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The MIT Encyclopedia of
Communication Disorders

The MIT Encyclopedia of
Communication Disorders

Edited by Raymond D. Kent

A Bradford Book
The MIT Press
Cambridge, Massachusetts
London, England

( 2004 Massachusetts Institute of Technology

All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical
means (including photocopying, recording, or information storage and retrieval) without permission in
writing from the publisher.

This book was set in Times New Roman on 3B2 by Asco Typesetters, Hong Kong, and was printed and
bound in the United States of America.

Library of Congress Cataloging-in-Publication Data

The MIT encyclopedia of communication disorders / edited by Raymond D. Kent.
p. cm.
Includes bibliographical references and index.
ISBN 0-262-11278-7 (cloth)
1. Communicative disorders—Encyclopedias. I. Kent, Raymond D. II. Massachusetts Institute of
Technology.
RC423.M56 2004
616.850 50 003—dc21
2003059941

Contents
Introduction ix Dysarthrias: Characteristics and Classification 126
Acknowledgments xi Dysarthrias: Management 129
Dysphagia, Oral and Pharyngeal 132
Early Recurrent Otitis Media and Speech
Part I: Voice 1 Development 135
Acoustic Assessment of Voice 3 Laryngectomy 137
Aerodynamic Assessment of Vocal Function 7 Mental Retardation and Speech in Children 140
Alaryngeal Voice and Speech Rehabilitation 10 Motor Speech Involvement in Children 142
Anatomy of the Human Larynx 13 Mutism, Neurogenic 145
Assessment of Functional Impact of Voice Orofacial Myofunctional Disorders in Children 147
Disorders 20 Phonetic Transcription of Children’s Speech 150
Electroglottographic Assessment of Voice 23 Phonological Awareness Intervention for Children with
Functional Voice Disorders 27 Expressive Phonological Impairments 153
Hypokinetic Laryngeal Movement Disorders 30 Phonological Errors, Residual 156
Infectious Diseases and Inflammatory Conditions of Phonology: Clinical Issues in Serving Speakers of
the Larynx 32 African-American Vernacular English 158
Instrumental Assessment of Children’s Voice 35 Psychosocial Problems Associated with Communicative
Laryngeal Movement Disorders: Treatment with Disorders 161
Botulinum Toxin 38 Speech and Language Disorders in Children: Computer-
Laryngeal Reinnervation Procedures 41 Based Approaches 164
Laryngeal Trauma and Peripheral Structural Speech and Language Issues in Children from Asian-
Ablations 45 Pacific Backgrounds 167
Psychogenic Voice Disorders: Direct Therapy 49 Speech Assessment, Instrumental 169
The Singing Voice 51 Speech Assessment in Children: Descriptive Linguistic
Vocal Hygiene 54 Methods 174
Vocal Production System: Evolution 56 Speech Development in Infants and Young Children
Vocalization, Neural Mechanisms of 59 with a Tracheostomy 176
Voice Acoustics 63 Speech Disfluency and Stuttering in Children 180
Voice Disorders in Children 67 Speech Disorders: Genetic Transmission 183
Voice Disorders of Aging 72 Speech Disorders in Adults, Psychogenic 186
Voice Production: Physics and Physiology 75 Speech Disorders in Children: A Psycholinguistic
Voice Quality, Perceptual Evaluation of 78 Perspective 189
Voice Rehabilitation After Conservation Speech Disorders in Children: Behavioral Approaches to
Laryngectomy 80 Remediation 192
Voice Therapy: Breathing Exercises 82 Speech Disorders in Children: Birth-Related Risk
Voice Therapy: Holistic Techniques 85 Factors 194
Voice Therapy for Adults 88 Speech Disorders in Children: Cross-Linguistic
Voice Therapy for Neurological Aging-Related Voice Data 196
Disorders 91 Speech Disorders in Children: Descriptive Linguistic
Voice Therapy for Professional Voice Users 95 Approaches 198
Speech Disorders in Children: Motor Speech Disorders
of Known Origin 200
Part II: Speech 99 Speech Disorders in Children: Speech-Language
Apraxia of Speech: Nature and Phenomenology 101 Approaches 204
Apraxia of Speech: Treatment 104 Speech Disorders Secondary to Hearing Impairment
Aprosodia 107 Acquired in Adulthood 207
Augmentative and Alternative Communication Speech Issues in Children from Latino
Approaches in Adults 110 Backgrounds 210
Augmentative and Alternative Communication Speech Sampling, Articulation Tests, and Intelligibility
Approaches in Children 112 in Children with Phonological Errors 213
Autism 115 Speech Sampling, Articulation Tests, and Intelligibility
Bilingualism, Speech Issues in 119 in Children with Residual Errors 215
Developmental Apraxia of Speech 121 Speech Sound Disorders in Children: Description and
Dialect, Regional 124 Classification 218

vi Contents

Stuttering 220 Lingustic Aspects of Child Language Impairment—
Transsexualism and Sex Reassignment: Speech Prosody 344
Di¤erences 223 Melodic Intonation Therapy 347
Ventilator-Supported Speech Production 226 Memory and Processing Capacity 349
Mental Retardation 352
Morphosyntax and Syntax 354
Part III: Language 229 Otitis Media: E¤ects on Children’s Language 358
Agrammatism 231 Perseveration 361
Agraphia 233 Phonological Analysis of Language Disorders in
Alexia 236 Aphasia 363
Alzheimer’s Disease 240 Phonology and Adult Aphasia 366
Aphasia, Global 243 Poverty: E¤ects on Language 369
Aphasia, Primary Progressive 245 Pragmatics 372
Aphasia: The Classical Syndromes 249 Prelinguistic Communication Intervention for Children
Aphasia, Wernicke’s 252 with Developmental Disabilities 375
Aphasia Treatment: Computer-Aided Preschool Language Intervention 378
Rehabilitation 254 Prosodic Deficits 381
Aphasia Treatment: Pharmacological Approaches 257 Reversibility/Mapping Disorders 383
Aphasia Treatment: Psychosocial Issues 260 Right Hemisphere Language and Communication
Aphasic Syndromes: Connectionist Models 262 Functions in Adults 386
Aphasiology, Comparative 265 Right Hemisphere Language Disorders 388
Argument Structure: Representation and Segmentation of Spoken Language by Normal Adult
Processing 269 Listeners 392
Attention and Language 272 Semantics 395
Auditory-Motor Interaction in Speech and Social Development and Language Impairment 398
Language 275 Specific Language Impairment in Children 402
Augmentative and Alternative Communication: General Syntactic Tree Pruning 405
Issues 277 Trace Deletion Hypothesis 407
Bilingualism and Language Impairment 279
Communication Disorders in Adults: Functional
Approaches to Aphasia 283 Part IV: Hearing 411
Communication Disorders in Infants and Toddlers Amplitude Compression in Hearing Aids 413
285 Assessment of and Intervention with Children Who Are
Communication Skills of People with Down Deaf or Hard of Hearing 421
Syndrome 288 Audition in Children, Development of 424
Dementia 291 Auditory Brainstem Implant 427
Dialect Speakers 294 Auditory Brainstem Response in Adults 429
Dialect Versus Disorder 297 Auditory Neuropathy in Children 433
Discourse 300 Auditory Scene Analysis 437
Discourse Impairments 302 Auditory Training 439
Functional Brain Imaging 305 Classroom Acoustics 442
Inclusion Models for Children with Developmental Clinical Decision Analysis 444
Disabilities 307 Cochlear Implants 447
Language Development in Children with Focal Cochlear Implants in Adults: Candidacy 450
Lesions 311 Cochlear Implants in Children 454
Language Disorders in Adults: Subcortical Dichotic Listening 458
Involvement 314 Electrocochleography 461
Language Disorders in African-American Electronystagmography 467
Children 318 Frequency Compression 471
Language Disorders in Latino Children 321 Functional Hearing Loss in Children 475
Language Disorders in School-Age Children: Aspects of Genetics and Craniofacial Anomalies 477
Assessment 324 Hearing Aid Fitting: Evaluation of Outcomes 480
Language Disorders in School-Age Children: Hearing Aids: Prescriptive Fitting 482
Overview 326 Hearing Aids: Sound Quality 487
Language Impairment and Reading Disability 329 Hearing Loss and the Masking-Level Di¤erence 489
Language Impairment in Children: Cross-Linguistic Hearing Loss and Teratogenic Drugs or Chemicals 493
Studies 331 Hearing Loss Screening: The School-Age Child 495
Language in Children Who Stutter 333 Hearing Protection Devices 497
Language of the Deaf: Acquisition of English 336 Masking 500
Language of the Deaf: Sign Language 339 Middle Ear Assessment in the Child 504

Contents vii

Noise-Induced Hearing Loss 508 Speechreading Training and Visual Tracking
Otoacoustic Emissions 511 543
Otoacoustic Emissions in Children 515 Suprathreshold Speech Recognition 548
Ototoxic Medications 518 Temporal Integration 550
Pediatric Audiology: The Test Battery Approach 520 Temporal Resolution 553
Physiological Bases of Hearing 522 Tinnitus 556
Pitch Perception 525 Tympanometry 558
Presbyacusis 527 Vestibular Rehabilitation 563
Pseudohypacusis 531
Pure-Tone Threshold Assessment 534 Contributors 569
Speech Perception Indices 538 Name Index 577
Speech Tracking 541 Subject Index 603

Introduction
The MIT Encyclopedia of Communication Disorders (MITECD) is a comprehensive
volume that presents essential information on communication sciences and disorders.
The pertinent disorders are those that a¤ect the production and comprehension of
spoken language and include especially disorders of speech production and percep-
tion, language expression, language comprehension, voice, and hearing. Potential
readers include clinical practitioners, students, and research specialists. Relatively
few comprehensive books of similar design and purpose exist, so MITECD stands
nearly alone as a resource for anyone interested in the broad field of communication
disorders.
MITECD is organized into the four broad categories of Voice, Speech, Language,
and Hearing. These categories represent the spectrum of topics that usually fall under
the rubric of communication disorders (also known as speech-language pathology
and audiology, among other names). For example, roughly these same categories
were used by the National Institute on Deafness and Other Communication Dis-
orders (NIDCD) in preparing its national strategic research plans over the past de-
cade. The Journal of Speech, Language, and Hearing Research, one of the most
comprehensive and influential periodicals in the field, uses the editorial categories of
speech, language, and hearing. Although voice could be subsumed under speech, the
two fields are large enough individually and su‰ciently distinct that a separation is
warranted. Voice is internationally recognized as a clinical and research specialty,
and it is represented by journals dedicated to its domain (e.g., the Journal of Voice).
The use of these four categories achieves a major categorization of knowledge but
avoids a narrow fragmentation of the field at large. It is to be expected that the
Encyclopedia would include cross-referencing within and across these four major
categories. After all, they are integrated in the definitively human behavior of lan-
guage, and disorders of communication frequently have wide-ranging e¤ects on
communication in its essential social, educational, and vocational roles.
In designing the content and structure of MITECD, it was decided that each of
these major categories should be further subdivided into Basic Science, Disorders
(nature and assessment), and Clinical Management (intervention issues). Although
these categories are not always transparent in the entire collection of entries, they
guided the delineation of chapters and the selection of contributors. These categories
are defined as follows:
Basic Science entries pertain to matters such as normal anatomy and physiology,
physics, psychology and psychophysics, and linguistics. These topics are the
foundation for clinical description and interpretation, covering basic principles
and terminology pertaining to the communication sciences. Care was taken to
avoid substantive overlap with previous MIT publications, especially the MIT
Encyclopedia of the Cognitive Sciences (MITECS).
The Disorders entries o¤er information on issues such as syndrome delineation,
definition and characterization of specific disorders, and methods for the iden-
tification and assessment of disorders. As such, these chapters reflect contempo-
rary nosology and nomenclature, as well as guidelines for clinical assessment and
diagnosis.
The Clinical Management entries discuss various interventions including behavioral,
pharmacological, surgical, and prosthetic (mechanical and electronic). There is a
general, but not necessarily one-to-one, correspondence between chapters in the
Disorders and Clinical Management categories. For example, it is possible that
several types of disorder are related to one general chapter on clinical manage-
ment. It is certainly the case that di¤erent management strategies are preferred by
di¤erent clinicians. The chapters avoid dogmatic statements regarding interven-
tions of choice.
Because the approach to communicative disorders can be quite di¤erent for chil-
dren and adults, a further cross-cutting division was made such that for many topics

x Introduction

separate chapters for children and adults are included. Although some disorders that
are first diagnosed in childhood may persist in some form throughout adulthood (e.g,
stuttering, specific language impairment, and hearing loss may be lifelong conditions
for some individuals), many disorders can have an onset either in childhood or in
adulthood and the timing of onset can have implications for both assessment and
intervention. For instance, when a child experiences a significant loss of hearing, the
sensory deficit may greatly impair the learning of speech and language. But when a
loss of the same degree has an onset in adulthood, the problem is not in acquiring
speech and language, but rather in maintaining communication skills. Certainly, it is
often true that an understanding of a given disorder has common features in both the
developmental and acquired forms, but commonality cannot be assumed as a general
condition.
Many decisions were made during the preparation of this volume. Some were
easy, but others were not. In the main, entries are uniform in length and number of
references. However, in a few instances, two or more entries were combined into a
single longer entry. Perhaps inevitably in a project with so many contributors, a small
number of entries were dropped because of personal issues, such as illness, that
interfered with timely preparation of an entry. Happily, contributors showed great
enthusiasm for this project, and their entries reflect an assembled expertise that is
high tribute to the science and clinical practice in communication disorders.

