Faculty Bibliography

OBJECTIVE:The purpose of this study is to characterize patients who work professionally as musical performers and undergo potassium titanyl phosphate (KTP) laser ablation of vocal fold lesions in the outpatient setting. METHODS:A retrospective chart review of patients who are vocal performers and underwent in-office KTP laser ablation of benign vocal fold lesions at a single academic institution between 2012 and 2023 was conducted. Demographics including occupation, were descriptively reviewed. Acoustic measures, including cepstral peak prominence (CPP) and mean fundamental frequency variance (F0CoV), were analyzed. Vocal fold vibratory amplitude and mucosal wave were evaluated on videostroboscopy utilizing the voice vibratory assessment with laryngeal imaging. Preablation and postablation outcome measures were compared via Wilcoxon signed rank and McNemar's test. RESULTS:26 patients who identified as singers successfully underwent single-treatment in-office KTP laser ablation of vocal fold polyps. Ten patients (38.5%) identified as professional performers, and all patients continued their occupation after ablation. 84.2% of patients had either complete recovery or mildly reduced mucosal wave and amplitude of the treated vocal fold following KTP laser ablation. Additionally, CPP vowel improved following in-office KTP laser ablation, and F0CoV decreased following the ablation. All patients were able to continue their occupation in the same capacity. CONCLUSION/CONCLUSIONS:In-office KTP ablation is a valuable, safe, and feasible intervention for professional performers with benign vocal fold polyps. This study provides insight into vocal outcomes in the largest cohort of professional performers with apt follow-up.

PURPOSE/OBJECTIVE:Dysphagia is a commonly occurring medical condition estimated to occur in between and 10% adults in the US. Despite this relatively high prevalence, the general population's understanding of this condition is currently unknown. Our aims were to (a) conduct a large-scale survey to determine the public's awareness and understanding of dysphagia in comparison to other three other health conditions and (b) compare this knowledge to relative prevalence rates of the conditions. METHODS:The survey was designed to measure four constructs of interest comparing dysphagia with insomnia, vertigo and ataxia. Constructs included: (1) Knowledge of the Condition, (2) Source of Knowledge, (3) Health Impact, (4) Treating Medical Professionals. The survey was launched via Qualtrics™ software and participants were recruited and paid using Prolific™. Descriptive statistics were used to compare participants knowledge of dysphagia with the other conditions. To obtain relative prevalence rates, Cosmos was used to quantify the number of Epic-based patient encounters with any ICD-10 code for each condition in 2023 and expressed as a percent of all patient encounters in the US in 2023. RESULTS:2000 adults (n = 1030 female) aged 18-95 (median 49, IQR = 33-62) completed our survey. When asked, 'Do you know what ____ is'? participants expressed higher familiarity with insomnia (99%) and vertigo (87%) in comparison to dysphagia (25%) and ataxia (18%). From a list of 8 options, 99% and 94% participants selected the correct impairment for insomnia and vertigo respectively, compared with 44% correct for dysphagia and 22% for ataxia. Participants selected an appropriate healthcare provider for dysphagia 47% of the time compared with 74% for insomnia, 56% for vertigo and 36% for ataxia. When asked to identify up to 3 sequelae (from a list of 9), only 4% of participants were able to correctly identify all three for dysphagia, in comparison to 16% for ataxia, 27% for vertigo and 60% for insomnia. The Cosmos analysis revealed that while insomnia had the highest prevalence in 2023 (5.5% of patient encounters), dysphagia occurred much more frequently (2.4%) than vertigo (0.68%) and ataxia (0.24%). CONCLUSIONS:These discrepancies highlight a notable gap in public awareness between dysphagia and more recognized conditions of insomnia and vertigo, even though the prevalence of dysphagia is higher than vertigo. Increasing public awareness of dysphagia is vital for early intervention, increasing quality of life, and advocating for equitable access to healthcare resources.

