嗓音训练治疗声门闭合不全所致功能性嗓音障碍的疗效分析

目的探讨嗓音训练对声门闭合不全的功能性嗓音障碍患者的疗效。方法对24例声门闭合不全的功能性嗓音障碍患者进行8周的嗓音训练,训练内容包括健康宣教、肌肉放松、喉部按摩、暖嗓、呼吸训练、嗓音训练和共鸣训练,训练前后对患者进行电子喉镜检查、GRBAS评估、嗓音障碍指数量表（VHI）评估、计算机嗓音声学分析,比较训练前后评估结果。结果24例患者训练后电子喉镜检查16例患者声门闭合良好（66.67%,16/24）,6例声门裂隙变小（25.00%,6/24）,2例声门裂隙无明显变化（8.33%,2/24）;GRBAS评分中总嘶哑度G(0.61±0.66)明显低于训练前(1.91±0.87)（P<0.05）,粗糙声Ｒ(0.51±0.58)明显低于训练前(1.41±0.52)（P<0.05）;VHI评分总分(29.21±21.02)分明显低于训练前的(52.35±23.45)分（P<0.05）;计算机嗓音声学分析最长发声时间（15.24±3.64）s比训练前（9.02±3.45）s明显延长（P<0.05）,基频微扰、最高基频、最低音强、嗓音障碍严重指数训练后分别为（0.21±0.08）%、（420.11±44.21）Hz、（54.21±3.20）dB、（1.62±0.82）比训练前的（0.92±0.12）%、（375.21±49.21）Hz、（56.81±3.42）dB、（0.21±1.02）有改善（P<0.05）。结论嗓音训练能改善声门闭合不全的功能性嗓音障碍患者的声门闭合及嗓音质量。     

几种嗓音疾病的声学分析和听感知分级的评价

目的评价嗓音声学分析和主观听感知评估对几种嗓音疾病测试的客观性及科学性。方法①研究对象：嗓音障碍患者72例,正常对照组30例。②主观听感知评估：采用日本言语语音协会的声音嘶哑评估标准GRBAS系统中的总嘶哑度G、粗糙声R、气息声B主观评估受试者的嗓音质量。③嗓音的客观检测：以/e/音作声样,进行嗓音声学和电声门图测试。结果随声嘶程度加重,反映声带振动的稳定性的基频微扰（jitter）、振幅微扰（shimmer）、电声门图-基频微扰（E-jitter）、电声门图-振幅微扰（E-shimmer）增大;反映声门闭合程度的标准化噪声能量（NNE）、电声门图-标准化噪声能量（E-NNE）,接触商微扰（CQP）增大;谐噪比（HNR）减小。嗓音客观参数在主观听感知评估分析患者间的差异有显著统计学意义（P〈0.05）,能区分出不同的嗓音障碍组,但在不同的疾病组间缺乏特异性。结论本实验中所选客观参数可客观评价嗓音疾病,为临床治疗提供依据。     

第二届嗓音医学研讨班圆满结束

由解放军总医院耳鼻咽喉一头颈外科主办的第二届嗓音医学研讨班于2005年9月8日-10日在总医院耳研究所举办。研讨班邀请了国内嗓音医学领域的知名专家及学者。授课内容涵盖嗓音医学的基础与临床，主要内容有：我国嗓音医学的现状与展望，发声的解剖与生理基础，艺术嗓音，嗓音障碍的检查，嗓音疾病及嗓音障碍的评估，声门闭合不良的治疗，喉肌电图的临床应用，喉支架外科，声带麻痹的外科治疗，嗓音显微外科手术及手术录像，喉癌功能外科手术，全喉切除术后食管发声训练，咽音训练与嗓音矫治。     

声带小结者嗓音分析和电声门图参数变化的比较

目的比较分析声带小结者嗓音参数和电声门图（EGG）参数的变化，评价这些参数在该病的诊断和疗效观察中的意义。方法采用Dr．SpeechScienceforWindows软件对42例未经手术的声带小给患者作嗓音分析和EGG检测，对其主要声学参数变化进行比较，并对声带小结的EGG波形作了观察。结果在声带小结的诊断中，两种方法中的声学参数基音频率微扰（jitter）和基音振幅微扰（shimmer）均是有价值的，二者可以相互替代。EGG的标准声门噪声能量（NNE）特异性高，嗓音分析中的NNE则敏感性高。结论EGG中声门波的特征结合嗓音分析及EGG的jitter和shimmer值对声带小结的诊断和疗效观察有较大的意义。     

