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Purpose The purpose of this viewpoint article is to facilitate research on vocal hyperfunction (VH). VH is implicated in the most commonly occurring types of voice disorders, but there remains a pressing need to increase our understanding of the etiological and pathophysiological mechanisms associated with VH to improve the prevention, diagnosis, and treatment of VH-related disorders. Method A comprehensive theoretical framework for VH is proposed based on an integration of prevailing clinical views and research evidence. Results The fundamental structure of the current framework is based on a previous (simplified) version that was published over 30 years ago (Hillman et al., 1989). A central premise of the framework is that there are two primary manifestations of VH-phonotraumatic VH and nonphonotraumatic VH-and that multiple factors contribute and interact in different ways to cause and maintain these two types of VH. Key hypotheses are presented about the way different factors may contribute to phonotraumatic VH and nonphonotraumatic VH and how the associated disorders may respond to treatment. Conclusions This updated and expanded framework is meant to help guide future research, particularly the design of longitudinal studies, which can lead to a refinement in knowledge about the etiology and pathophysiology of VH-related disorders. Such new knowledge should lead to further refinements in the framework and serve as a basis for improving the prevention and evidence-based clinical management of VH.

The purpose of the study was to examine the effect of two voice intervention approaches for hypophonia secondary to Parkinson's disease (PD) on self-reported measures of physical demand, mental demand, and vocal performance. Thirty-four persons with hypophonia secondary to PD were assigned to one of three groups: Lee Silverman Voice Treatment (LSVT) LOUD ( = 12), SpeechVive ( = 12), and nontreatment clinical control ( = 10). The LSVT LOUD and the SpeechVive participants received 8 weeks of voice intervention following the standardized protocol previously described for each approach. To confirm the effectiveness of each voice intervention, sound pressure level (dB SPL) data were analyzed for the experimental and control participants for a monologue sample obtained pretreatment, midtreatment, and posttreatment. During the voice intervention period, the LSVT LOUD and the SpeechVive participants were instructed to complete a modified version of the National Aeronautics and Space Administration Task Load Index rating scale to indicate the mental and physical demand required to complete the intervention activities, and to indicate how well they performed in completing the assigned vocal tasks. The LSVT LOUD and the SpeechVive participants demonstrated a significant posttreatment increase in SPL (dB), in comparison to the clinical controls, thus confirming a positive intervention effect. The LSVT LOUD participants reported significantly higher ratings of physical and mental demand over the course of treatment, in comparison to the SpeechVive participants. Consideration of the mental and physical demand associated with two voice intervention approaches, commonly used for PD, may help to foster improved therapeutic compliance and treatment outcomes.

Stroboscopy and High-Speed Imaging of the Vocal Function, Second Edition presents a complete picture of the art and science of stroboscopy. This unique professional resource includes not only comprehensive coverage of the imaging process, but also the disease process that exists in benign lesions, cancer, and neuropathology. Comparisons of normal images with pathologies are included to enhance readers' diagnostic skills, and the use of stroboscopic images before and after therapy to determine results enhances their clinical skills. The book also covers the entire range of laryngeal imaging for diagnostics, including rigid endoscopy, videostroboscopy, fiberoptic laryngoscopy, and high-speed imaging.

This study investigated the noninferiority and validity of an intensive speech treatment for people with Parkinson's disease (PD) delivered via telerehabilitation to the home. The effect of location on online delivery was also investigated. In this single-blinded, randomized controlled noninferiority trial, 31 participants with dysarthria associated with PD from a metropolitan area were randomly assigned to either face-to-face or online Lee Silverman Voice Treatment (LSVT LOUD). A cohort of 21 participants from nonmetropolitan areas was also recruited and treated online. Outcomes were assessed using acoustic, perceptual, and quality of life measures. Noninferiority of online treatment was confirmed through comparable clinical and quality of life outcomes for the metropolitan online and face-to-face treatment groups. Significant improvements posttreatment were achieved for several acoustic, perceptual, and quality of life measures across the groups. No significant effect of online treatment location was identified. Clinical and quality of life outcomes supported the noninferiority and validity of online delivery of intensive speech treatment to people with PD in the home. Future research should address the implementation of online treatment in a clinical service, cost analyses, and potentially technology-enabled clinical pathways for people with PD in order to maintain optimal communication and quality of life.

Introduction Voice problems are common following radiotherapy for laryngeal cancer. Few studies exist covering the effect of voice rehabilitation, and no previous studies exist regarding the cost of said rehabilitation. This randomized controlled study aimed to analyze the cost-effectiveness of voice rehabilitation after radiotherapy for patients with laryngeal cancer. Material and methods A total of 66 patients with laryngeal cancer with follow-up data 12 months post-radiotherapy were included. Patients were randomized into receiving either voice rehabilitation ( n  = 32) or no voice rehabilitation ( n  = 34). The patient outcome was measured as quality-adjusted life years (QALYs). The index range between 0 and 1, where 0 equals death and 1 represents perfect health. The QALYs were assessed with the European Organization for Research and Treatment of Cancer questionnaire QLQ-C30 mapped to EuroQoL 5 Dimension values. The cost of rehabilitation and other healthcare visits was derived from hospital systems. The patients reported the total amount of sick leave days during the first 12 months following radiotherapy. The cost-effectiveness of the voice rehabilitation was compared with no rehabilitation intervention based on the incremental cost-effectiveness ratio. Results The cost per gained QALY with voice rehabilitation compared to no rehabilitation from a societal perspective was − 27,594 € (SEK − 250,852) which indicates that the voice rehabilitation is a cost-saving alternative compared to no rehabilitation due to lower costs and a slightly better health outcome. From a healthcare perspective, the voice rehabilitation indicates a cost 60,800 € (SEK 552,725) per gained QALY. Conclusion From a societal perspective, i.e., including the costs of production loss, voice rehabilitation compared to no voice rehabilitation following radiotherapy for laryngeal cancer seems to be cost-saving. When analyzing only the healthcare costs in relation to health outcomes, voice rehabilitation indicates an incremental cost of 60,800 € per gained QALY, which is just above the threshold of the maximum willingness to pay level.