Rat ultrasonic vocalizations (USVs) have traditionally been used in psychosocial and psychobiological studies to understand emotion, social behavior, cognition, and associative learning. However, recent studies have expanded the goal of USVs to include the study of the laryngeal system and the effects of disease processes on vocal sensorimotor control. Without the foundational understanding of the goals of this area of laryngological research, fundamental differences in study objectives between psychobehavioral and laryngological studies can easily be missed, leading to misconceptions and misinterpretations of the role USVs play in laryngology-focused studies. Standardization of terminology and methods are also needed to improve communication, enhance study replicability, and prevent ambiguity that can lead to misinterpretations of study objectives and findings in this line of research. The primary objective is to describe the role of USVs in studies of laryngeal anatomy and physiology, with a focus on their connections to the neuromuscular and neurological aspects of the laryngeal system, particularly in relation to vocal sensorimotor control and voice disorders. It is intended for novice investigators interested in laryngology-specific USV research. Researchers experienced in USV studies within the context of the larynx and vocal sensorimotor control first outline the development and refinement of various USV elicitation methods. They provide insights into how these approaches have been tested across different studies and laboratories. Finally, they advocate for standardizing terminology and methodologies to enhance study replicability, reduce ambiguity, and foster collaboration across research groups.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:This study investigated the effects of the "crack-sob" onset-a distinctive vocal technique combining a sob gesture with an intentional pitch break-on vocal fold function during high-intensity singing. We hypothesized that this onset would either decrease glottal adduction and increase vocal fold vibration stability or alternatively, show no measurable effects while still providing perceived benefits to singers. STUDY DESIGN/METHODS:Prospective observational cohort study. METHODS:Twenty professional musical theatre singers (10 male, 10 female) performed high-intensity sustained notes with and without the crack-sob onset using both a control phrase and self-selected repertoire. Electroglottography measured contact quotient (CQ) and its relative standard deviation (relSDCQ). Acoustic analysis quantified smoothed cepstral peak prominence (CPPS), harmonics-to-noise ratio (HNR), and vocal intensity (dB SPL). Linear mixed effects modeling was used to analyze the effects of the crack-sob maneuver, with sex and vocal phrase as covariates. RESULTS:The crack-sob onset showed no significant effects on any measured parameters. CQ remained consistent at 66% regardless of onset type. No significant changes were observed in CPPS, dB SPL, relSDCQ, or HNR when using the crack-sob onset, with all effect sizes below 0.1. Significant differences were found between control and self-selected phrases, with the control phrase showing higher CPPS (+2.6 dB), intensity (+2.7 dB SPL), and HNR (+4.3). CONCLUSIONS:The crack-sob onset does not significantly alter objective measures of vocal fold adduction or vibratory stability during sustained high-intensity phonation in trained singers. The technique's reported benefits may be primarily perceptual rather than physiological, suggesting its value as a pedagogical tool for managing singer effort without compromising vocal function.

PURPOSE/UNASSIGNED:Most auditory-perceptual voice research utilizes the judgments of trained listeners rather than everyday listeners with no previous training in speech pathology. Online crowdsourcing of behavioral data from untrained participants is rapidly increasing in popularity but has yet to be a common procedure for auditory-perceptual studies of the voice. The objective of this pilot study was to assess the functionality of this model for judgments of voice by using an online experiment platform to replicate a lab-based, voice-specific age estimation study. METHOD/UNASSIGNED:Fifty crowdsourced untrained listeners estimated the age of a single talker based on audio samples taken from 20 speeches over a 48-year span. The primary outcome was overall age estimation accuracy. RESULTS/UNASSIGNED:The crowdsourced age estimations closely matched those of a previous highly controlled in-person laboratory study using the same auditory samples. Listeners generally overestimated the talker's age when the talker was younger and underestimated his age when he was older. The age at which the estimated age equaled the talker's chronological age was 54 years. CONCLUSIONS/UNASSIGNED:Online crowdsourcing may be a feasible modality for auditory-perceptual voice ratings with the potential to add low-cost, high-number options to validate and enhance clinical and laboratory-based studies by (a) including a wider diversity of participants and (b) providing the means for rapidly recruiting more participants. Further research investigating crowdsourced ratings of the complex parameters of voice quality using more listeners is needed to continue supporting this methodology as a tool for perceptual voice research.

OBJECTIVE:This study aims to evaluate the clinical outcomes of patients receiving in-office vocal fold steroid injections (VFSI), highlighting relatively new measures around vocal pitch. METHODS:Patients with a diagnosis of vocal fold scar who received in-office VFSI from 2013 to 2024 were evaluated. Pre- and post-steroid Voice Handicap Index (VHI-10) scores, stroboscopic vibratory parameters, acoustic measures of cepstral peak prominence (CPP), and fundamental frequency coefficient of variation (F0CoV) during sustained phonation were analyzed using Wilcoxon signed-rank tests and McNemar's tests. RESULTS:Twenty-two patients had follow-up data 1-3 months after steroid injection. The median decrease in VHI-10 after one injection was 4 points (p = 0.02). We found no difference in CPP and F0CoV measures at follow-up. Forty-five percent of patients improved in mucosal wave and amplitude of at least one vocal fold. Earlier presentation from vocal injury was associated with improvement in mucosal wave and amplitude of the left vocal fold (p = 0.03). We found no difference in sex, tobacco smoking history, singing status, secondary diagnosis, and baseline VHI-10 score between patients who improved in vibratory parameters and those who did not. CONCLUSION/CONCLUSIONS:This single-center study is one of the largest exploring patient outcomes following in-office VFSI. Though patients reported modest improvement in voice use after VFSI, this may not be as impactful as previously believed. Improvement in videostroboscopy is expected in about half of the patients, with recency from vocal injury a likely predictor of success. These partially negative results provide insight into counseling patients regarding benefits from in-office VFSI. LEVEL OF EVIDENCE/METHODS:4 Laryngoscope, 2024.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:An increasing number of older adults are seeking behavioral voice therapy to manage their voice problems. Poor adherence to voice therapy is a known problem across all treatment-seeking populations. Given age-related physical and cognitive impairments and multiple chronic conditions, older adults are more susceptible to low adherence to behavioral therapies. The purpose of this study was to test the feasibility of an at-home, vocal training intervention for older adults without a known voice disorder living in a senior living community, as well as compare the effects of two modes of mobile health (mHealth) technology-assisted vocal training targeting vocal function and adherence in older adults. STUDY DESIGN/METHODS:Cohort Study (Prospective Observational Study). METHODS:Twenty-three individuals were recruited from a single residential retirement community and randomly allocated into two experimental groups. Both groups were asked to practice the Vocal Function Exercises with increasing frequency over an 8-week period. Tablets with instructions for performing the exercises were provided to all participants. The feedback group's tablets also contained an application providing real-time feedback on pitch, loudness, and duration. Acoustic and aerodynamic measures of vocal function and cognitive measures were obtained before and after the intervention. Self-reported measures of practice frequency, perceived vocal progress and changes, and motivation were obtained weekly. RESULTS:The feedback control group adhered to the requested practice sessions more in the latter half of the intervention (weeks 5 and 8). Vocal function measures remained stable. Overall, a pattern reflecting self-reported vocal progress and a general improvement in working memory and global cognitive functioning was observed in the feedback group. CONCLUSIONS:This study demonstrated that an 8-week mHealth intervention is viable to facilitate vocal practice in older adults. Although vocal ability did not improve with training, results indicated that vocal performance remained stable and age-related vocal changes did not progress. Future research on implementation of mHealth applications in conjunction with behavioral voice therapy is warranted to assess adherence and improvements in vocal function in individuals with age-related voice problems.