早期嗓音训练对改善甲状腺术后声带麻痹患者嗓音质量的疗效观察

目的　探讨早期发声训练对改善甲状腺术后声带麻痹患者嗓音质量的效果。方法 选取西安交通大学第一附属医院耳鼻咽喉头颈外科甲状腺术后声带麻痹的48例患者为研究对象,随机分为实验组及对照组（各24例）。实验组自术后1周开始进行系统嗓音训练,对照组不进行干预。对两组术后1周、12周及24周的嗓音主客观评估及频闪喉镜评估数据进行对比分析。结果　术后12周,实验组嗓音障碍指数、听感知评估评分中气息声、无力感评分、基频微扰、振幅微扰、最长发声时间及声门闭合程度均与对照组有显著性差异（P 均<0.05）。术后24周实验组嗓音障碍指数、最长发声时间仍优于对照组（P 均<0.05）,其余所有指标两组比较均无显著性差异（P 均>0.05）。结论　早期嗓音训练可改善声带麻痹患者的嗓音质量。     

喉部按摩法治疗功能性嗓音障碍的临床研究

目的探讨喉部按摩法在功能性嗓音障碍治疗中的意义。方法对33名功能性嗓音障碍患者进行喉部按摩治疗,比较分析其治疗前后平均言语基频（MSFF）、基频标准差（SD）,基频微扰（Jitter）．振幅微扰（shimmer）、标准化噪声能量（NNE）5个参数的变化和症状改善情况。结果治疗后患者的平均言语基频,基频标准差、基频微扰．振幅微扰与治疗前相比均有极显著性差异（P〈0．01）。并达到正常值范围;而标准化噪声能量与治疗前相比无显著性差异（P〉O．05）。结论喉部按摩法对大多数功能性嗓音障碍有较好疗效;嗓音治疗中应将现代化的客观测量技术与传统治疗手段相结合。     

音质障碍测量与治疗的个案研究

目的通过嗓音音质治疗的个案研究,验证音质参数在嗓音测量中的临床评估与监控作用。方法测试者为1名音质障碍患儿,男性,2000年6月出生,采用“喉功能检测仪”对嗓音音质进行实时评估;嗓音治疗为期3个月,每周两次,将音质评估(Jitter,Shimmer,NNE等)贯穿于整个矫治过程中,并采用单一被试法进行统计分析;结果嗓音治疗前后的数据比较发现:Jitter,Shimmer,NNE均存在显著性差异(P<0.05);而嗓音F0无明显差异(P>0.05)。结论①音质评估在嗓音治疗过程中起着非常重要的作用,其中Jitter,Shimmer,NNE被证明是衡量嗓音音质的3个有效参数;②患儿接受的嗓音矫治方法是有效的。     

电声门图参数与声嘶的心理听觉评价的相关关系研究

目的 研究电声门图参数与声嘶程度心理听觉评价之间的关系。方法 对134例受试者进行电声门图(EGG)检查,按心理听觉评估结果,根据GRBAS分级,将36例正常人及98例病理嗓音患者分成四组,对各组的电声门图参数及其与声嘶程度的关系进行统计学处理。结果 各组EGG参数均有显著性差异,标准化噪声能量(NNE)与接触率(CQ)是判别声嘶程度最有意义的两个参数,5个参数(jittter,shimmer,NNE,CQ,CQP)均与声嘶程度心理听觉评价有良好的相关关系,且频率微扰与粗糙声(R),NNE、CQ与气息声(B)相关性较好。结论 电声门图作为一种反映声带振动模式的方法,它和心理听觉评价声嘶的分级和程度有显著相关性,两者皆为临床应用提供诊断依据,但前者更为客观精确。     

早期喉癌等离子消融术后的嗓音评价

目的　评价经支撑喉镜等离子消融术治疗的早期声门型喉癌术后嗓音的康复情况。方法　2014年1月~2016年9月在我院就诊的42例早期声门型喉癌患者,经支 撑喉镜内镜辅助下行喉部肿瘤等离子消融切除术,手术前及术后3、6、9及12个月应用嗓音障碍指数VHI-10、RBH听感知评估及Praat嗓音分析对患者嗓音进行主客观评估。结果　所有患者随访12个月以上,嗓音评估显示术后3个月嗓音质量明显下降,6个月后逐渐好转,9~12个月后,除气息声和基频以外其他嗓音评估参数均较术前提高（P 均<0.05）。其中T1a级患者术后嗓音客观参数均较T1b及T2级恢复更好（P 均<0.05）。结论　经支撑喉镜等离子消融切除术治疗早期喉癌术后嗓音功能恢复较好。     