Raymond D. Kent

Acknowledgments
MITECD began as a promising idea in a conversation with Amy Brand, a previous
editor with MIT Press. The idea was further developed, refined, elaborated, and re-
fined again in many ensuing e-mail communications, and I thank Amy for her con-
stant support and assistance through the early phases of the project. When she left
MIT Press, Tom Stone, Senior Editor of Cognitive Sciences, Linguistics, and Brad-
ford Books, stepped in to provide timely advice and attention. I also thank Mary
Avery, Acquisitions Assistant, for her help in keeping this project on track. I am
indebted to all of them.
Speech, voice, language, and hearing are vast domains individually, and several
associated editors helped to select topics for inclusion in MITECD and to identify
contributors with the necessary expertise. The associate editors and their fields of re-
sponsibility are as follows:
Fred H. Bess, Ph.D., Hearing Disorders in Children
Joseph R. Du¤y, Ph.D., Speech Disorders in Adults
Steven D. Gray, M.D. (deceased), Voice Disorders in Children
Robert E. Hillman, Ph.D., Voice Disorders in Adults
Sandra Gordon-Salant, Ph.D., Hearing Disorders in Adults
Mabel L. Rice, Ph.D., Language Disorders in Children
Lawrence D. Shriberg, Ph.D., Speech Disorders in Children
David A. Swinney, Ph.D., and Lewis P. Shapiro, Ph.D., Language Disorders in
Adults
The advice and cooperation of these individuals is gratefully acknowledged. Sadly,
Dr. Steven D. Gray died within the past year. He was an extraordinary man, and
although I knew him only briefly, I was deeply impressed by his passion for knowl-
edge and life. He will be remembered as an excellent physician, creative scientist, and
valued friend and colleague to many.
Dr. Houri Vorperian greatly facilitated this project through her inspired planning
of a computer-based system for contributor communications and record manage-
ment. Sara Stuntebeck and Sara Brost worked skillfully and accurately on a variety
of tasks that went into di¤erent phases of MITECD. They o¤ered vital help with
communications, file management, proofreading, and the various and sundry tasks
that stood between the initial conception of MITECD and the submission of a full
manuscript.
P. M. Gordon and Associates took on the formidable task of assembling 200
entries into a volume that looks and reads like an encyclopedia. I thank Denise
Bracken for exacting attention to the editing craft, creative solutions to unexpected
problems, and forbearance through it all.
MITECD came to reality through the e¤orts of a large number of contributors—
too many for me to acknowledge personally here. However, I draw the reader’s at-
tention to the list of contributors included in this volume. I feel a sense of community
with all of them, because they believed in the project and worked toward its com-
pletion by preparing entries of high quality. I salute them not only for their con-
tributions to MITECD but also for their many career contributions that define them
as experts in the field. I am honored by their participation and their patient cooper-
ation with the editorial process.

Raymond D. Kent

.

Part I: Voice .

.

The National Center for Voice and . which is an especially ception (Zwicker and Fastl. and in part because of long-term precedent for Inverse filter measures perturbation (Lieberman. however. jitter. for example. to characterize deviations with pure periodicity as a ref- turbations and signal-to-noise ratios on both f0 and in. Independently. 1995.Acoustic Assessment of Voice Table 1. the dependence of per. Furthermore. 2001). Real-Time Pitch. an abbreviated or The first two. and NHR—can provide haps because of the time-consuming and strenuous na- some very basic characterizations of vocal health. at the perceptual level. In acoustic assessment. 1997). Most voice quality algorithms are based on statistics. these tasks are recorded nally. Short-term perturbations sity (shimmer). and other measures of irregularity. and other software/hardware sys. The mate. ture of a full voice profile. These measures are f0 /amplitude covariations widely used. Table 1 cate. and in many cases they are so ex- treme as to preclude identification of a regular period. 2000) based on primary basic gree to which a given sample deviates from pure period- signal representations from which measures are derived. levels spanning a the other measures. many factors related to dence between f0 and intensity is mapped in a voice deviations from a pure f0 can contribute to pitch per- range profile. respectively—and by a set number of semitones. some more modern algorithms tal morphology is multidimensional—superior-inferior process components through several types. 2000). and some anterior- Baken and Orliko¤. Because prehensive of the range of available measures or the phonation is ideally a nearly periodic process. (For more asymmetry is a basic feature of the two-mass model detail on the measurement types. 1991). Baken dardized to control for this dependence e‰ciently. Outline of Traditional Acoustic Algorithm Types f0 statistics Short-term perturbations Acoustic assessment of voice in clinical applications is Long-term perturbations dominated by measures of fundamental frequency ( f0 ). posterior asymmetry is also inevitable—rendering it un- proaches should be selected for (1) interpretability with likely that a glottal pulse will be marked by a discrete or respect to aerodynamic and physiological models of even a single instant of glottal closure. are usually valid only when the prior identification of the periodic component in the extracted from sustained vowel phonations. and (Ishizaka and Flanagan. f0 and intensity. 2000. There are many conceptual problems with this Although these categories are intended to be exhaustive simplification. the deviations from periodicity may be either measures to characterize vocal function. 1987): an increase in any one of the underlying dardized elicitation protocols that include sustained phenomena detected by a single measure will also a¤ect vowel phonations at habitual levels. At the physiological level. 2000. it should be understood that perturbations and over headset microphones with direct digital acquisition NHR-type measures will usually covary for many rea- at very high sampling rates (at least 48 kHz). these basic acoustic descriptors—f0 . signal (based on glottal pulses in the time domain or These basic descriptors are not in any way com. per- intensity. focused profiling in which samples related to habitual f0 tual correlates—pitch and loudness. 1994. 1961) and spectral noise Radiated signal measurements (Yanagihara. brand. Interdependence of Basic Measures. sons. in part because of the availability of elec. Pabon. or related to habitual should be assessed for both stability and variability and intensity by a set number of decibels. could be stan- compared to age and sex norms (Kent. Awan. shimmer. have very clear percep. The chief problem with (Titze. 1967). the simplest ones being methodological (Hillen- rials to be assessed should be obtained following stan. it is available signal properties and dimensions. This dependence is not often assessed rigorously. Cepstra tems). Multi-Dimensional Voice Long-term average spectra Program [MDVP]. 1990). however. such Long-term perturbations as noise-to-harmonics ratio (NHR). perturbation nation of f0 . At the level of the phonation and (2) the incorporation of multivariate signal. Note. erence. the primary level of con- tensity is well known (Klingholz. see Buder. 1990. that not all nearly all acoustic assessments of voice is the determi- measures will be appropriate for all tasks.) Modern algorithmic ap. random or correlated. and speech tasks designed to elicit variation Periodicity as a Reference. valuable assessment for the professional voice user At any or all of these levels. it becomes questionable (Coleman. 1993). Waveform perturbations Spectral measures tronic and microcomputer-based instruments (e.. icity. Finally. However. Ideally. harmonic structure in the frequency domain). running speech. Kay Spectrographic measures Elemetrics Computerized Speech Laboratory [CSL] or Fourier and LPC spectra Multispeech.g. Absolute measures Flow-mask signals of vocal intensity are equally basic but require calibra. The interdepen. logical to conceive of voice measures in terms of the de- gorizes measures (Buder. Dynamic measures tions and associated instrumentation (Winholtz and Titze. cern is the signal. 1972). glot- and mutually exclusive. or phonetogram. Amplitude statistics cycle-to-cycle perturbations of period ( jitter) and inten. client’s vocal range in both f0 and intensity. Fi- and Orliko¤.

. 2001). 2001). period-doubling/tripling/. Average f0 . fundamental.) In this sustained vowel phonation by a middle-aged The acoustic measures of the segments displayed in woman with spasmodic dysphonia. %shimmer. including stable points. Figure 1 reveal the nontrivial di¤erences that result. As in most highly nonlinear fundamental is valid during this episode. depending on where in the waveform the algo- Figure 1 displays a common form for one such bifur. categorized on the basis of bifurcations.4 Part I: Voice Figure 1. inspec- for further subtypes). analyses (bottom panel).. quency. . one at the ommending a typology for categorizing deviations from targeted level of approximately 250 Hz and another periodicity in voices (see also Baken and Orliko¤. although it can also be understood in this limit cycles. Satalo¤ tal. rithm is applied. harmonics is clearly visible in segment b (similar pat. There is therefore some ambiguity as to which and Hawkshaw. 1994. and Speech issued a summary statement (Titze. all the major categories. %jitter. deviations from periodicity can be tomatic analysis could plausibly identify either frequency. a transition to sub. (Here the waveform-matching algorithm implemented in itative changes in vibratory pattern from one of these CSpeechSP [Milenkovic. extractions are presented for this segment. . 2000. 1997] does identify either fre- states to another. SNR results for selected segments were from the ‘‘newjit’’ rou- tion waveform (top panel) with two fundamental frequency tine of TF32 program (Milenkovic. 1995) rec. and an au- dynamic systems. which the tracker finds one octave below this. Approximately 900 ms of a sustained vowel phona. Two f0 eration. justify this 125-Hz analysis as a new fundamental fre- tems. quency. depending on the basic glottal pulse form under consid- terns occur in individuals without dysphonias). initiating the algorithm within the cation and illustrates the importance of accounting for subharmonic segment predisposes it to identify the lower its presence in the application of perturbation measures. . and chaos can context as a subharmonic to the original fundamen- be observed in voice signals (Herzel et al. When the pulses of segment a are considered. This typology capitalizes on the tion of the waveform and a perceived biphonia both categorical nature of dynamic states in nonlinear sys. or sudden qual.

but again. At right is a spectrum schematic showing four e¤ects. which is positively correlated with overall har. correlated with high-frequency harmonic energy). but the segment-by. aerodynamic models Figure 2. due to high airflow through the glottis is schematized by (d). Spectral features associated with models of phonation. In any case. in segment b. showing the rate of change sures of the glottal flow waveform). See voice acoustics for other flow derivative. ments. assessment by means of perturbation However. this argument may need to be reversed for the segment validity of applying perturbation measures with acoustic domain. In clinical settings. If. inferences from acoustic signal. Acoustic Assessment of Voice 5 the perturbations around the base period associated with ings. Regarding perceptual voice rat. The e¤ect of turbulence in flow. However. acoustic analysis is thoroughly grounded for interpreta- ment b and into c. The LF harmonic energy. this low-frequency region is also positively model of glottal flow is shown at top left. acoustic voice assess- tions might be analyzed with respect to the subharmonic ment often serves to corroborate perceptual assessment. Alternatively. mechanism). and Physiological Correlates In attempting to draw safe and reasonably direct of Acoustic Measures. jitter model that any assessment on acoustic grounds can be and shimmer are ascribed to ‘‘random’’ variations. (b) dynamic leakage or non-zero return phase and spectral characteristics. graphical and quantitative associations between glottal status monic energy). However. then interpreted (though this does not preclude development the correlated modulations of a strong subharmonic ep. It is only by reference to a specific a particular f0 as reference. and (c) pulse including the Liljencrants-Fant (LF) model of glottal flow and skewing (which is negatively correlated with low-frequency aperiodicity source models developed by Stevens. tional assessments on several important methodological turbations around the longer periods of the lower f0 are and theoretical points. Perceptual. These e¤ects include three derived parameters of the LF model: indicating the associated appearance of high-frequency aperi- (a) excitation strength (the maximum negative amplitude of the odic energy in the spectrum. At bottom left is the correlated with open quotient and peak volume velocity mea- LF model of glottal flow derivative. Many important of phonation. while shimmer and the apply to acoustic analysis if (1) acoustic analysis is vali- signal-to-noise ratio show some degradation). these points may not still low ( jitter is improved. f0 . Gerratt and Kreiman (2000) have critiqued tradi- the high f0 are low and normative. consider not just voice typing. following the point of maximum excitation (which is negatively . as guided by auditory experience and in con- statistics with no consideration of their underlying junction with the ear and other instrumental assess- sources is unwise. of an independent model for a pathological phonatory isode should be excluded. Gerratt and Kreiman also argue that methodological and theoretical questions should be clinical classification may not be derived along a contin- raised by such common scenarios in which we must uum that is defined with reference to normal qualities. and (2) perturbations around the high f0 tracked through seg. per. as is often assumed. the perturbation statistics are all tion in some clear aerodynamic or physiological model increased by an order of magnitude. dated on its own success and not exclusively in relation when all segments are considered together to include the to the problematic perceptual classifications. Aerodynamic. the perturba. careful acoustic analysis can be oriented to the identification of physiological status.

