auditory-perceptual assessment of voice in the clinical setting often differ from those used in research settings. This study examined whether ratings made with the knowledge of a patient's identity and clinical status are consistent with those made under randomized and blinded laboratory conditions. Data derived from a prospective observational clinical trial were used in this mixed laboratory (blinded, randomized, anchored) and field (clinical) correlational study. Ninety-nine adults scheduled for thyroidectomy were evaluated by one of two speech-language pathologists (SLPs) using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) before and up to three times after surgery over a 6-month period. Subsequently, voice recordings were played over headphones in randomized order within speaker to three experienced SLPs, including the two who conducted clinical ratings. Listeners were blinded to speaker identity and recording session, and were provided with auditory anchors for "moderate" dysphonia. Each of the two SLPs who rated the speakers' voices clinically demonstrated moderately strong correlations with ratings of the same voices under laboratory conditions (r=0.807 and 0.708 for overall severity), but clinical ratings tended to be higher (more severe) than laboratory ratings particularly when dysphonia was moderate to severe. Intraclass correlations across the three SLPs for laboratory ratings were moderate (r=0.645 for overall severity). Correlations between clinical and the median of the three laboratory ratings across all sessions were moderate (r=0.526-0.792), with the strongest correlation for overall severity. Clinical bias may play a role in observed discrepancies between clinical and laboratory ratings of dysphonia. Additionally, auditory anchors available during laboratory procedures may contribute to these discrepancies. These findings highlight the need to standardize procedures for clinical voice assessment.

INTRODUCTION Comprehensive protocols of voice disorders have to consist of both subjective and objective tools to study vocal performance. Comparing subjective to objective measures is essential to determine their usefulness in assessing dysphonia. AIM The aim of the study is to study the correlation of objective voice measures and the patient's subjective self-rating assessment. SUBJECTS AND METHODOLOGY A total of 100 patients with voice complaints due to various pathological disorders were subjected to voice assessment protocol using: auditory perceptual assessment, acoustic voice assessment, aerodynamic measures, and Voice Problem Self-Assessment Scale (VPSS). RESULTS The results revealed a variable correlation between functional and emotional clusters of VPSS and overall grade of dysphonia. A moderate correlation between Dysphonia Severity Index (DSI) and VPSS total and emotional cluster was found. Acoustic parameters such as Shim (Shimmer Percent), APQ (Amplitude Perturbation Quotient), and NHR (Noise to Harmonic Ratio), in addition to MPT (Maximum Phonation Time), contributed to total VPSS and emotional cluster scores. The subglottic pressure was the only predictor variable for phonasthenic cluster scores. CONCLUSION This cross-sectional study highlights that patients' self-perception of a voice problem is related to their difficulty in sustaining controlled loudness and adequate glottic closure rather than in controlling frequency irregularity.

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.

OBJECTIVES: To examine the impact of voice on the quality of life of teachers and to assess whether the degree of dysphonia and otorhinolaryngologists'(ORL) diagnostics are correlated with the quality of life. METHODS: Eighty-eight female teachers from the municipal schools of Belo Horizonte who were in speech therapy at the Speech Therapy Clinic of the Hospital das Clínicas of Minas Gerais participated in the study. The variables studied were age, ORL diagnosis, perceptual-hearing assessment of voice through GRBAS scale, and vocal activities and participation profile (VAPP) protocol. Statistical analysis was performed through the descriptive analysis of the data and the Spearman coefficient of correlation. RESULTS: The average age of the participants was 38 years. Vocal deviation: degree 1-56 teachers (63.6%); degree 2-27 teachers (30.6%); and without vocal deviation-five teachers (5.6%). It was found that 57.9% of the teachers presented combined ORL diagnosis. No statistically significant relationship was observed among the ORL diagnosis, the degree of dysphonia, and the parameter values of quality of life assessed by VAPP. CONCLUSIONS: The examined participants of this study presented light degree of vocal deviation and ORL combined diagnosis. According to the figures obtained by VAPP, there was negative impact of voice on the quality of life of female teachers, but these impacts were not correlated with ORL diagnosis and grade of dysphonia.