嗓音声学分析和电声门图的比较研究

目的比较嗓音声学分析和电声门图在嗓音障碍客观评估中的意义。方法声样采自153例嗓音障碍患者和80名嗓音正常者。客观检测采用Dr．Speech for Windows嗓音评估软件，在长元音／α：／上检测下列参数：基频(Fo)、基频微扰(jitter)、振幅微扰(shimlner)、基频标准差(FoSD)、基频震颤、振幅震颤、最大基频、最小基频、标准化噪声能量(NNE)、谐噪比(HNR)和信噪比(SNR)。主观听感知评估参数采用日本言语语音学会声音嘶哑评估GRBAS系统中的总嘶哑度，4级评估标准。结果除基频震颤和振幅震颤外，声学分析的基频微扰、振幅微扰、基频标准差、标准化噪声能量、谐噪比和信噪比的可靠性和敏感性高于电声门图。两种测试方法的基频、最大基频和最小基频基本一致。结论嗓音障碍的客观评估应选择声学分析参数。     

Functional results after external vocal fold medialization thyroplasty with the titanium vocal fold medialization implant

OBJECTIVES/HYPOTHESIS: A persistent insufficiency of glottal closure is mostly a consequence of a unilateral vocal fold movement impairment. It can also be caused by vocal fold atrophy or scarring processes with regular bilateral respiratory vocal fold function. Because of consequential voice, breathing, and swallowing impairments, a functional surgical treatment is required. The goal of the study was to outline the functional results after medialization thyroplasty with the titanium vocal fold medialization implant according to Friedrich. METHODS: In the period of 1999 to 2001, an external vocal fold medialization using the titanium implant was performed on 28 patients (12 women and 16 men). The patients were in the age range of 19 to 84 years. Twenty-two patients had a paralysis of the left-side vocal fold, and six patients, of the right-side vocal fold. Detailed functional examinations were executed on all patients before and after the surgery: perceptive voice sound analysis according to the "roughness, breathiness, and hoarseness" method, judgment of the s/z ratio and voice dysfunction index, voice range profile measurements, videostroboscopy, and pulmonary function tests. In case of dysphagia/aspiration, videofluoroscopy of swallowing was also performed. The respective data were statistically analyzed (paired t test, Wilcoxon-test). RESULTS: All patients reported on improvement of voice, swallowing, and breathing functions postoperatively. Videostroboscopy revealed an almost complete glottal closure after surgery in all of the patients. All voice-related parameters showed a significant improvement. An increase of the laryngeal resistance by the medialization procedure could be excluded by analysis of the pulmonary function test. CONCLUSIONS: The results confirm the external medialization of the vocal folds as an adequate method in the therapy of voice, swallowing, and breathing impairment attributable to an insufficient glottal closure. The titanium implant offers, apart from good tissue tolerability, the advantage of an easy, time-saving, and individually adjustable application during the operation.     

Functional outcome of vocal fold medialization thyroplasty with a hydroxyapatite implant

OBJECTIVES: Unilateral vocal fold paralysis can cause a persistent incomplete glottal closure during phonation, resulting in impaired voice function. The aim of this study was to evaluate functional results of medialization thyroplasty using a hydroxyapatite implant (VoCoM). STUDY DESIGN: Prospective observational cohort study. METHODS: Between 1999 and 2003, a total of 26 patients (19 men, 7 women) undergoing medialization thyroplasty using a hydroxyapatite implant because of unilateral vocal fold paralysis were enrolled in the study. To evaluate voice function, the following parameters were measured preoperatively and postoperatively: mean fundamental frequency, mean sound pressure level, frequency and amplitude range (voice range profile), and maximum phonation time. A perceptual assessment of hoarseness was conducted using the Roughness, Breathiness, Hoarseness scale. Furthermore, the magnitude of voice related impairment of the patient's communication skills was rated on a 7-point scale. A combined parameter called the Voice Dysfunction Index (VDI) was used to rate vocal performance. RESULTS: All patients showed a statistically significant improvement in the VDI, in perceptual voice analysis, in maximum phonation time, and in the dynamic range of voice. One patient experienced a postoperative wound hemorrhage as a minor complication. No further complications or implant extrusions were observed. CONCLUSIONS: Medialization thyroplasty using a hydroxyapatite implant is a secure and efficient phonosurgical procedure. Voice quality and patient satisfaction improve significantly after treatment.     