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Callen Lieberman. 110. and Bucella. 597–603. as is a model with clear and meaningful gram. D. 1991. P. M. and Kreiman. Perturbation-free measurement of the Group.6 Part I: Voice of glottal behavior present important links to the quality measurement (pp. Theoretical and method- ological development in the study of pathological voice Strube. P. and Vilkman. Figure 2 summarizes selected parameters quality... D. N. J..). Glottal characteristics of female (1997) and the glottal turbulence source following speakers: Acoustic correlates. M. and Hearing Research. J. 1989) and useful in refined Speech and Hearing Research. Voice quality measurement transduced acoustic recording (Davis. Nı́ Chasaide and Gobl. Qi. and Sundberg. In M. Berry. P. (2000). B. model for acoustic speech signals. nation. 213–219. E. see also voice acoustics for other ap. CA: Singular Publishing Group. and additive noise in synthetically generated voice signals.. P. 1973) or a microphone. and Saleh. e¤orts at inverse filtering (Fröhlich. 1999.. Strube. R. J.. 67–79. D. and Tasko. A four-parameter terpretation of spectral features. Spectral correlates of the LF model have proved to be meaningful in acoustic glottal voice source waveform characteristics. 51. E. (2000). harmonics-to-noise ratio in voice signals using pitch syn- Buder. 706–720. such as the Liljencrants-Fant (LF) model 43. Aspen. (2000). Selec- tion and combination of acoustic features for the descrip- References tion of pathologic voices. Acoustic voice analysis by means of the hoarseness dia- Stevens. (1997). Glottal character- Other spectral-based measures implement similar istics of male speakers: Acoustic correlates and comparison model-based strategies by selecting spectral component with female data. Chasaide and Gobl. H. ciety of America. 700–706. S. 1999). Speech Transmission Laboratory of the first harmonics and at the formant frequencies. Sources of variation in phonetograms. Journal of the Acoustical 1997. MD: ison. H. H. (1994). perturbations and modulations (Murphy. J. Liljencrants. (1972). D. and Palmer. America. D. the glottal-to-noise. Baken. and Strube. Roy... Michaelis. M. Quarterly Progress and Status Report. Journal of the Acoustical Soci- ulation of algorithms 1902–1990. (1975).. D. Fröhlich. R. 1994. In M. J. E. 103–116).. 2000). S.). D. Glottal parameter: A new method for quantification of the glottal to noise excitation ratio: A new measure for describing flow. 1233–1268. (1997). TX: techniques for voice will only improve with the inclusion Pro-Ed. or employ curve-fitting 1008–1019. 33. Journal of Phonetics. resentations (Wolfe. Parabolic spectral Michaelis. 1975). 37. 30. Rather than attempting to Journal of Voice. A methodological study of perturbation (Alku. P. The voice diagnostic profile: A practical Milenkovic. proved to be labor-intensive and prone to error (Nı́ Coleman. Fröhlich. San Diego. Journal of Speech and Hearing Research. Kent. Journal of the Acoustical Society of ratios (e. Journal of Speech and Hearing Research. . L. of the LF source model following Nı́ Chasaide and Gobl Hanson. R. —Eugene H. (1994). may be an e¤ective alternative when guided by knowl. Liljencrants.. I. Klingholz. CA: Singu- physiological domain. Synthesis of voiced detecting turbulence at the glottis. Gramss. sounds from a two-mass model of the vocal cords. (1993). and Lin. 1–13.. Cornell. (1997). Fröhlich. and statistical models to produce more robust measures Hillenbrand. M. Hanson. 22. and Orliko¤. Figure 2. F. (2001). H. Clinical measurement WI: University of Wisconsin–Madison. and infer. and Gerratt.

. (1991). N. R. De Bodt. (1990). I. 2000). These approaches have been primarily employed to study re- A number of methods have been used to quantitatively spiratory function during continuous speech and singing assess the air volumes. 1997. Montgomery. body is altered during respiration (see Cala et al.. F. B. 43. CA: Singular Pub. The clinical use of aerodynamic measures to e¤orts to develop more accurate methods for non- assess patients with voice disorders has been increasing invasively monitoring chest wall activity to capture finer (Colton and Casper. 1990). (1997). Hearing Research. Whitteridge. (1994). and Palmer. Air volumes 427–461). Chaos in 1971) or pneumotachograph (Isshiki. Airflow associated with pho- human communication has focused primarily on the nation is usually specified in terms of volume velocity measurement of the air volumes that are typically (i. Cornell. Objective acoustic voice-quality timeters. 1959).. R. 1973. 796–809.. The estimation of total lung volume. Journal of Voice. J. Hoit et al. Conversion of a head- mounted microphone signal into calibrated SPL units. and Titze. 105. signal-to-noise ratio in continuous speech for disordered Both direct and indirect methods have been used to voices. Journal of the Acoustical Society of America. . of voice (e. L.. Hillman. Principles of voice production. W. M. cubic cen- Pabon.. and air pressures in. Germany: Springer-Verlag. and velocity airflow rates for voice production are typically on specifying the ranges of lung inflation levels across reported in metric units of volume displaced (liters or which such tasks are normally performed (cf. The use of a medicine: Source readings. San Diego. and subjects in a sealed chamber called a body plethysmo- Hearing Research.. Voice source variation. tasks that include both voiced and voiceless sound pro- volved in voice production. which are su‰cient for assessing selected Schoentgen. 11. There are also ongoing duction. 53. tent. C.. Direct 2532–2535. The handbook of phonetic sciences (pp. airflows. cubic centimeters) per second. Aerodynamic Assessment of Vocal Function 7 Nı́ Chasaide. R. and Hearing Research. 1964). Stevens. Cambridge. Volume expended during selected speech and singing tasks. I. R. (2000). The Dysphonia Severity tional changes in body torso size. M. V. (1991). (2000). (1995). to a measurement device such as a spirometer (Beckett.). velopment and application of indirect measurement Winholtz.e. is that changes in lung volume are reflected in propor- Heylen. and details of how the three-dimensional geometry of the Zeitels. (1998). Acoustic phonetics. 34.. 1967). Bensaid. S. NJ: Prentice Hall. models. 203–216. and Hawkshaw.). IA: National Center for Voice man and Kobler. 509–516. Journal of Speech and the body during respiration (Draper. Measurement of Air Volumes. Lan. Acoustic corre.. The methods have been duction. H. 1996. In J. approaches.. MA: so that auditory feedback is reduced or distorted and MIT Press. and Gobl. One relatively cum- Index: An objective measure of vocal quality based on a bersome but time-honored approach has been to place multiparameter approach. Hixon. 1985. Hillman and Kobler. as opposed to assessing air volume usage during mostly used in research to investigate mechanisms that phonatory tasks that involve only laryngeal production underlie normal and disordered voice and speech pro. G. mouthpiece essentially limits speech production to sus- lishing Group. Qi. (2001). (1999).. Workshop on acoustic voice analysis: Sum. which are inherent to the use of devices placed Cli¤s.. sustained vowels). L. J. milliliters) and lung inflation levels are usually parameters in the computer phonetogram. movements and that the oral acoustic signal is degraded.. Heidelberg. M. measurement of orally displaced air volumes during Rothenberg. Language. Watson and Hixon. There are also to characterizing dysphonic voices. volume of air displaced per unit of time). and Fastl. Millet. 531–541. 1493–1508.. graph to allow estimation of the air volume displaced by Yanagihara. 1994) that unob- trusively monitor changes in the dimensions of the rib Aerodynamic Assessment of Vocal cage and abdomen (referred to collectively as the chest Function wall) that account for the majority of respiratory-related changes in torso dimension (Mead et al. K.g. concerns that face masks interfere with normal jaw guage. Laver (Ed. These limi- Titze. F. 2000) have helped motivate the de- and Speech. Titze. Hoit and Hixon. (1973). using indirect approaches for estimating lung volumes lates of pathologic voice types. specified in terms of a percentage of the vital capacity or 5. Journal of Speech. Goldman. and Milstein. Oxford. I. (Eds. Englewood tations. plus additional measurement-related restrictions (Hill- mary statement. UK: Blackwell.. 1632–1645. inductance plethysmo- graphs: Sperry. in or around the mouth to directly collect oral airflow. Multi- variate statistical analysis of flat vowel spectra with a view volumetric-based phonatory parameters. Remacle. T. simultaneous acoustic analysis is limited. measure air volumes expended during phonation. Jour. The basic assumption underlying the indirect approaches Wuyts. Goldman. 1996). and Mead.. Molenberghs.. (1997). are measured in standard metric units (liters. Most speech breathing research has been carried out Wolfe. 1973. Satalo¤. Hillman. A new inverse-filtering technique for phonatory tasks can be accomplished. Ladefoged. to a limited ex- deriving the glottal air flow waveform during voicing. C. Journal of Speech and by means of monitoring changes in body dimensions. M. Respiratory research in Measurement of Airflow. tained vowels. and Perkell. Y. S. by means of a mouthpiece or face mask connected nal of the Acoustical Society of America. Journal of Speech. R. (1967). P. H. and Mead. Hillman. Psychoacoustics: Facts and ing research are transducers (magnetometers: Hixon. and Hearing Research. 1987. A. E.. R. Iowa City. 43. 417–421. C. et al.. More often used for speech breath- Zwicker. Journal of Voice.. N. and Bucella. M. 10. Significance of harmonic changes and noise components in hoarseness.

the acoustic signal.8 Part I: Voice Estimates of average airflow rates can be obtained by rapidly opens and closes during flow-induced vibration simply dividing air volume estimates by the duration of of the vocal folds (the glottal volume velocity wave- the phonatory task. Thus. and glottal waveform parameters. 1988). average subglottal air pressure. There has nance activity (formants) of the vocal tract. The glottal volume velocity waveform cannot be usually been estimated during vowel phonation by using directly observed by measuring the oral airflow signal a mouthpiece or face mask to channel the oral air stream because the waveform is highly convoluted by the reso- through a pneumotachograph (Isshiki. Hillman. aerodynamically by processing the output of a fast- tal airflow rates can be obtained from the oral airflow responding pneumotachograph (high-frequency re- during vowel production because the vocal tract is rela. intraoral air pressure. sponse) using a technique called inverse filtering. the vocal tract. 1964). Instrumentation and resulting signals for simultaneous collection of oral airflow. Estimates of average glot. lung volume. mated and the oral airflow signal is processed (inverse There have also been e¤orts to obtain estimates of the filtered) to eliminate them (Rothenberg. Figure 1. in tively nonconstricted. Average glottal airflow rates have form). and Perkell. 1977. This has typically been accomplished Colton. Signals shown in the bottom panel are processed and measured to provide estimates of average glottal airflow rate. Holm- actual airflow waveform that is generated as the glottis berg. and chest wall (rib cage and abdomen) dimensions during production of the syllable string /pi-pi-pi/. 1987). re- also been somewhat limited use of hot wire anemometer covery of the glottal volume velocity waveform requires devices (mounted in a mouthpiece) to estimate average methods that eliminate or correct for the influences of glottal airflow during sustained vowel phonation (Woo. with no major sources of turbulent which the major resonances of the vocal tract are esti- airflow between the glottis and the lips. . and Shangold.