The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment.

Background Voice and swallowing symptoms are frequently reported after thyroidectomy even in absence of objective voice alterations. We evaluated the influence of the video-assisted approach on voice and swallowing outcome of thyroidectomy. Methods Sixty-five patients undergoing total thyroidectomy (TT) were recruited. Eligibility criteria were: nodule size ≤30 mm, thyroid volume ≤30 ml, no previous neck surgery. Exclusion criteria were: younger than aged 18 years and older than aged 75 years, vocal fold paralysis, history of voice, laryngeal or pulmonary diseases, malignancy other than papillary thyroid carcinoma. Patients were randomized for video-assisted (VAT) or conventional (CT) thyroidectomy. Videostrobolaryngoscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) evaluation were performed preoperatively and 3 months after TT. Subjective evaluation of voice (voice impairment score = VIS) and swallowing (swallowing impairment score = SIS) were obtained preoperatively, 1 week, 1 month, and 3 months after TT. Results Fifty-three patients completed the postoperative evaluation: 29 in the VAT group, and 24 in the CT group. No laryngeal nerves injury was shown at postoperative VSL. Mean postoperative MPT, F 0 , F low , F high , and the number of semitones were significantly reduced in the CT group but not in the VAT group. Mean VIS 3 months after surgery was significantly higher than preoperatively in CT group but not in the VAT group. Mean SIS was significantly decreased 1 and 3 months after VAT but not after CT. Conclusions The incidence and the severity of early voice and swallowing postthyroidectomy symptoms are significantly reduced in patients who undergo VAT compared with conventional surgery.

Voice ambulatory biofeedback (VAB) has potential to improve carryover of therapeutic voice use into daily life. Previous work in vocally healthy participants demonstrated that motor learning inspired variations to VAB produced expected differences in acquisition and retention of modified daily voice use. This proof-of-concept study was designed to evaluate whether these VAB variations have the same desired effects on acquisition and retention in patients with phonotraumatic vocal hyperfunction (PVH). Seventeen female patients with PVH wore an ambulatory voice monitor for 6 days: three baseline days, one biofeedback day, one short-term retention day, and one long-term retention day. Short- and long-term retention were 1- and 7-days postbiofeedback, respectively. Patients were block-randomized to receive one of three types of VAB: 100%, 25%, and Summary. Performance was measured in terms of adherence time below a subject-specific vocal intensity threshold. All three types of VAB produced a biofeedback effect with 13 out of 17 patients displaying an increase in adherence time compared to baseline days. Additionally, multiple patients from each VAB group increased their adherence time during short- and/or long-term retention monitoring compared to baseline. These findings show that VAB can be associated with acquisition and retention of desired voice use in patients with PVH. Specifically, all three feedback types improved multiple patients' performance and retention for up to 1 week after biofeedback removal. Future work can investigate the impact of incorporating VAB into voice therapy.

Purpose: The purpose of this document is threefold: (a) review the uses of the terms \"vocal fatigue,\" \"vocal effort,\" \"vocal load,\" and \"vocal loading\" (as found in the literature) in order to track the occurrence and the related evolution of research; (b) present a \"linguistically modeled\" definition of the same from the review of literature on the terms; and (c) propose conceptualized definitions of the concepts. Method: A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scientific Electronic Library Online. Four terms (\"vocal fatigue,\" \"vocal effort,\" \"vocal load,\" and \"vocal loading\"), as well as possible variants, were included in the search, and their usages were compiled into conceptual definitions. Finally, a focus group of eight experts in the field (current authors) worked together to make conceptual connections and proposed consensus definitions. Results: The occurrence and frequency of \"vocal load,\" \"vocal loading,\" \"vocal effort,\" and \"vocal fatigue\" in the literature are presented, and summary definitions are developed. The results indicate that these terms appear to be often interchanged with blurred distinctions. Therefore, the focus group proposes the use of two new terms, \"vocal demand\" and \"vocal demand response,\" in place of the terms \"vocal load\" and \"vocal loading.\" We also propose standardized definitions for all four concepts. Conclusion: Through a comprehensive literature search, the terms \"vocal fatigue,\" \"vocal effort,\" \"vocal load,\" and \"vocal loading\" were explored, new terms were proposed, and standardized definitions were presented. Future work should refine these proposed definitions as research continues to address vocal health concerns.

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.