喉内窥镜计算机图像处理系统的临床应用价值

目的 :评价喉内窥镜计算机图像处理系统在诊断喉部疾病时所起的作用。方法 :对 10 0例初诊为喉病患者进行定量的频闪喉镜、声学和电声门图同步测试 ,即通过喉内窥镜计算机图像处理系统获得的定量数据。结果 :该图像处理系统改变了 14例的初诊意见 ,使其中 6例避免了手术 ,8例从初诊决定行嗓音和药物治疗改为手术治疗。结论 :在常规的喉内窥镜检查中 ,将声学和电声门图测试相结合可获得具有实质性诊断价值的补充资料。     

Factors predicting patient perception of dysphonia caused by benign vocal fold lesions

OBJECTIVES/HYPOTHESIS: To assess factors that may be predictive of patient perception of dysphonia severity, as quantified by the Voice Handicap Index (VHI) score. We hypothesize that 1) level of vocal demand; 2) auditory-perceptual evaluation of dysphonia severity; and 3) vocal function, as defined by phonatory glottal closure and mucosal wave vibration, are the most significant predictors of VHI score. STUDY DESIGN:: Retrospective review of 100 patients with benign vocal fold lesions. METHODS: Variables assessed for predictive value to VHI score are level of vocal demands, auditory-perceptual evaluation of dysphonia severity, integrity of mucosal wave vibration and phonatory glottal closure, lesion type, duration of current complaint, smoking, age, and sex. Harmonic to noise ratio was assessed in a subset of 50 patients. RESULTS: Patients with routine voice use had significantly lower VHI scores than those with more intensive (nonsinging/acting) vocal demands. Patients who quit smoking had greater VHI scores than those who currently smoke or never started. Patients with long-standing dysphonia tended to have lower VHI scores than those with shorter duration vocal complaints. Auditory-perceptual assessment of dysphonia severity and harmonic to noise ratio were weak predictors of VHI score. Age, sex, lesion type, phonatory glottal closure, and mucosal wave vibration were not significant predictors of VHI score. CONCLUSIONS: Patient perception of dysphonia severity is independent of many factors commonly assessed during the evaluation of voice disorders. It appears to be an important independent element in the assessment of the effect of a benign vocal fold lesion and critical to therapeutic decision-making.     

Long term outcome of psychogenic voice disorders

Objectives

To evaluate different therapy for psychogenic voice disorders.

Methods

Epidemiological data, organic and psychological symptoms, therapeutic options and outcome were prospectively analyzed in 40 consecutive patients with psychogenic voice disorders. Their voice was evaluated by subjective means and self assessment (voice handicap index) and an organic or functional disorder was excluded by videolaryngostroboscopy. Additionally, a detailed psychological examination and exploration were made. Every patient received intensive voice exercises with biofeedback by a phoniatrician and counseling by a clinical psychologist. Following this, therapy options of psychotherapy or a combination of psychotherapy and voice therapy were given. After an interval (average 16 months) from first contacting our section, every patient was asked to complete a questionnaire about their therapies and quality of voice.

Results

Patients had previously received insufficient voice therapy or antibiotics. The psychological examination detected psychological disorders as a basic problem. Overall, in 70% of patients there was either an improvement or resolution of voice problems. For all patients psychotherapy or a combination of voice therapy and psychotherapy was recommended, but only accepted in 37.5%. In all cases, when psychotherapy in combination with speech therapy took place, it was successful, whereas speech therapy alone provided improvement only in 12.5%.

Conclusion

Psychogenic voice disorders are often misdiagnosed, leading to inadequate therapy. Psychotherapy (often in combination with voice therapy) was most effective also in the long term, but is often not accepted by patients. Voice therapy alone had a poor success rate.     

Differential diagnosis and treatment of psychogenic voice disorder

Forty consecutive patients with psychogenic voice disorder were studied prospectively to shed light on some problems of differential diagnosis met by the otolaryngologist. The females (n = 35) were on average younger than males (n = 5) (mean age 34.5 vs 51.8 years, respectively). Although an upper respiratory tract infection preceding the voice disorder was reported by no more than 25% of the patients, as many as 40% had been treated with antibiotics on one or more occasions. Other treatment and voice rest had been prescribed to a further 20% of the patients. The frequency rate of reported asthma/allergy-like symptoms (37.5) exceeded the incidence of asthma/allergy in the normal Swedish adult population. Minor laryngeal abnormalities found in 10 patients could be rejected as causative since they were inconsistent with the voice disturbance. In most of the patients (n = 27), vocal function returned to normal or improved after voice therapy combined with counselling. Vocal abnormalities remained unchanged in three patients. The patients who required multiple therapy sessions (n = 10) were older (mean age 48.8 years) and seemed to have more profound personal problems than the average. The findings suggest that psychogenic voice disorder may often be misdiagnosed as acute laryngitis or asthma/allergy. Restricted use of antibiotics and other drugs is to be recommended in the treatment of benign voice disorders.     