Journal of Speech and can be obtained via the placement of an elongated Hearing Disorders. R.. Respi- and Hixon. J. San Diego. indirect estimates of subglottal air pres. vocal function.). C. (1959). J. tion. 1964). M. Goldman. data for aerodynamic measures that is universally sures associated with voice and speech production are accepted and applied in research and clinical work. and Boves. T. anesthetization of the larynx that is required can a¤ect San Diego. Pressure measurements dur- of lung volume. dynamic phonatory parameters in the normal popula- way through a puncture in the anterior neck at the cri. and Zeitels. R. Kenyon. sert a very thin catheter through the posterior cartilagi. CA: /pi-pi-pi-pi-pi/) at constant pitch and loudness. Ferrigno. The needle is connected that provide estimates of normative values for selected to a pressure transducer by tubing. (1996). J. Holmberg. parameters aimed at better elucidating underlying Hoit. Journal of Speech and Hearing pressure just behind the lips with a translabially placed Research. or that relate aerodynamic vocal folds are of primary interest for characterizing the parameters to simultaneously obtained acoustic mea- pressure di¤erential that must be achieved to initiate and sures. abdomen. 1981). and lung... Understanding voice level. Di. Cala.. balloon-like device into the esophagus (Liberman. A. This is usually done by sensing air ratory muscles in speech. during /p/ production. There have been numer. Methods for collecting such data have not been stan- Both direct and indirect methods have been used to dardized. This Singular Publishing Group.. As is the case for most measures of essentially equal to atmospheric pressure and only sub. sure transducers: Impact on models for speech production. G. 30. Aerodynamic mea- intraoral pressure measures are obtained as subjects sures of voice production. up positive supraglottal pressures. or to use an array of —Robert E. (1985). 2. Hixon. Baltimore: Williams and Wilkins. there is not currently a set of normative glottal pressure measurements are obtained. 81. It is also possible to in. 16–27. Clinical measurement of voice and speech. 16. matics of the chest wall during speech production: Volume ous attempts to extend the utility of aerodynamic mea. displacements of the rib cage.. Measurements of air usually take the form of ratios that relate aerodynamic pressures below (subglottal) and above (supraglottal) the parameters to each other. Under these condi- tions.. (2000).. and the heavy topical Baken. M. Montgomery. Air pres. 78–115.. Such derived measures Journal of Speech and Hearing Research. CA: Singular Publishing Group. In R.. These methods References cannot be tolerated by all subjects. S. 36. thus allowing pressure to equili. Carnevali. 1981). 1996). Journal of the Acoustical Society of America. Accurate use of this treatment. Hillman miniature transducers positioned directly above and be- low the glottis (Cranen and Boves. Age and speech breathing. B. 1543– sure during specially constrained utterances (Smitheran 1551. and Whitteridge. The respirometer as a diagnostic and Indirect estimates of tracheal (subglottal) air pressure clinical tool in the speech clinic. P. J. method works because the vocal folds are abducted Hillman. 77. (2) vocal tory phonation. Kent and M. 5. it is usually assumed that supraglottal pressure is Normative Data. J. su‰cient size or appropriately stratified in terms of age rect measures of subglottal air pressure can be obtained and sex to ensure unbiased estimates of underlying aero- by inserting a hypodermic needle into the subglottal air. into the esophagus to be positioned at the midthoracic Colton. Current Opinion in Otolaryngology–Head and Neck Surgery. catheter connected to a pressure transducer. and Mead. usually specified in centimeters of water (cm H2 O). Hillman. 1996. R. These Hillman. P. Aerodynamic Assessment of Vocal Function 9 Measurement of Air Pressure. Col- accurate but also very invasive. D. R. ton and Casper. M. The catheter is connected to a pressure transducer problems: A physiological perspective for diagnosis and and the balloon is slightly inflated. there are several sources in the literature cothyroid space (Isshiki. and Casper. R. that is typically inserted transnasally and then swallowed Journal of Applied Physiology. Aliverti. and Kobler. and study samples have generally not been of measure subglottal air pressures during phonation. T..g. 351–366. S... ing speech production using semiconductor miniature pres- Noninvasive. Chest wall and lung The deflated esophageal balloon is attached to a catheter volume estimation by optical reflectance motion analysis. (1997). M.. air pressure measurements e‰ciency (Schutte. normal function. J. (1996). However. This method is very aerodynamic measures (Kent. invasive method also requires simultaneous monitoring Cranen. L. . (1996). (1973). 172–175. 1988). 1988). Kine- Additional Derived Measures. sure can be obtained by measuring intraoral air pres. L. (1971). B. Common examples include (1) airway (glottal) maintain vocal fold vibration during normal exhala. and (3) measures that interrelate glottal acquired during vowel phonation when there are no volume velocity waveform parameters (Holmberg. Baken.. Current diagnostics and o‰ce practice: Use of ob- brate throughout the airway. making intraoral pressure jective measures of vocal function in the multidisciplin- equal to subglottal pressure (Fig. D. H. and Hixon. 1968). 235–241. E. 1980. J. 1). Ladefoged. Ball (Eds. 1985). and Per- related specifically to voice production are typically kell. Pedotti. nous glottis (between the arytenoids) to sense subglottal air pressure during phonation. M.. In practice. K. Beckett.. The handbook of voice quality measurement. 2680–2689. Draper. (1987). J. ary management of voice disorders. A. P. 1994. mechanisms of vocal function. et al. W. Hill- vocal tract constrictions of su‰cient magnitude to build man. E. and Perkell. resistance (see Smitheran and Hixon. Journal sures by using them in the derivation of additional of Speech and Hearing Research. See also voice production: physics and physiology. produce strings of bilabial /p/ þ vowel syllables (e.

which seeks to conserve portions of the larynx. tion (Diedrich and Youngstrom. and Shangold. the upper aerodynamic (oral and pharyngeal) pathway. Reference manual for communicative near the sternal notch. general categories in which an alternative. and Perkell. ward to the anterior midline neck and sutured into place Kent. H. 138–146. Pul- the primary structure for voice generation lost. from squamous epithelial tissue of the true vocal fold 1994) and tracheoesophageal (TE) speech (Singer and (Bailey. cative component to be addressed via voice and speech tion in a patient with nodules. if Schutte. 33. and Mead. (1968). 84. typi- Loss of the larynx due to disease or injury will result in cally an electronic source. 96. J. There are two Research. or the electrolarynx. J. nal of Speech and Hearing Research. lignant lesions are su‰ciently large or when the location hence. The fundamental di¤erences physiological. for estimating laryngeal airway resistance during vowel production. alaryngeal Woo. The dis- Otology. 1383–1384. tinction between these two methods is contingent on the manner in which the alaryngeal voice source is achieved.. Doyle. (1981). J. and Laryngology. Under these circumstances. Regulatory mechanisms of vocal intensity communication. 1998. and loca- et al. and because of the Blom. ynx. Holmberg. P. Hillman. that is. and Perkell. Speech breathing in children and adolescents. 1994). Direct comparison of subglottal and When the laryngectomy is completed. (1977). L. J. larynx. Isshiki. 1787].. P. and esophagus. 7. when ma. height.. R. Colton.. Journal of Speech and Hearing Disorders. normal. Phonatory voice source may be achieved.10 Part I: Voice Hoit. N. 511–529. some alternative method of providing a new. an alternative method of creating an Smitheran.. Gronin. N. psychosocial. 20. Jour. Journal of Medical Speech. and between intrinsic and extrinsic methods of alaryngeal communication domains. E. 1157–1164. 85(4).. Although total laryn- Intrinsic Methods of Alaryngeal Speech gectomy may occur in some instances due to traumatic injury. total laryngectomy neces- sciences and disorders. The e‰ciency of voice production. 28. extrinsic methods of alaryngeal speech rely on the use of an external sound source. (1987). alterna- Rehabilitation tive physical-anatomical structures are used to generate sound.. D. the majority of cases worldwide are the result of The two most prominent methods of intrinsic alaryngeal cancer. and Hixon. psychological. While these two intrinsic methods of location of many of these lesions. 1999). Science. (1994). The Netherlands: Kemper. that of the structures of the upper airway. Annals of described as intrinsic and extrinsic methods. 1980). Respiratory kinematics in classical (opera) singers. R. E. Approximately 75% of all laryngeal tumors arise speech are esophageal speech (Diedrich. J.. P. 137–145. J. 104–122. Hixon. J. is disrupted. 155–176. the most significant communi- an inductance plethysmograph to assess respiratory func. 1966. 2. laryngectomy. (1980). Peterson. Journal of Speech and Hearing Research. intimate relationship between the pulmonary system and Rothenberg. 1966. One . W. Therefore. T. (1985). (1988). ating oscillation of tissues in the area of the lower phar- tion. This vibratory structure is the use of combined chemoradiation protocols (Hillman somewhat variable in regard to width. verbal communication is to be acquired and used post- gen. J. Glottal airflow and transglottal air pressure measurements E¤ects of Total Laryngectomy for male and female speakers in soft. Surgical removal of the lar- speech are discussed below. the preferred term for this alaryngeal voicing of the tumor threatens the lymphatic compartment of source is the pharyngoesophageal (PE) segment. Journal of the Acoustical way will remain separate from the oral cavity. D. In contrast. rehabilitation is the lost voice source. Society of America. 43. Methods of Postlaryngectomy Communication Sperry... 549–555. or ynx and upper esophagus. Measurement of airflow in speech. the larynx. total laryngectomy is often indicated for rea- (1990). sons of oncological safety (Doyle. San Diego. S. This rely on generation of an alaryngeal voice source by cre- may include radiation therapy or partial surgical resec. and loud The two most prominent e¤ects of total laryngectomy as voice [published erratum appears in Journal of the Acousti.. The use of Following laryngectomy. These categories are best airflow analysis in patients with laryngeal disease. but the monary ventilation measured from body surface move- ments. Once the larynx is Language Pathology. Damste. pharynx. Watson. J. sequently the vocal tract. social. E. Grimgy. Lieberman. involves resectioning the entire framework of the larynx. the trachea is brought for- 17–29. Orliko¤ et al.. Thus.. Hillman. both proaches to medical intervention may be pursued. N. (1964). the tracheal air- esophageal pressure during speech. In some instances.. from the top of the trachea. Rhinology. H. and con- Journal of Speech and Hearing Research. T. 156. 1989. R. a surgical procedure are change of the normal airway cal Society of America. Journal of Speech and Hearing ‘‘alaryngeal’’ sound source is required. or what is termed the artificial numerous and significant changes that cross anatomical. S. alaryngeal speech are dissimilar in some respects. (1967). 1986). P. Watson. Intrinsic alaryngeal methods imply that the alaryngeal Alaryngeal Voice and Speech voice source is found within the system.. M. (1994). T. However. removed. J. 51–69. and Hixon. CA: Singular Publishing sitates that the airway be permanently separated from Group. E. not only is Mead. J. R. less aggressive ap. Once the larynx is surgically removed variation. or total laryngectomy. B. J. R. 1985). and Morgan.. A clinical method alaryngeal voice source must be achieved. 46. Journal of the and loss of the normal voicing mechanism for verbal Acoustical Society of America.