OBJECTIVE:Vocal tremor (VT) poses treatment challenges due to uncertain pathophysiology. VT is typically classified into two phenotypes: isolated vocal tremor (iVT) and essential tremor-related voice tremor (ETvt). The impact of phenotypes on upper aerodigestive tract physiology during swallowing remains unclear. Qualitative and quantitative measures were employed to characterize tremor phenotypes and investigate the effects on swallowing physiology. METHODS:Eleven ETvt participants (1 Male, 10 Female; x̄ age = 74) and 8 iVT participants (1 Male, 7 Female; x̄ age = 71) swallowed 20 mL boluses in cued and uncued conditions under standardized fluoroscopic visualization. Sustained/a/productions were captured to assess the rate and extent of fundamental frequency (F0) modulation. Penetration and Aspiration Scale (PAS) scores were obtained and swallowing biomechanics were captured using Swallowtail™ software. Participants also completed the Swallowing Quality of Life (SWAL-QOL) questionnaire. RESULTS:Hypopharyngeal transit was faster in both VT phenotypes compared with Swallowtail™ normative reference data. Total pharyngeal transit times, however, were only faster in patients with iVT, relative to reference data. No significant differences were observed on the SWAL-QOL or PAS between tremor phenotypes. SWAL-QOL scores revealed that these patients rarely reported dysphagia symptoms. CONCLUSIONS:Subtle differences in swallowing patterns were observed across VT phenotypes, possibly related to adaptive mechanisms resulting in quicker pharyngeal bolus transit. Most patients did not report swallowing issues or dysphagia symptoms. This study is foundational for larger studies on this challenging population. LEVEL OF EVIDENCE/METHODS:4 Laryngoscope, 134:4599-4603, 2024.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:This study assessed the vocal health of performers returning to full-time performance after the COVID-19 pandemic shutdown and investigated how differences in voice usage, exposure to voice care professionals, and vocal pathology before and during the pandemic contributed to variability in self-perceived and instrumental vocal outcome measures. STUDY DESIGN/METHODS:This was a prospective, case-control observational study conducted at a single outpatient site. METHODS:Twenty-two patients, 11 cases and 11 controls, were enrolled for the study. All participants were full-time singing professionals prior to the COVID-19 pandemic. Cases were recruited from patients presenting to a tertiary care voice center for vocal or pharyngeal complaints. Controls were healthy volunteers recruited from the general population of professional singers in the surrounding metropolitan area. All participants provided responses to the Voice Handicap Index-10, Evaluation of Ability to Sing Easily, and Laryngopharyngeal Measure of Perceived Sensation validated questionnaires as well as a study survey with questions regarding vocal use and history prior to and during the pandemic. All participants underwent instrumental acoustic and videostroboscopic voice evaluations. RESULTS:Cases had poorer outcome measures overall and were more likely to report their voices were worse at study enrollment when compared to their prepandemic perception (P = 0.027). Cases tended to be older and less likely to have pursued alternative employment during the pandemic that involved increased speaking voice use (27% vs 55%), but these differences were not statistically significant. CONCLUSIONS:There was a variable response among performers to the prolonged hiatus from performing during the COVID-19 pandemic. Those with poorer outcomes tended to be older and may have used their voice less during the pandemic. These findings are consistent with detraining periods in the exercise physiology literature and support the construct of treating vocal performers as vocal athletes.