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INTRODUCTION Vocal outcomes after medialization laryngoplasty are variable and may change over time. A revision procedure via open approach or an injection laryngoplasty may be necessary to improve vocal outcomes. METHODS A retrospective chart review was performed. RESULTS Twenty-nine subjects were identified and stratified into group 1A (n = 9) if the allograft was repositioned/replaced, group 1B (n = 4) if the allograft was removed, and group 2 (n = 16) if an injection laryngoplasty was performed. Statistically significant differences were found between all data prerevision to postrevision (P < or = 0.05) for group 1A and group 2 when multiple paired-sample t tests were calculated for patient-reported voice severity ratings and voice impact ratings as well as clinician-reported voice ratings of grade, roughness, and breathiness. Results of group 2 were often temporary, with 10 of 16 (62.5%) subjects receiving multiple injections. CONCLUSION Both open revision laryngoplasty and injection laryngoplasty are successful at providing improved vocal outcomes. Results are often temporary after injection laryngoplasty and often require multiple procedures.

OBJECTIVE The purpose of this study was to test the hypothesis that no significant difference exists in the speech outcomes between patients with severe velopharyngeal incompetence (VPI) who receive a pharyngeal flap and patients with less severe VPI who receive a Z-plasty for management of VPI. DESIGN This retrospective study from 1993 to 2002 included a review of pre- and postoperative perceptual speech and resonance assessments of patients with marginal VPI who received a Furlow double-opposing Z-plasty and patients with VPI who received a pharyngeal flap. SETTING All patients had surgical management of VPI at the Cleft Palate-Craniofacial Clinic at University of Iowa Hospitals and Clinics. RESULTS Both groups benefited from surgery with significant reduction in perceived hypernasality (p <.001). Comparison of postoperative assessments indicated no difference between the groups in hypernasality or hyponasality ratings. Neither group had a significant increase in hyponasality. CONCLUSION Both pharyngeal flap and double-opposing Z-plasty proved equally effective at reducing hypernasality when the selection of the surgical procedures was based on preoperative ratings of perceived hypernasality and evaluation of velopharyngeal physiology. Severity of the VPI is an important factor when considering surgical management of VPI. Thorough preoperative evaluations of patients with VPI are essential in appropriate treatment planning.

OBJECTIVE The objective of the study was to evaluate the results of autologous fat injection laryngoplasty in the long-term management of unilateral vocal cord paralysis. STUDY DESIGN A retrospective chart review and clinical voice re-evaluation of patients treated for unilateral vocal cord paralysis with autologous fat injection at the University of Iowa Hospitals and Clinics (Iowa City, IA) between May 1992 and September 1999. METHODS The data analyzed included patient demographics, early and long-term vocal outcomes, additional surgical treatments, and patient survival. RESULTS Fifty patients were treated with fat injection laryngoplasty, which included 44 treated for unilateral vocal cord paralysis. Thirty-one of the patients had fat injection as their primary procedure for permanent voice restoration. Eight patients treated had preoperative and postoperative voice data available. Using the GRBAS subjective voice assessment scale (0, normal; 3, severely abnormal), mean grade improved from 2.1 to 1.3 and breathiness improved from 1.4 to 0.5, at a mean period of 52 days. Thirteen of the 31 patients (41%) required additional procedures to achieve acceptable vocal outcomes. The median time to failure for these patients was 163 days. The initial treatment failure rate at 2 years was 30%, and the rate reached 45% by 4 years. CONCLUSION Although fat injection laryngoplasty reliably improves the voice over the short term, the long-term voice outcome is unpredictable. Additional surgeries to deal with subsequent vocal deterioration are common. The role of autologous fat injection laryngoplasty in the modern era is limited.

Objectives Determine the frequency of, the characteristics predictive of, and potential associated survival benefit from sentinel lymph node biopsy in a population of patients with desmoplastic melanoma of the head and neck. Study Design Analysis of a national database. Setting The 17-registry Surveillance, Epidemiology, and End Results (SEER) database. Subjects and Methods Using the SEER database, the authors identified patients diagnosed with cutaneous desmoplastic melanoma of the head and neck between 2003 and 2007. Nodal metastasis and impact of sentinel lymph node biopsy on survival were determined. Results The authors identified 467 cases of desmoplastic melanoma. Although most were locally advanced (median Breslow depth 3.5 mm), few had regional lymph node metastases (3.4%) or distant spread (3.2%) at the time of initial management. Of 165 patients who had sentinel lymph node biopsy, 5% had positive regional lymph nodes. Breslow depth, ulceration, age, and sex were not predictive of positive sentinel lymph node biopsy. Patients who had sentinel lymph node biopsy did not have different cause-specific survival from those who did not undergo sentinel lymph node biopsy. Conclusion Positive sentinel lymph node biopsies are rare in patients with desmoplastic melanoma of the head and neck. The low (5%) incidence of positive sentinel lymph node biopsy, coupled with the absence of identifiable survival benefit from its use, supports a more selective application of sentinel lymph node biopsy to this group of patients.