thesis and into the esophageal reservoir. this air can be used way TE puncture voice prosthesis (Singer and Blom. This is 1994). many esophageal voice restoration is not problem-free. Horii. 1961). Because of this. intensity. voicing source as traditional esophageal speech. segment. 1963): (1) the ability to phonate reliably on de. and Esophageal Speech. either by hand the tissue of this sphincter will oscillate. (2) the ability to maintain a short latency between tional) characteristics of the signal in response to air insu¿ation and esophageal phonation. This is a direct consequence of the esoph- methods require the individual speaker to actively ma. is enhanced dation skills have been shown to reflect those progressive considerably. However. (e. the intensity is greater. air will move in an utterance. TE for esophageal voice production. and durational process of skill building that must be achieved under the variables to be altered in a fashion di¤erent from that of direction of an experienced instructor. This access The acquisition of esophageal speech is a complex permits a variety of frequency. 1953. which method of air insu¿ation is used. fundamental esophageal and TE methods of alaryngeal speech. juncture).. Though widely used. Specifically. yngeal muscle. that when the tracheostoma is occluded. and as a result. his or her ability to (Berlin. volumes of air into the reservoir.e. Beyond the commonality in the use of the esophageal speakers will exhibit limitations in the phy- PE segment as a vicarious voicing source for both sical dimensions of speech. 1980). either at the time of laryngectomy or as a second following other methods of air insu¿ation. signal (i. Regardless of occur. stop consonants). the PE spheric pressure within the oral cavity/vocal tract (Die.. maintain voicing. Speech intelligibility is also tonically closed PE segment in order to insu¿ate decreased due to limits in the aerodynamic and voicing the esophageal reservoir (located inferior to the PE seg. While a dis.. Snidecor. this air can then The design of the TE puncture voice prosthesis is such be forced back up across the PE segment. the prosodic contour of may be accomplished with nonspeech tasks (tongue esophageal speech and associated features is often per- maneuvers) or as a result of producing specific sounds ceived to be abnormal. tinction between direct and indirect methods permits TE speech is best described as a surgical-prosthetic increased understanding of the physical requirements method of voice restoration. Limitations in speakers who exhibit high levels of proficiency will often application must be considered. Snidecor. the TE method capitalizes on the individual’s access to In contrast. for many reasons.g. in TE speech the speaker is able to drich and Youngstrom. that of normal speech. intensity is reduced by about 10 dB SPL from that of the normal speaker (Weinberg. the Smith. perceptual identification of b for p) direct or indirect approaches to insu¿ation.. typically involves tasks that address four skills believed Pauloski. 1984. This esophageal or via use of a complementary tracheostoma breathing sound source can then be manipulated in the upper valve. the speaker indirectly creates a negative several distinct advantages relative to esophageal speech. intensity. For esophageal speech. Doyle. (3) the ability changes in the aerodynamic driving source. Similarly. Direct are common. and (4) the associated changes in prosodic elements of the speech ability to sustain voicing while articulating. which ultimately alters the normal across the segment (inferiorly) into the esophagus. 1968. access and use pulmonary air as a driving source. Clinical emphasis the traditional esophageal speaker (Robbins et al. and the . to generate PE segment vibration in the same manner 1980). which o¤ers insu¿ation. 1968). pressure in the esophageal reservoir via rapid inhalation through the tracheostoma. When pressure build-up is achieved in the oral must frequently reinsu¿ate the esophageal reservoir to cavity via compression maneuvers. geal speech. and when the pres. In contrast to esophageal speech. air is directed from the trachea through the pros- regions of the vocal tract into the sounds of speech. Air then moves passively across the PE segment achieved by the surgical creation of a controlled midline in order to equalize pressures between the pharynx and puncture in the trachea. the frequency is reduced by about one octave (Curry and manner in which these methods are achieved does di¤er. 1998). Diedrich. Because the TE speaker has direct ac- to be fundamental to functional esophageal speech cess to a pulmonary air source. TE speech uses the same pressure in the esophagus relative to the normal atmo. intonation. Such changes have a positive impact on abilities that have historically defined speech skills of auditory-perceptual judgments of this method of alaryn- ‘‘superior’’ esophageal speakers (Wepman et al. stress. procedure at some point following laryngectomy.g. These foun. modify the physical (frequency. for the indirect (inhalation) method of air pulmonary air for esophageal insu¿ation. However. characteristics of esophageal speech. and the durational characteristics of speaker must move air from the oral cavity across the speech are also reduced.. Thus. Alaryngeal Voice and Speech Rehabilitation 11 muscle that comprises the PE segment is the cricophar. Esophageal speakers sure. Regardless of which method of insu¿ation is used. Two methods of insu¿ation may be utilized. followed by insertion of a one- esophagus. voiced-for-voiceless per- These methods might be best described as being either ceptual errors (e. and dura- mand. This results in a negative Tracheoesophageal Speech. As it is not an ment). the successful acquisition of While the frequency of TE speech is still reduced from esophageal speech may be limited. it is not uncommon to sure becomes of su‰cient magnitude to overcome the see esophageal speakers exhibit pauses at unusual points muscular resistance of the PE segment. Once insu¿ation occurs. and complications may utilize both methods for insu¿ation. abductory-adductory system. This rhythm of speech. 1966. along with to maintain adequate duration of voicing. ageal speaker’s inability to insu¿ate large or continuous nipulate air in the oral cavity to e¤ect a change in pres.

The mechanism of esophageal speech. 1984). For TE speech. P. B. G. the individual speaker’s needs. 400–407. is seeking to modify the nature of the electronic sound source produced. and Reed. the speaker is able to sion of the complex picture of a successful return to as modulate the electrolaryngeal source into speech. Curry. Speech dergone a laryngectomy will confront myriad restrictions can be acquired relatively quickly. communicative. Further. C. Its major limitations have traditionally related to dress these areas may increase the likelihood of a suc- negative judgments of electrolaryngeal speech relative to cessful postlaryngectomy outcome. All individuals who have un- The electrolayrnx is generally easy to use. use of a given changes in the overall physical character of TE speech method may be enhanced so that the individual may o¤ers considerable advantages from the perspective of achieve the best level of social reentry following lar- communication rehabilitation.. 42–51. background noise. normal. Current research See also laryngectomy. . 1988) tion must focus on making any given alaryngeal method despite continued voiced-for-voiceless perceptual errors. the mechanical nature of many devices. for artificial tation following laryngeal cancer. have distinct advantages and 71. While ‘‘normal’’ speech Doyle. Laryn- cation. H. and at least Hearing Disorders. 415–424. These devices good speech intelligibility) and is ‘‘functional’’ for basic provide an external energy (voice) source that is intro. disadvantages for esoph. C. alaryngeal speech has been acquired and it has been sic method of producing alaryngeal speech uses an elec. and Youngstrom. Foundations of voice and speech rehabili- a prosthetic device with associated costs. Lis- cannot be restored with these methods. Bailey and for-voiceless errors) due to the fact that the electrolarynx H. All methods of alaryngeal speech. and Snidecor. L. 53. (1963). In R. placing a device directly on the tissues of the neck The reacquisition of verbal communication is without (transcervical). Surgery of the larynx (pp. P. Biller (Eds. no matter how teners’ perceptions of consonants produced by esophageal proficient the speaker’s skills. whether esophageal. 155. (1986). As a those who have undergone total laryngectomy (Doyle. Danhauer. must be considered. 85–92). 303–317. speech. (1966). results in tronic artificial larynx. The most frequently used extrin. Advantages for esophageal speech include Damste.). communication purposes. CA: Singular larynx speech. psychological. J. ageal speech include lowered pitch. as proficient as possible. this does not imply that ‘‘re- duced either directly into the oral cavity (intraoral) or by habilitation’’ has been successfully achieved. I. loudness gectomee rehabilitation (2nd ed. result. they are portant caveat is necessary: Just because a method of not widely used today. quickly by most people and may be used in conditions of Annals of the New York Academy of the Sciences. A. and speech rate and prosody is near College-Hill Press. C. Doyle and Tanya L. TE. W. In this way. Philadelphia: Saunders. P. deemed ‘‘proficient’’ at the clinical level (e. postlaryngectomy rehabilitation e¤orts that ad- 1994). 257–278).e. Whether the electrolaryngeal tone is question a critical component of recovery and rehabili- introduced into the oral cavity directly or through tation postlaryngectomy. Journal of Speech and postlaryngectomy communication options. pp. given the external nature of the alaryngeal voice source and the electronic character of References sound production. Darley (Eds. Methodology and curves of skill acquisition. Doyle.). Bailey. and the device o¤ers in multiple domains. and social. M. 28. or electrolaryngeal. J. C. But an im- some pneumatic devices have been introduced. or electrolarynx. F. (1985). In contrast. Extrinsic methods of though one or another may be preferred in a given alaryngeal voice production are common. disadvantages. however. Berlin. (1988). Thomas.. a mechanical quality is common and it Publishing Group. Although communication context or environment. C. and Reed. San Diego: exceeds normal. it involves use and maintenance of speech. pitch is near normal. it may be acquired Diedrich. is a continuous sound source (Weiss and Basili.12 Part I: Voice durational capabilities meet or exceed those of normal one method can be used with a functional communica- speakers (Robbins et al. J. Springfield.g. IL: Charles C. Physical measurement and pitch perception in esophageal speech. Some obstacles to learning esophageal a nonmechanical and hands-free method of communi. normal a life as possible. Rehabilitative Considerations Journal of Speech and Hearing Disorders. (1994). Although clinical interven- may be observed (Doyle. L.. nothing prevents an individual from using multiple methods of alaryngeal speech. voiced. In B. research into tive outcome in most instances. it is only one dimen- transmission via tissues of the neck. Alaryngeal rate. al- Artificial Laryngeal Speech. (1968). requires the use of one hand... the rapidity of speech reacquisition in addition as well as the relative strengths and weaknesses of each to the relative increases in speech intelligibility and the method. all methods are viable and tracheoesophageal talkers. L. physio- a reasonable method of functional communication to logical. (1961). yngectomy. The intelligibility of electrolaryngeal —Philip C. Professionals who work the influence of increased aerodynamic support in TE with individuals who have undergone total laryngectomy speakers relative to traditional esophageal speech on must focus on identifying a method that meets each speech intelligibility has suggested that positive e¤ects speaker’s particular needs. Clinical measurement of esophageal speech: I. Laryngoscope. Glottic carcinoma. San Diego.. A reduction in speech intelligibility is primarily observed for voiceless consonants (i. and speech Diedrich. Eadie speech is relatively good. Clearly. T. K. for artificial larynx speech. E.. Keith and F. For TE speech. 1985).. Danhauer. Finally. W. including anatomical. J. loudness. M.

Language Pathology. S. CA: College-Hill Press. B. 562–567. F. American Journal of becoming lodged in the trachea or bronchi (which would Otolaryngology. San Weiss. 605–612. 1–7. restoration following total laryngectomy (pp. ysis and enhancement of alaryngeal speech (pp. W. Journal of Speech and nique for restoration of voice after laryngectomy. Archives of Doyle.. Hengested. and phonation.). and Hearne. E. M. considerations in the treatment and rehabilitation of head and Archives of Otolaryngology–Head and Neck Surgery. W. R. G.. Essentials for alaryngeal speech: Psy- Snidecor.. Blom.. Rickard. Applications of the voice prosthesis during Further Readings laryngectomy. Iverson-Thoburn. E. Thomas. (Eds. 2–27.. T. Results of therapy. The larynx is intimately involved in respi- Gates. (1991). geal speech. A.. Anatomy of the Human Larynx 13 Hillman. Speech rehabilitation of the laryngec. D. 3.. The upper esophageal sphincter: Role in sive esophageal speech development. 120–126. Madasu. L. 98. and Keith. Current status of laryngectomy rehabilitation: II.. E. R. Ryan. A. J. C. M. R. Major complications fol. Di¤erences in speaking 576–578. (2000). and review of acoustic and temporal characteristics of lowing tracheoesophageal puncture for voice restoration. (1997). 417– Wepman. speech. The larynx is an organ that sits in the hypopharynx. R. Larynx preserva- Pauloski. H. F.. Blom. In E... 3. Darley tomized. J. Weinberg. G. J. 247–251. J. Contemporary after chemoradiation for advanced laryngeal carcinoma. J. and Hamaker. American Journal of Otolaryngology. Tumors of the head and neck: Clinical Springfield. E. I. I. Journal of the Acoustical Society of America. Assessing vocal function Doyle. J. Rhinology. Austin. 427. In A. Functional outcomes following treat. Archives of Oto- ment for advanced laryngeal cancer. D. Head and Neck Surgery.). (1967). Attitudes about laryn. (1984). H. Using an artificial larynx.. Wong.. A. and Laryngol- ogy.. A. J. Speech after laryngectomy: An overview D. (1987). Ryan. produced by laryngectomized subjects: Perceptual char. D.. R. Although it is the E. W. N. (1981). T. 31–33). M. T. R. Thomas. et al. I. C. Self-help for the laryngectomee (pp. Shanks. TX: 858–864. and Hayden. Production of intona- tion and contrastive contrasts in electrolaryngeal speech. 5.. Springfield. Lauder (Ed. sures in relation to judgment of alaryngeal speech accept- 294–300. Annals of Otology. P. (1998). (1982). Singer. R. Fisher. Haines. B. ability. M. Woodson.. Harrison. Scarpino. and tracheoesophageal speech production. C.. (1980). (1985). Otology. Sekey (Ed. Cantu.. Mickel. An endoscopic tech. C. R. (Eds. D. Wolf. cancer: Preliminary results. E. and R. E. B. P.. E. B. (1968). A. 216–219. B. it must be viewed primarily as a respiratory Gates. B. 111. 67. Andrews. MacGahan. 2. Causes of failure. 3.. CA: Singular Publishing Group. I.). and perceptual mea- acteristics.. and swallowing. Speech and voice rehabilitation of patients Otolaryngology.. G. Annals of Otology. and Laryngology.. 5–48). geal. Journal of Speech and Hearing Research. T.. tion with combined chemotherapy and radiation therapy in istics of tracheoesophageal voice. Kraus. IL: Charles C. San Reed. Blom. J. E. Robbins. Alaryngeal Orliko¤. advanced but respectable head and neck cancer. (1953).. D. B. Lawlis. C. 46. A comparative acoustic study of normal. prevents food from gectomee rehabilitation should change. at the crossroads of the upper respiratory and upper di- 8–14. Y. R. Pro-Ed. anism. Monahan. Current Opinion in Oto. M. Blom. Communicative Disorders. 111. M. (1984).. Sessions. ration. 8. A. esopha. S. (1982). Ryan. D. treated for head and neck cancer. B... C. cessful chemoradiation treatment for advanced laryngeal Pfister. ton.. 109–124. C. American Journal of Otolaryngology. J. and Smith. J. Tra. 9. esophageal and normal speech. Journal of Speech and Hearing Research. (1982). Strong. 850–859. 89. 18. Journal of Singer. Hayashi. The objective measurement of progres. E. chology and physiology. S. (1989). 8. Gates. 921–925. 182–186. M. Annals of Otology. Fisher. and Blom.. 97.. Hanson. TX: Lauder Enterprises. C. Weinberg. and Laryngology. 85–99. Phonoscope. M. and Watson. (1982). G.. B. and Weinberg. and Singer. through . and Yoshida. W.. 10. In this capacity it controls the flow of air into and of laryngectomee rehabilitation: IV. Baltimore: Wil. R. 161–168. E. 49. S. Surgical-prosthetic techniques for alaryn- Diego. 67–77. L. Pfister.. Singer. F. J. W. mary voice restoration at laryngectomy. L. Pri- Hong. I. Pfister. Hamaker (Eds. G. Keith and F. D. Cantu. spectral and intensity characteristics of esophageal speech... G. Electrolaryngeal speech Diego. 1781– cheostoma valve for postlaryngectomy voice rehabilita. Murry. M. Salmon. S. threaten life and interfere with breathing). (1985). J. laryngology and Head and Neck Surgery.). (1996/1997). esophageal speech. Journal of San Antonio. 529–533. Journal of Medical Speech- and Zelefsky. Frequency. Long-time liams and Wilkins. 97–103. IL: Charles C. K. and Lauder. G. M. 123–141). and. E... and Hamaker. (1979).. gestive tracts. E. and Blom. Junctural contrasts in Singer. C. J. I. Acoustic and aerodynamic character. (1982). 1784. Cooper. Y. I. In R. J. and Shel. Singer. 28. Journal of Speech and alaryngeal speech acquisition. G. (1983). (2003). 122. Vocal function following suc. and Weinberg. G.).. (1996). G.. Horii. D. L. D. laryngology. Annals of Hearing Research.. out of the lower respiratory tract. M. C. Hamaker. P. Shipp..). Budnick. 202–210... 91. 107.. (1998). S118–S123. (1999). Rhinology. Rhinology. J. 337–349).. G. (1988). Rhinology and Laryngology. (1985). (1980). Gandour.. D. M. J. K. Speech and Hearing Disorders. G. Batsakis. and pathological considerations (2nd ed. S. (1986). I. Williams. P. G. Hearing Disorders. tion. neck cancer: Voice. et al. Electroacoustic anal- Laryngoscope. Singer. C. et al. S. proficiencies in three laryngectomy groups. duration. speech utilization: A survey. Supplement II.. Current status of laryn- primary sound generator of the peripheral speech mech- gectomee rehabilitation: I. J. C. A.. 27. Laryngectomee rehabiliation (pp. C.. W. In E. E. J. Tracheoesophageal voice Clinical Oncology. deglution. and Basili. G. Current status organ. and Ward. P... Walsh.. D.. Rosen. Anatomy of the Human Larynx Journal of Speech and Hearing Research..