Quantitative Analysis of Videostroboscopic Images in Presbylarynges

Objective/Hypothesis Age‐related dysphonia, or presbylarynges, is often identified as the cause of voice disorders in older individuals. It is a diagnosis of exclusion that typically includes the subjective videostroboscopic findings of vocal fold bowing or atrophy and incomplete glottal closure. We hypothesize that vocal fold bowing correlates directly with glottal gap in patients with presbylarynges and that these characteristics may be quantified objectively using measures obtained from videostroboscopic images. Study Design Retrospective analysis of patient data and prospective analysis of control subjects. Methods The quantitative measures of bowing index and normalized glottal gap, as well as a novel measure, normalized laryngeal outlet, were calculated from the videostroboscopic examinations of 46 patients with presbylarynges and 20 normal control subjects. Results The mean bowing index values from the presbylarynges and control groups differed significantly, although there was overlap of individual values between groups. Bowing index values did not consistently predict normalized glottal gap values. Mean normalized laryngeal outlet values of the patients with presbylarynges were significantly smaller than those of the control group. Conclusions Bowing does not consistently predict the extent of glottal gap. Therefore, other presbylaryngeal changes are probably contributing to incomplete glottal closure, which are not well‐visualized stroboscopically, so the finding of bowing is not sufficiently specific to identify presbylarynges. The significantly smaller normalized laryngeal outlet values suggest that this identifies a compensatory strategy for glottal gap to optimize vocal function. This is a novel finding that contrasts with medial ventricular fold squeezing, which is more routinely sought and is typically considered a maladaptive compensatory strategy. Despite the advantages of quantitative stroboscopic measures, limitations in reliability limit their clinical utility.     

Behandlung von Glottisschlussinsuffizienzen

Glottal gaps can be either physiological or pathological. The latter are multifactorial, predominantly organic in origin and occasionally functional. Organic causes include vocal fold paralysis or scarring, as well as a deficiency or excess of tissue. In addition to loss of the mucosal wave, the degree of hoarseness is primarily determined by the circumferential area of the glottal gap. It is thus important to quantify the extent of glottal insufficiency. Although a patient’s symptoms form the basis for treatment decisions, these may be subjective and inadequately reflected by the results of auditory-perceptual evaluation, voice analysis and voice performance tests. The therapeutic approach should always combine phonosurgery with conventional voice therapy methods. Voice therapy utilises all the resources made available by the sphincter model of the aerodigestive tract and knowledge on the mechanism of voice production. The aim of phonosurgery is medialization, reconstruction or reinnervation by injection laryngoplasty or larynx framework surgery. These different methods can be combined and often applied directly after vocal fold surgery (primary reconstruction). In conclusion, the techniques described here can be effectively employed to compensate for glottal gaps.     

Vocal fold vibrations: high-speed imaging, kymography, and acoustic analysis: a preliminary report

OBJECTIVES: To evaluate a new analysis system, High-Speed Tool Box (H. Larsson, custom-made program for image analysis, version 1.1, Department of Logopedics and Phoniatrics, Huddinge University Hospital, Huddinge, Sweden, 1998) for studying vocal fold vibrations using a high-speed camera and to relate findings from these analyses to sound characteristics. STUDY DESIGN: A Weinberger Speedcam + 500 system (Weinberger AG, Dietikon, Switzerland) was used with a frame rate of 1,904 frames per second. Images were stored and analyzed digitally. Analysis included automatic glottal edge detection and calculation of glottal area variations, as well as kymography. These signals were compared with acoustic waveforms using the Soundswell program (Hitech Development AB, Stockholm, Sweden). METHODS: The High-Speed Tool Box was applied on two types of high-speed recordings: a diplophonic phonation and a tremor voice. Relations between glottal vibratory patterns and the sound waveform were analyzed. RESULTS: In the diplophonic phonation, the glottal area waveform, as well as the kymogram, showed a specific pattern of repetitive glottal closures, which was also seen in the acoustic waveform. In the tremor voice, fundamental frequency (F0) fluctuations in the acoustic waveform were reflected in slow variations in amplitude in the glottal area waveform. For studying details of mucosal movements during these kinds of abnormal vibrations, the glottal area waveform was particularly useful. CONCLUSIONS: Our results suggest that this combined high-speed acoustic-kymographic analysis package is a promising aid for separating and specifying different voice qualities such as diplophonia and voice tremor. Apart from clinical use, this finding should be of help for specification of the terminology of different voice qualities.