OBJECTIVES Recurrent infection from stones retained in Wharton's duct after submandibular gland resection warrants intraoperative attention to the duct remnant. Our hypothesis was that retrograde sialendoscopy would help ensure complete stone removal in submandibular gland removal for sialolithiasis. METHODS We reviewed 9 sequential cases of submandibular sialolithiasis treated surgically via open procedures at a tertiary care center by a single surgeon between November 2007 and December 2009. The review focused on the clinical history and intraoperative findings. RESULTS We identified successful application of a new technique of retrograde sialendoscopy performed to detect and remove stones that were retained in Wharton's duct at the time of submandibular gland resection. An index case of complications from a stone retained after submandibular gland resection is presented in a sequential series of cases in which retrograde sialendoscopy was developed. CONCLUSIONS Retrograde sialendoscopy is a novel technique that is useful as an adjunct to standard submandibular gland resection in the management of sialolithiasis.

Oromandibular dystonia (OMD) consists of prolonged spasms caused by contraction of the muscles of the mouth and mandible and involves the muscles of mastication, facial expression, tongue, and eye lids. A multidisciplinary treatment approach is presented including the fabrication of a dental prosthesis to reduce/eliminate the symptoms of OMD. Etiology and treatment issues are discussed, emphasizing the importance of an interdisciplinary treatment approach.

BACKGROUND This study examined risk factors for dysphagia, a common and serious condition in patients with head and neck cancer, and the association between severity of dysphagia and survival. METHODS Chart reviews were performed on patients diagnosed with head and neck cancer between January 2001 and April 2003, who had dysphagia diagnoses or swallowing evaluations. Regression analyses determined factors associated with dysphagia and the association between observed survival and severity of dysphagia. RESULTS Almost 50% of the 407 patients had dysphagia. Risk factors included advanced stage, older age, female sex, and hypopharyngeal tumors. The most severe dysphagia ([L.] nil per os or "nothing by mouth" status), which was associated with lower survival rates, was the strongest independent predictor of survival. CONCLUSIONS Swallowing problems should be considered when determining appropriate cancer-directed treatment and posttreatment care. Because of dysphagia's high incidence rate and association with survival, a speech-language pathologist should be involved to ensure routine diagnostic and therapeutic swallowing interventions. © 2011 Wiley Periodicals, Inc. Head Neck, 2011.

Tracheocutaneous fistulas may persist after tracheostomy. Suture closure of the fistula may result in complications, including infection, wound dehiscence, and pneumomediastinum. We present a simplified and relatively safe technique to close persistent fistulas that may be performed under local anesthesia. A retrospective chart review was performed on 13 patients who were successfully treated, including 1 with incomplete closure that was successfully addressed by additional procedures. Our review included analysis of reported risk factors for persistence of tracheocutaneous fistulas: previous irradiation of the neck, an extended duration of cannulation, previous tracheostomies, obesity, and use of a Bjork flap or 4-flap epithelial-lined tracheostomy. All 13 patients in the study were found to have at least 1 of these risk factors.

The presence of a palatal cleft at birth should not prevent good speech production in most children provided they have (1) appropriate surgical intervention to close the palate at or around the child's first birthday,(2) careful monitoring of speech development throughout childhood,(3) speech therapy when needed, and (4) secondary surgical or speech-prosthetic intervention when needed. When managed carefully by an experienced, well-prepared multidisciplinary team that applies the criteria listed above,~70% of children with nonsyndromic palatal clefts will have no significant difficulties with speech intelligibility or speech quality due to velopharyngeal insufficiency by the time they enter elementary school. Speech assessment is the first step toward comprehensive team management of children with cleft palate. The purpose of this chapter is to describe the use of instrumentation in the evaluation of speech of children with palatal clefts, within the context of a multidisciplinary team. The focus of this article is on instruments that are used to supplement the perceptual assessment to document current speech status and plan management strategies.