it lies between the third and sixth cervical vertebrae. which could obstruct the airway and interfere the rate of vibration of the vocal folds. elimination of bodily wastes. the larynx undergoes maturational and involutional (aging) changes (Kahane. The thyroid cartilage is composed of two attachment for the vocal folds. thus pre.]. The larynx is located in the midline of the neck. all but one pair of the quadrangular plates that are united at midline in an intrinsic laryngeal muscles. and sound production. The root. vocal folds. ciples of experimental phonetics. Muscle fibers of the inferior pharyngeal constrictor at- tach to the posterolateral aspect of the thyroid and cri- coid cartilages. with concomitant changes in tension. the epiglottis closes this rotation e¤ects lengthening and shortening of the over the entrance into the laryngeal cavity. Muscle fibers originating from the cricoid cartilage form part of the muscular valve.. The arytenoid cartilages are intercon. Despite these naturally and slowly occurring structural changes. The cricothyroid dimorphism emerges after puberty. the hypo- pharynx. These pyramid-shaped cartilages serve as points of arytenoids on the upper rim of the cricoid cartilage allow . Rocking motions of the joint. Regional Anatomical Relationships. St. thereby protecting this vital passageway for unencumbered movement of air into and out of the lower airway. ensuring continuity of the airway from the (Stone and Nuttal. articulated (bottom) at the laryngeal joints. of the tongue is interconnected with the epiglottis of the larynx by three fibroelastic bands. and the vestibular folds. J. which influence its capacity as a sound source. and Kahane. Lass [Ed. which lage whose deformability results from its elastic cartilage in turn are attached to the upper rim of the cricoid. tilage and posteriorly to the arytenoid cartilages. The thyroid. (From Orliko¤. attached anteriorly to the inside face of the thyroid car- tory tract). The hyoid bone. Since the vocal folds are larynx into the trachea (the origin of the lower respira. Louis: Mosby. The lowermost portion of the pharynx. The cricoid cartilage joint joins the thyroid and cricoid cartilages and allows is signet ring shaped and sits on top of the first ring of the cricoid cartilage to rotate upward toward the cricoid the trachea. [1996]. while in the female it is obtuse. Laryngeal cartilages shown separately (top) and ligaments and membranes. It lies in front of the vertebral column and between the hyoid bone above and the trachea below. The thyroid and cricoid carti. and the epiglottis (Fig. F. The esophagus lies inferior and posterior to the larynx. one pair of arytenoids. The larynx also plays a central role in the development of the intrathoracic and intra-abdominal pressures needed for lifting. This is a tribute to the elegance of its structure. or pharyngeal portion.) cavity. The hyoid bone is not part of the larynx but is attached to it by the thyrohyoid lages are composed of hyaline cartilage. In N. The cartilaginous components of the larynx are joined by Figure 1. Reproduced These cartilages support the soft tissues of the laryngeal with permission. The larynx is composed of five major cartilages: thyroid. which opens to allow food to pass from the phar- ynx into the esophagus. In adults. Prin- the cricothyroid joints and surround the laryngeal cavity. cricoid and arytenoid cartilages are In the male. which provides membrane. 1996). is not part of it. surrounds the posterior aspect of the larynx. the glossoepiglottic folds. cricoid. Cartilaginous Skeleton. They are interconnected by Structure and function of the larynx. Throughout life. C. This sexual cricothyroid and cricoarytenoid joints. them with form and rigidity. Such venting food and liquids from passing into the laryngeal changes in tension are the principal method of changing cavity. composition. 1974). the angle. R. tenoid joint joins the arytenoid cartilages to the supero- nected to the cricoid cartilage via the cricoarytenoid lateral rim of the cricoid. J. the larynx continues to function relatively flawlessly. The epiglottis is a flexible leaf-shaped carti. assists in dislodging material from the lower airway. During swallowing. angle called the thyroid angle or laryngeal prominence. 1). The cricoary- with breathing.14 Part I: Voice the cough reflex. the junction of the laminae forms an acute interconnected to each other by two movable joints. though inti- mately associated with the larynx. It is a muscular tube that interconnects the pharynx and the stomach.

where the shape and size of the rima glottidis or glottis (space between the vocal folds) is modified during respiration. Lass. pain. which is of importance in laryngeal articulation. and sphincteric closure. The upper portion is a somewhat ex- panded supraglottal cavity or vestibule whose walls are reinforced by the quadrangular membrane. and an intracartilaginous por- tion. The laryngeal cartilages surround an suprahyoid and infrahyoid muscles attach to the hyoid irregularly shaped tube called the laryngeal cavity. L. and tactile stimuli. is bounded by the vocal folds. C. the arytenoids and the attached vocal folds to be drawn These receptors are innervated by sensory branches away (abducted) from midline and brought toward from the superior and recurrent laryngeal nerves. [1988]. and D.]. Although these muscles do not attach the laryngeal inlet (laryngeal aditus). ventricles. In N. Reproduced with permission. E. The e¤ect of such movements is to change the size and shape of the glottis. The middle region. It extends from muscles (Fig. the space between the vocal Laryngeal Muscles. as viewed posteriorly. it also provides filtration and moisturization McReynolds. J. 1976). The importance of these actions has are essential components of the exquisitely sensitive been emphasized by von Leden and Moore (1961). moved through displacement of the hyoid bone. These fibroelastic suprahyoid and infrahyoid muscles also stabilize the tissues (quadrangular membrane and conus elasticus) hyoid bone. of cranial and spinal nerves. which is sup- B. Decker. They (adducted) midline.) plied by an array of sensory receptors sensitive to pressure. is bounded by the conus elasticus. Yoder [Eds. Toronto: ing connective tissue form the muscosa. Stratified squamous epithelium covers surfaces subjected to contact. The larynx is acted upon by ex- folds. thyroid cartilage is connected to the hyoid bone by the geal cavity is continuous with the lumen of the trachea. which is located between the vocal processes and the bases of the arytenoid cartilages. Northern. through which it to the larynx.g. which is bordered by the soft tissues of the vocal folds. Anatomy and physiology of the organs of the peripheral speech mechanism. Hand. as protective reflex mechanism within the larynx that in- they are necessary for developing the transglottal impe. (From glottis. and vibratory forces. chemical. C. Cranial nerves V and VII . The area of primary laryngeal valving is the glottal region. The laryngeal cavity. producing devoicing and pauses. Here the laryn. J. L. Typical respiratory epithelium (pseudo- stratified ciliated columnar epithelium with goblet cells) is plentiful in the laryngeal cavity and lines the supra- Figure 2. which directly on the laryngeal cartilages. The epithelium and immediately underly- book of speech-language pathology and audiology. Anatomy of the Human Larynx 15 The laryngeal cavity is conventionally divided into three regions. hyothyroid membrane and ligaments. The suprahyoid and become altered through muscle activity. The epithelium that lines the laryngeal cavity exhibits regional specializations. passive stretch infrahyoid muscles are innervated by a combination from adjacent structures. The elastic tissues lined with epithelium. folds. and sphinc- dances to airflow that are needed to initiate vocal fold teric closure. The inferior border of the cricoid cartilage. 3). to the larynx and have one or more sites of attachment to a distant site (e. vibration. vocalization. The overall dimensions of the intracartilaginous glottis remain relatively stable except during strenuous sphincteric valving. 2). the posterior two-fifths of the rima glottidis. it is the narrowest portion. the infraglottal or subglottal region. The lowest region. to the level of the neck through their action on the hyoid bone. the sternum or hyoid bone). The anterior two-thirds of the glottis is an area of dynamic change occasioned by the positioning and aerodynamic displacement of the vocal folds. which bone and are generally considered extrinsic laryngeal forms the interior of the larynx (Fig. compressive. and aeromechanical forces. J. cludes initiating coughing. of flowing air. allowing other muscles in the neck to act restore the dimensions of the laryngeal cavity. L.. The larynx is The walls of the laryngeal cavity are formed by fibro. The Laryngeal Cavity. and nonvibrating portions of the vocal Kahane. throat clearing. called the glottal region. and direc- tion and velocity of airflow (Wyke and Kirchner. they influence laryngeal position in the communicates with the hypopharynx. and facilitating modes The extrinsic laryngeal muscles are attached at one end of vocal atttack. The rima glottidis consists of an intramembranous portion. trinsic and intrinsic laryngeal muscles (Tables 1 and 2).