Abstract The study investigated the effect of immediate feedback in training listeners to perceive subtle differences in voice quality, a perceptual skill that is important for speech-language pathologists. Sixty naive listeners were randomly assigned to a feedback group (Group F), a no feedback group (Group NF), and a no training group acting as a control group (Group C). The task was to evaluate the severity of a perceptual voice quality (breathiness) by using a reference-matching paradigm. All participants took part in three rating sessions (pre-training, 2 days after training and 1 week after training). Group F and Group NF participated in a training session immediately after the first rating session, where Group F practiced with immediate feedback given and Group NF practice with no immediate feedback given. The results showed that Group F and Group NF had significant improvement after training, but Group F did not retain the improvement in the third rating session. The use of a reference-matching training paradigm without giving frequent immediate feedback is suggested for auditory-perceptual voice evaluation training. The most effective frequency of immediate feedback is yet to be determined.

OBJECTIVES/HYPOTHESIS: Instrumental measures of voice allow practitioners to assess the severity of voice disorders and objectively measure treatment outcomes. Instrumental measures should be calculated on both sustained vowel and connected speech samples to ensure ecological validity. However, there is a lack of appropriate, validated acoustic measurements for use in the pediatric population. The Acoustic Voice Quality Index (AVQI) is a multivariate acoustic measure of dysphonia that has been found to be reliable, valid, and have diagnostic accuracy and response to change in an adult population. This study aimed to evaluate the AVQI in a pediatric population. STUDY DESIGN: This study was a prospective observational study of a sample of dysphonic and normophonic children. METHODS: Sixty-seven preterm participants (born at less than 25 weeks gestation) aged between 6 and 15 years were recruited. Participants were excluded because of either inability to comply with task requirements or other speech-related factors that affected acoustic measurement. Forty normophonic term-born participants aged between 5 and 15 years were also recruited. AVQI analysis was conducted on a prolonged vowel sample and a sample of continuous speech. RESULTS: The AVQI was found to have diagnostic accuracy and specificity in this population of children with and without dysphonia. It was moderately correlated with ratings of severity on the GRBAS (overall grade of hoarseness (G), roughness (R), breathiness (B), aesthenicity (A), and strain (S)), a subjective rating scale. The threshold for pathology of this sample of 3.46 showed strong sensitivity, specificity, and accuracy, with good-to-excellent likelihood ratios. CONCLUSIONS: This study found that the AVQI has diagnostic accuracy in a pediatric population, suggesting that it is an appropriate assessment tool to determine the presence and severity of pediatric voice disorders.

BACKGROUND The term 'speech usage' refers to what people want or need to do with their speech to fulfil the communication demands in their life roles. Speech-language pathologists (SLPs) need to know about clients' speech usage to plan appropriate interventions to meet their life participation goals. The Levels of Speech Usage is a categorical scale intended for client self-report of speech usage, but SLPs may want the option to use it as a proxy-report tool. The relationship between self-report and clinician ratings should be examined before the instrument is used in a proxy format. AIMS The primary purpose of this study was to compare client self-ratings with SLP ratings on the Levels of Speech Usage scale. The secondary purpose was to determine if the SLP ratings differed depending on whether or not the SLPs knew about the clients' medical condition. METHODS & PROCEDURES Self-ratings of adults with communication disorders on the Levels of Speech Usage scale were available from prior research. Vignettes about these individuals were created from existing data. Two sets of vignettes were created. One set contained information about demographic information, living situation, occupational status and hobbies or social activities. The second set was identical to the first with the addition of information about the clients' medical conditions and communication disorders. Various communication disorders were represented including dysarthria, voice disorders, laryngectomy, and mild cognitive and language disorders. Sixty SLPs were randomly divided into two groups with each group rating one set of vignettes. The task was completed online. While this does not replicate typical in-person clinical interactions, it was a feasible method for this study. For data analysis, the client self-ratings were considered fixed points and the percentage of SLP ratings in agreement with the self-ratings was calculated. OUTCOMES & RESULTS The percentage of SLP ratings in exact agreement with client self-ratings was 44.9%. Agreement was lowest for the less-demanding speech usage categories and highest for the most demanding usage category. There was no significant difference between the two groups of SLPs based on knowledge of medical condition. CONCLUSIONS & IMPLICATIONS SLPs often need to document the speech usage levels of clients. This study suggests the potential for SLPs to misjudge how clients see their own speech demands. Further research is needed to determine if similar results would be found in actual clinical interactions. Until then, SLPs should seek the input of their clients when using this instrument.

PURPOSE To analyze the impact of auditory training for auditory-perceptual assessment carried out by Speech-Language Pathology undergraduate students. METHODS During two semesters, 17 undergraduate students enrolled in theoretical subjects regarding phonation (Phonation/Phonation Disorders) analyzed samples of altered and unaltered voices (selected for this purpose), using the GRBAS scale. All subjects received auditory training during nine 15-minute meetings. In each meeting, a different parameter was presented using the different voices sample, with predominance of the trained aspect in each session. Sample assessment using the scale was carried out before and after training, and in other four opportunities throughout the meetings. Students' assessments were compared to an assessment carried out by three voice-experts speech-language pathologists who were the judges. To verify training effectiveness, the Friedman's test and the Kappa index were used. RESULTS The rate of correct answers in the pre-training was considered between regular and good. It was observed maintenance of the number of correct answers throughout assessments, for most of the scale parameters. In the post-training moment, the students showed improvements in the analysis of asthenia, a parameter that was emphasized during training after the students reported difficulties analyzing it. There was a decrease in the number of correct answers for the roughness parameter after it was approached segmented into hoarseness and harshness, and observed in association with different diagnoses and acoustic parameters. CONCLUSION Auditory training enhances students' initial abilities to perform the evaluation, aside from guiding adjustments in the dynamics of the university subject.

The purpose of this study was to investigate the effect of the Global Voice Therapy Model (GVTM) on acoustic, aerodynamic, and perceptual voice measures of four adults seeking voice therapy for a voice disorder. A speech-language pathologist facilitated speaking voice therapy with the four participants using the GVTM. Participants completed acoustic, aerodynamic, and perceptual voice measures at pre- and post-therapy time points. Differences were seen in the voice measures from pre- to post-therapy. The GVTM was successful in facilitating an improvement in the acoustic, aerodynamic, and perceptual measures of the participants.

PURPOSE: Perceptual estimates of voice quality obtained using rating scales are subject to contextual biases that influence how individuals assign numbers to estimate the magnitude of vocal quality. Since rating scales are commonly used in clinical settings, assessments of voice quality are also subject to the limitations of these scales. Instead, a matching task can be used to obtain objective measures of voice quality, thereby facilitating model development and tools for clinical use. Methods Twenty-seven individuals participated in a rating task or at least one of three matching tests (named after their modulation functions: SINE, SQUARE, POWER) to quantify the degree of roughness in dysphonic voice stimuli. Participants evaluated the roughness of 34 voice samples using an amplitude-modulated complex carrier. RESULTS: The matching thresholds were highly correlated with the ratings estimates. Reliability of thresholds did not significantly differ across tasks, but linear regressions showed that the POWER test resulted in larger perceptual distances. CONCLUSIONS: A matching task can be used to obtain reliable estimates of roughness in dysphonic voices. The POWER comparison is recommended since the variability in matching thresholds across the range of roughness was evenly distributed, and the perceptual distances between stimuli were maximized.