lowers descendens hypoglossi hyoid bone hyoid bone. larynx is raised Table 2. Ansa cervicalis manubrium. Recurrent laryngeal cricoarytenoid cricoid cartilage process of arytenoid closes rima glottidis nerve (cranial cartilage nerve X) Posterior Cricoid lamina Muscular process of arytenoid Abducts vocal folds. pars obliqua lengthens and tenses (cranial nerve X) and lower portion fibers attach to anterior vocal folds (pars obliqua) margin of inferior corner of thyroid cartilage Lateral Upper border of arch of Anterior aspect of muscular Adducts vocal folds. muscularis fibers parts of muscles are attach more laterally active) . Recurrent laryngeal cricoarytenoid cartilage opens rima glottidis nerve (cranial nerve X) Interarytenoid Transverse Horizontally coursing Dorsolateral ridge of opposite Approximates bases of Recurrent laryngeal fibers fibers extending arytenoid cartilage arytenoid cartilages. Raises hyoid bone Cranial nerve V extending from deep surface of mandible at midline to hyoid bone Geniohyoid Inferior pair of genial Anterior surface of body Raises hyoid bone Cervical nerve I carried tubercles of mandible of hyoid bone and draws it via descendens forward hypoglossi Infrahyoid Muscles Sternohyoid Deep surface of manubrium. laryngeal nerve portion (pars recta) cartilage. assists vocal fold nerve X) lateral ridges of each adduction arytenoid cartilage Oblique fibers Obliquely coursing fibers Inserts onto apex of opposite Same as transverse fibers Recurrent laryngeal from base of one arytenoid cartilage nerve (cranial arytenoid cartilage nerve X) Thyroarytenoid Deep surface of thyroid Fovea oblonga of arytenoid Adduction. when hyoid is fixed. Morphological Characteristics of the Suprahyoid and Infrahyoid Muscles Muscles Origin Insertion Function Innervation Suprahyoid Muscles Anterior digastric Digastric fossa of mandible Body of hyoid bone Raises hyoid bone Cranial nerve V Posterior digastric Mastoid notch of temporal To hyoid bone via an Raises and retracts Cranial nerve VII bone intermediate tendon hyoid bone Stylohyoid Posterior border of styloid Body of hyoid Raises hyoid bone Cranial nerve VII process Mylohyoid Mylohyoid line of mandible Median raphe. Medial portion of Depresses hyoid Ansa cervicalis medial end of clavical inferior surface of bone body of hyoid bone Omohyoid From upper border of Inferior aspect of body Depresses hyoid Cervical nerves I–III scapula (inferior belly) of hyoid bone bone carried by the ansa into tendon issuing cervicalis superior belly Sternothyroid Posterior surface of Oblique line of thyroid Lowers hyoid bone. tensor. fibers anterior lateral half of of the cricoid and of superior divide into upper inferior border of thyroid thyroid cartilages. edge of first cartilage stabilizes hyoid costal cartilage bone Thyrohyoid Oblique line of thyroid Lower border of body When larynx is Cervical nerve I. through cartilage and greater wing of stabilized. nerve (cranial between the dorso. Recurrent laryngeal cartilage at midline cartilage. Morphological Characteristics of the Intrinsic Laryngeal Muscles Muscle Origin Insertion Function Innervation Cricothyroid Lateral surface of cricoid Pars recta fibers attach to Rotational approximation External branch cartilage arch.16 Part I: Voice Table 1. vocalis fibers relaxer of vocal folds nerve (cranial attach close to vocal (depending on what nerve X) process.

Among the most important functional or elastic and collagenous fibers in these layers. called the ex. One of the tenoid muscle (Fig. Charles C Thomas. Springfield. posed of sparse amounts of loosely interwoven collage- tomical properties of the intrinsic laryngeal muscles are nous and elastic fibers. and elasticity). This area. for developing the agitation and patterning of air mole- The intrinsic muscles of the larynx (Fig. mass per unit area. These branches are usually referred to as the superior and inferior laryngeal nerves. three layers of connective tissue well as on research data on the action of the extrinsic (lamina propria). The muscles can be categorized Reinke’s space. The vocal folds are multilayered vibra- fundamental frequency changes by exerting forces on the tors. hyoid.. (2) changing the position of the laryngeal cartilages relative to each other.. which is the most mobile portion of the vocal fold. In particular. 1982) have enabled us to appreciate the unique properties of the intrinsic muscles. The vocal fold consists of one adopted here is based on strict anatomical definition as layer of epithelium. ternal frame function. tension. E. (From Bateman. IL: standard morphological reference for striated muscles. each with di¤erent physical properties The designation of extrinsic laryngeal muscles and only 1. 1963.e. is important clinically because it is the according to their e¤ects on the shape of the rima glot. fundamental frequency. owing to the The suprahyoid and infrahyoid muscles have been tendency for fibers to intermingle in their longitudinal implicated in fundamental frequency control under a and transverse planes. All of the infrahyoid muscles are innervated by (4) individual muscle fibers tend not to be uniform in spinal nerves from the upper (cervical) portion of the their directionality within a fascicle but exhibit greater spinal cord.) the limb muscles. The and the vibratory behavior of the vocal folds. Anatomy of the Human Larynx 17 biomechanical outcomes of the actions of the intrinsic laryngeal muscles are (1) abduction and adduction of the vocal folds. cules in transglottal airflow during voice production. The intrinsic laryngeal muscles contain. particularly with changes in cover. 5). Hirano (1974) laryngeal skeleton that e¤ect length and tension changes showed that the vocal folds are composed of several in the vocal folds. Sensory fibers from these nerves supply the entire laryngeal cavity.. Reproduced with permission. in varying proportions.2 mm thick. in several ways: (1) they typically have a smaller mean diameter of muscle fibers. Histochemical studies of intrinsic laryngeal muscles (Matzelt and Vosteen. while all other intrinsic laryngeal muscles are innervated by the inferior (recurrent) laryngeal nerve. compliance. These movements are essential while the thyrohyoid raises it. (2) they are less regular in shape. 2 fibers). It provides . 4) are a col. M. and the vocalis fibers of the thyroary- laryngeal muscles during speech and singing. Shipp demonstrated that the Wavelike mucosal disturbances travel along the surface sternothyroid lowers the larynx with decreasing pitch. folds. Sonninen suggested that the extrinsic laryngeal muscles are involved in producing Vocal Folds. the epithe- hyoid muscles systematically change the vertical position lium and superficial layer of the lamina propria form the of the larynx in the neck. vocal folds following vocal abuse or in laryngitis. Hirano intermediate and deep layers of the lamina propria are and Kakita (1985) nicely summarized these behaviors called the transition. The ana. Applied anatomy and physiol- ogy of the speech and hearing mechanism. The vocal ligament is formed from (Table 3). R. not a single homogeneous band. Based on examination of ultra- most convincing studies in this area was done by Shipp high-speed films and biomechanical testing of the vocal (1975). who showed that the sternothyroid and thyro. during sound production. also known as summarized in Table 2. length. variability in the course of muscle fibers. The extrinsic laryngeal muscles. [1984]. Hirano (1974) found that functionally. and (5) laryngeal muscles have a construct proposed by Sonninen (1956). Rosenfield et al. and (4) modifying laryngeal airway resistance by changing the size or shape of the glottis. and Mason. The intrinsic laryngeal muscles are innervated by nerve fibers carried in the trunk of the vagus nerve. principal site of swelling or edema formation in the tidis. the positioning of the folds relative to midline. (3) transiently changing the dimensions and physical properties of the vocal folds (i. fibers that control fine movements for prolonged periods (type 1 fibers) and fibers that develop tension rapidly within a muscle (type Figure 3. laryngeal muscles di¤er from the H. greater investment of connective tissues. uniform in diameter across the various intrinsic muscles. The cricothyroid muscle is innervated by the superior laryngeal nerve. layers of tissues. lection of small muscles whose points of attachment are The superficial layer of the lamina propria is com- all in the larynx (to the laryngeal cartilages). (3) the muscle fibers are generally supply all of the suprahyoid muscles except the genio.

Decker. J. Reproduced with permission. The intrinsic laryngeal muscles as shown in lateral (A). E. L. McReynolds. Anatomy and physiology of the organs of the periph. Northern. language pathology and audiology. Toronto: B. C. and D. L. In N. J. Yoder [Eds. C. J. and superior (C) views.]. Lass.) eral speech mechanism. L. [1988]. .18 Part I: Voice Figure 4. (From Kahane. Handbook of speech- posterior (B).

Electroenoptische und which form the body of the vocal folds. Harrison (Eds. Acta in length-adjustment of the vocal cords in singing. K. Supplement. Archives of Otolaryngology.) resiliency and longitudinal stability to the vocal folds M. D. In R. San Diego. Cover-body theory of vo. VOC. Vertical laryngeal positioning during contin- References uous and discrete vocal frequency change. 707–718. Morphological structure of the vocal Stone. Journal of Speech and Hearing Research. O‰cial report: Phonosurgery. and Kakita. Repro- duced with permission.). 26. Crary (Eds. ance and elasticity of the vibrating surface (cover). Rosenfield. during voice production. (1982). A. D. A. IA. B. posterior cricoarytenoid muscle. Y.. 541–550. Life span changes in the larynx: An foundations of otolaryngology (pp. In R. Figure 5. (1985). influencing the tension in the vocal fold and the compli.). H. italics indicate marked e¤ect. M. and Heinemann. 118. interarytenoid muscle. 73. J. (1974). M. (1996). (1960). (From Hirano. Abbreviations: CT. G. parentheses indicate slight e¤ect. Speech science: arytenoid joint. 51. vocalis muscle fibers. collaginous fibers. Neurology of the Press. S. Reproduced with permission. and Moore. Speech science: Recent advances. (1976).und Kehlkopfheil- fibers are active in regulating fundamental frequency by kunde. 89–111).. A. Scientific Kahane. PCA. 239–440. Matzelt. CA: College-Hill Wyke. R. These muscle enzymatische Untersuchungen an menschlicher Kehlkopf- muskulatur. and Nuttal. Cover-body theory of vocal fold vibration. Hirano. A... CA: College-Hill Press. P. Elf. D. E. B. 18. Anatomy of the Human Larynx 19 Table 3. M. Faaborg-Andersen. Relative movements of cord as a vibrator and its vartions. 108. von Leden. (1985). Danolo¤ (Ed.). T. and Sonninen. B. San Diego. and Kakita. vocalis muscle. The transition is sti¤er than the San Diego. lation in dogs. of Otolaryngology (Stockholm). the thyroid and cricoid cartilages assisted by neural stimu- 89–94. elastic fibers.. (1956). of laryngeal muscle. Folia Phoniatrica. Actions of Intrinsic Laryngeal Muscles on Vocal Fold Position and Shape Vocal Fold Parameter CT VOC LCA IA PCA Position Paramedian Adduct Adduct Adduct Adduct Level Lower Lower Lower 0 Elevate Length Elongate Shorten Elongate (Shorten) Elongate Thickness Thin Thicken Thin (Thicken) Thin Edge Sharpen Round Sharpen 0 Round Muscle (body) Sti¤en Sti¤en Sti¤en (Slacken) Sti¤en Mucosa (cover Sti¤en Slacken Sti¤en (Slacken) Sti¤en and transition) Note: 0 indicates no e¤ect. Hirano. Archives Otolaryngologica. G. larynx. cover but more pliant than the vocalis muscle fibers.. strong e¤ect. lateral cricoarytenoid muscle. (1963). P. Kahane Shipp. London: anatomical perspective. 447–457. Co. K. 662– 666. J.. R. H. Danilo¤ (Ed. B. cricothyroid muscle. In W. normal type indicates consistent. M. R. 89–93. Y. and Patten. 546–574). LCA. The lead- ing edge of the vocal fold with its epi- thelium is at left.. CA: Singular Publishing Group. Brown. (1974).. C. Basic and clinical investigations. (1975). M. —Joel C. 1–46). Acta Otolaryngologica. Morphologic and histochemical characteristics See also voice production: physics and physiology. H. Sessions. Hinchcli¤e and D. 135–140. 181. The role of the external laryngeal muscles of the extrinsic laryngeal muscles at di¤erent pitch. Archives of Otolaryngology. Miller. and Kirchner. Oto- logia [Fukuoka]. Archiv für Ohren-Nasen. The mechanics of the crico- cal fold vibration. . Schematic of the layered structure of the vocal folds. In R. M. 21. [1975]. (1961). and Vosteen. L. The function Sonninen. A. Recent advances (pp. 218–231. Organic voice disorders (pp.. From Hirano. B.). 78. Vinson.