OBJECTIVES: Perceptual judgments and patients' perception of voice and speech after concurrent chemoradiotherapy (CCRT) for advanced head and neck cancer. STUDY DESIGN: Prospective clinical trial. METHODS: A standard Dutch text and a diadochokinetic task were recorded. Expert listeners rated voice and speech quality (based on Grade, Roughness, Breathiness, Asthenia, and Strain), articulation (overall,[p],[t],[k]), and comparative mean opinion scores of voice and speech at three assessment points calculated. A structured study-specific questionnaire evaluated patients' perception pretreatment (N=55), at 10-week (N=49) and 1-year posttreatment (N=37). RESULTS: At 10 weeks, perceptual voice quality is significantly affected. The parameters overall voice quality (mean,-0.24; P=0.008), strain (mean,-0.12; P=0.012), nasality (mean,-0.08; P=0.009), roughness (mean,-0.22; P=0.001), and pitch (mean,-0.03; P=0.041) improved over time but not beyond baseline levels, except for asthenia at 1-year posttreatment (voice is less asthenic than at baseline; mean,+0.20; P=0.03). Perceptual analyses of articulation showed no significant differences. Patients judge their voice quality as good (score, 18/20) at all assessment points, but at 1-year posttreatment, most of them (70%) judge their "voice not as it used to be." In the 1-year versus 10-week posttreatment comparison, the larynx-hypopharynx tumor group was more strained, whereas nonlarynx tumor voices were judged less strained (mean,-0.33 and +0.07, respectively; P=0.031). Patients' perceived changes in voice and speech quality at 10-week post- versus pretreatment correlate weakly with expert judgments. CONCLUSION: Overall, perceptual CCRT effects on voice and speech seem to peak at 10-week posttreatment but level off at 1-year posttreatment. However, at that assessment point, most patients still perceive their voice as different from baseline.

AIMS: Perceptual rating of voice quality is a key component in the comprehensive assessment of voice, but there are practical difficulties in making reliable measurements. We have developed the Newcastle Audio Ranking (NeAR) test, a new referential system for the rating of voice parameters. In this article, we present our first results using NeAR. METHODS: We asked five experts and 11 naive raters to assess 15 male and 15 female voices using the NeAR test. We assessed: validity with respect to the GRBAS scale; interrater reliability; sensitivity to subtle voice differences; and the performance of expert versus naïve raters. RESULTS: There was a uniformly excellent agreement with GRBAS (r=0.87) and interrater agreement (intraclass correlation coefficient=0.86). Considering each GRBAS grade of voice separately, there was still good interrater agreement in NeAR, implying it has good sensitivity to subtle changes. All these results were equally true for expert and naive raters. CONCLUSION: The NeAR test is a promising new tool in the assessment of voice disorders.

INTRODUCTION: Perceptual evaluation of voice quality remains a key standard for judgment of vocal impairment. The GRABS method has become a commonly-used scale for rating severity of dysphonia, but it has no published, standardised protocol to follow. Training is important for reaching good interrater agreement for its parameters; however, the references most often cited for the GRABS provide no guidelines for clinical administration, speech material or rating calibration. This study investigated the effect of anchors (standard reference voices) and visible speech (narrow band spectrogram) in training non-expert professionals in the GRABS method. MATERIAL & METHODS: Four inexperienced listeners evaluated 107 recorded pathological voices using the GRABS scale in 2 separate sessions; at first, without a visible spectrogram and then, 6 months later, with anchors and a narrow band spectrogram as additional information. RESULTS: The results show that anchors and visible speech helped to improve the reliability of G, B, A and S parameters. Interrater agreement according to k statistics was significantly stronger with the addition of spectrographic information for rating breathiness and strain. DISCUSSION: This study found that non-expert listeners showed significant improvement after training with external anchors (standard reference voices) and a narrow band spectrogram.

OBJECTIVES/HYPOTHESIS This study investigates the effect of consensus training of listeners on intrarater and interrater reliability and agreement of perceptual voice analysis. The use of such training, including a reference voice sample, could be assumed to make the internal standards held in memory common and more robust, which is of great importance to reduce the variability of auditory perceptual ratings. STUDY DESIGN A prospective design with testing before and after training. METHODS Thirteen students of audiologopedics served as listening subjects. The ratings were made using a multidimensional protocol with four-point equal-appearing interval scales. The stimuli consisted of text reading by authentic dysphonic patients. The consensus training for each perceptual voice parameter included (1) definition,(2) underlying physiology,(3) presentation of carefully selected sound examples representing the parameter in three different grades followed by group discussions of perceived characteristics, and (4) practical exercises including imitation to make use of the listeners' proprioception. RESULTS Intrarater reliability and agreement showed a marked improvement for intermittent aphonia but not for vocal fry. Interrater reliability was high for most parameters before training with a slight increase after training. Interrater agreement showed marked increases for most voice quality parameters as a result of the training. CONCLUSION The results support the recommendation of specific consensus training, including use of a reference voice sample material, to calibrate, equalize, and stabilize the internal standards held in memory by the listeners.