K. 74. M. tional impact of the voice disorder due to the Internet in using patient-based outcome measures to establish e‰- cacy of treatments and the desire to match treatment Voice Disorders and Outcomes Research needs with patient’s needs. Assessment of functional impact on the voice is barely lution of the assessment of functional impact of voice beyond the infancy stage. Louis: Mosby. Hart (Eds. Lass (Ed. O. and time on diagnosing and ticular individual. treatment (Dejonckere. New York: Raven Press. These measures do not necessarily discriminate the se- St. (1998) Hast. and Cortesina. L. (1998). . (1998). acoustic. H. and handicap (World Voice Disorders Health Organization. Schuller (Eds. function in a normal social environment (Smith et al. Rossi. there are three levels of a disorder: impairment. not necessarily to the severity of the disease. the disease. 1–14. 413–438. looks at whether perceptual. M. However. jective measures are correlated with the diagnosis of tion of the larynx. In C. Functional impact relates to the de- on the daily needs of the patient. (1981). talent. Functional histology of the larynx primarily assess specific treatments and do not encom- and vocal folds. This may be considered treatment ef- measuring the severity of voice disorders with various fectiveness. Histological color atlas of the measures of abnormal voices to normal voices have gone human larynx. Negus. verity (Rosen. C. J. but rather While voice scientists and clinicians have focused most addresses the value of a particular treatment for a par- of their energy. A more comprehensive approach might problem that interferes with their employment. (1965). The restriction of work.20 Part I: Voice Further Readings relationship of communication ability to global quality- of-life measurement. and Murry. the voice disorder (Wolfe. Hassan and Weymuller (1993). 575–592. little or not a treatment can produce an expected result based attention has been given to the e¤ects of a voice disorder on previous studies. and Martin. The peripheral ner. (1993). Ludlow and M. Interest in the issues relating to disorders and selected applications of those assessments. but mental phonetics. H. The 11). et al.). Handicap is the impact of the impairment of the disability on the social. pass functional outcomes from the patient’s perspective. G. Konig. Archives of Otolaryngology. In N. 1853–1868). does not directly address treatment e‰cacy. functional use of the voice stems from the development Assessment of the physiological consequences of of instruments to measure all aspects of vocal function voice disorders has evolved from a strong interest in the related to the patient. of life following treatment for head and neck cancer. ing acoustic objective measures of voice and relating Hirano.. Harker. List Fink. J. Otolaryngology Clinics of North America. and the treatment. acoustic/physiological profiles of the disease (Hartl et al. Structure and func. Acta latter issue is important in all diseases and disorders Otolaryngologica. M. interest has increased in determining the func. on for a number of years. (1970). or physiological instruments. E‰cacy. C.). Fitch. V.. Rockville. J. In C. none have been related to the patient’s the laryngeal muscles in man: Insertions and courses of perception of the severity of his or her problem. categorize brane. Otolaryngology Head and Neck Surgery (pp. 1980). The developmental anatomy of the larynx. Frederickson. W. verity of handicap as it relates to specific professions. San Diego. A few objective and sub- Orliko¤. 2000). Cummings. due to a voice di¤erent from assessment of disease status in that it disorder has gone virtually undocumented until recently. Louis: 2001). Structure of the vocal fold in normal and essential element in patients’ perception of their quality disease states anatomical and physical studies. Louis: Mosby. CA: Singular Publishing Group.. objective measures Kahane. Proceedings of the Confer. Patient-based assessment of voice handicap has been ence on the Assessment of Vocal Pathology (ASHA Reports lacking in the area of noncancerous voice disorders. MD: American Speech-Language-Hearing developments and improvements of software for assess- Assoc. and Kahane. disability. The human larynx.. environ- Introduction mental. Functional impact relates to the degree of handicap Assessment of Functional Impact of or disability. and it is this physical well-being that generally and in as many as 12% of children. 1997). or economic functioning of the individual. J. when life is not threatened since it is ultimately the patient’s perception of disease severity and his or her motivation to seek treatment that dictates the degree of treatment success. R. Picarillo (1994). W. Treatment usually relates to the physical well-being of a Voice disorders occur in approximately 6% of all adults patient. L. (1996). Within the adult takes priority when attempting to assess the severity of group. This article reviews the evo.. Over the past few gree of impact a disorder has on an individual patient. J. 2000). G. and Murry et al. Morphological study of until recently. specific professions report the presence of a voice the handicap. (1961). and von Leden.. F. Measurement of functional impact is somewhat 1998). and Sato. M. or lifestyle. 59. Principles of experi. B. motor end-plates and proprioceptors. F. C. years. St. The mechanism of the larynx. and measure changes that occur as a result of Mosby.). As many seek to address the patient’s own impression of the se- as 50% of teachers and 33% of secretaries complain of verity of the disorder and how the disorder interferes voice problems that restrict their ability to work or to with the individual’s professional and personal lifestyle. 3. This muscle fibers. Lombard. The mucous mem. have all demonstrated that voice communication is an Hirano. St. on the other hand. Objective test batteries are useful to quantify disease se- vous system of the human larynx: I. (1928). A. Krause. Accordingly. (1975). and D. E.

Outcome Measures: General Health Versus Development of the Voice Handicap Index Specific Disease In 1997. or other general quality-of-life scales. One measure that has been used ments that describe the impact of a person’s voice on to look at the e¤ect of disease on life is the Medical his daily activities. videostroboscopic visual perceptual findings. Rather. there are certain parameters of voice dis. to the severity of the voice compared to normal. It should be noted. The health survey (McHorney et al. etc. which is regulated by the Department of treatment. Jacobson et al. following various interventions in auditory function. The emotional subscale indicates the Outcomes Study (MOS). bodily pain may not be quite appropriate. the subscale of the SF-36 known as voice handicap provide significant information that can. her satisfaction with treatment regardless of the disease state. 1993). patient-based measures of tain voice disorders. Voice handicap measures may measure an individu. otherwise known as SF-36. topics once it was shown to be a valid measure of The measurement of voice handicap must take into the degree of general health.. 36 is not a direct assessment of voice handicap but rather ables traditionally used in voice assessment models. These handicap will be reflected to the extent that the voice is measures have been used to quantify functional outcome usable in those situations. The quality and ac. Thus. 1998). physical.. that there are sessment of voice handicap involves the patient’s ability handicap/disability measures developed for other aspects to use his or her voice under normal circumstances of of communication. pharmacology. or is that one or more of the subscales may not be impor- quality of voice) than the acoustic measures obtained in tant or appropriate. SF-36 has been used for a wide range of disease-specific and vocal e¤ectiveness.. these curacy of surgery or the level of voice therapy may not measures do not provide insight as to the degree of necessarily reflect the long-term outcome if the patient handicap and disability that a specific patient is experi- does not cooperate with the treatment procedure. this assessment has patient’s ability to speak in the classroom or a factory been used to validate other assessments of quality of life will undoubtedly provide a more accurate assessment and handicap that are disease specific. namely hearing loss and dizziness social and work-related speaking situations. general health. The functional subscale includes state- to the specific disorder.. such as endurance. The 36-item items in the physical subscale are statements that relate short form. For example. While this tool Currently there are no federal regulations defining voice measures the disease-related status of the patient. functioning. Treatment that involves surgery. From an original 85-item list. However. economic. functioning. a general measure of well-being. This patient self- well-being. role high a pitch. cancer. it does handicap. The voice (Newman et al. while Voice disorders are somewhat di¤erent than the measures such a perceptual judgments of voice charac- treatment of a life threatening disease such as laryngeal teristics. a 30-item . The ratory. as already indicated. namely emotional. her ability to continue with her current presents problems unlike the development of the SF-36 employment versus opting for a change in employment. The other is to compare his or her voice to assessment tool consists of ten items in each of three normal voice measures. The challenge to develop a specific scale related to a al’s perceived level of general health. because enough to be heard over the noise of factory machines?’’ each scale has been determined to be a reliable and valid An outcome measure that takes into account the measure of health in and of itself. 1990. encing. Thus. mental health. an individual’s specific organ function such as a scale for voice disorders quality of life. when considering cer- the voice laboratory. the degree to which swallowing status Labor. recovery from disease. 1993). Moreover. the SF- not be obtained from biological and physiologic vari. acceptance of a new voice. As. acoustic perceptual judgments. 1990). functional. Assessment of Functional Impact of Voice Disorders 21 Moreover. 1994). and functional aspects of social factors as well as physical factors that are related voice disorders. or the cost of the treatment. The task of measuring the severity of a voice improves and voice communication returns to normal disorder may be somewhat di‰cult because of the areas are measured by instruments that generally focus on that are a¤ected. one of of voice handicap (although not necessarily an accurate the di‰culties with using such a test for a specific disease assessment of the disease. bodily pain. One is to look at the patient’s overall Index (VHI) (Jacobson et al. measures eight to either the patient’s perception of laryngeal discomfort areas of health that are commonly a¤ected or changed or the voice output characteristics such as too low or too by diseases and treatments: physical functioning. as well as physiological or voice therapy requires the patient’s full cooperation measures objectively obtained provide some input as throughout the course of treatment. vitality.. The first usually encompasses domains: emotional.. Jacobson and her colleagues proposed a mea- There are two primary ways to assess the handicap of sure of voice handicap known as the Voice Handicap a voice disorder. and health transition. social orders that cannot be easily measured in the voice labo. unlike the handicap measures associated with not presume to assess overall patient satisfaction with hearing loss. Outcome of treatment Assessing Voice Handicap for laryngeal cancer is typically measured using Kaplan- Myer curves (Adelstein et al. a 36-item short-form general patient’s a¤ective responses to the voice disorder. In addition. The SF-36 is a pencil-and- account issues such as ‘‘can the person teach in the paper test that has been used in numerous studies for classroom all day?’’ or ‘‘can a shop foreman talk loud assessing outcomes of treatment. physical. however. quality of life (McHorney et al.

Activity limitation refers to constraints imposed on voice activities and participation restriction refers to a reduction or avoidance of voice activities. detailed analysis of patient data using this test has The VHI significantly separated singers from nonsingers recently been published (Benninger et al. e¤ect on daily communication.2 for the 336 nonsingers. 4. It can be seen that in general. and e¤ect on emotion. . Murry and Rosen examined to be certain that a change is due to intervention and not 73 professional and 33 nonprofessional singers and to unexplained variability. reliable assessment of the patient’s perception of handicap severity before and after treat. The 10-item questionnaire with benign vocal fold lesions demonstrated the lowest provides a quick. The VAPP has been found to be a reliable and valid assessment tool for Figure 1.7. and vocal fold paralysis prior to and fol. Subjects related with the original VHI. (polyps/cysts). was finally The same investigators examined the application of obtained. These authors presented a measure of voice-related quality of life (VR-QOL).and post-treatment voice handicap scores for assessing self-perceived voice severity as it relates to selected populations. others have pro. However. or a combina- indicating he ‘‘never’’ felt this about his voice problem to tion of both. even The mean VHI score for the 106 singers was 34. needs as well as the seriousness of a singer’s handicap. voice therapy. activity and participation in vocal activities. Additional work has been done by Hogikyan (1999). tive to singers. was a perception of significantly reduced voice handicap. The results vocal fold paralysis displayed the highest self-perception suggest that a 10-question VHI produces is highly cor- of handicap both before and after treatment. Murry and Rosen (2001) evaluated the clinicians that the use of the VHI points to the specific VHI in three groups of speakers to determine the rela. and Mont- bined groups. Hogikian (1999) and 43. perception of voice handicap. Rosen and Murry (in press) presented re- lowing treatments. 2000). Although lower Glicklich (1999) have both demonstrated their assess. in 81% of the patients. tive severity of voice disorders in patients with muscular Although the quality of voice may be mildly disordered. posed similar tests of handicap. ment. Overall reliability of the nificantly lower. VHI scores were found in singers than in nonsingers. for assessing voice problems in singers. Singers are scales. Gliklich. Glovsky. A shift in unique in that they often complain of problems related the total score of 18 points or greater is required in order only to their singing voice. the professional singers was significantly lower (31. those encountered by tracheoesophageal speakers. the mean VHI score for Since the VHI has been published.to post-treatment. This tool assesses the e¤ects voice disorders have on limiting and participating in activities which require use of the voice (Ma and Yiu. is known as the Although the VHI scores following treatment were sig. singers (Murry and Rosen. 2001). there group of patients with unilateral vocal fold paralysis. in terms of severity. Voice Outcome Survey (VOS). benign vocal fold lesions the voice handicap may be significant. Recently. e¤ect on social commi- nication. A compared with a mean of 53. strument. The findings of this study should alert ment (1998). They also found that this self-administered 10-question patient assessment of se- verity was related to changes in treatment. 1998). which contains five questions. there still remained a measure of hand. either because of surgery. was designed to assess all types of voice disorders. this ment tools to have validity and reliability in assessing a does not imply that the VHI is not a useful instrument patient’s perception of the severity of a voice problem. 1999).0 vs.. On the contrary. One of the additional uses of the VHI as suggested by several questions were singled out as specifically sensi- Benninger and others is to assess measures after treat. orders. tension dysphonia (MTD). VOS was related to the subscales of the SF-36 for a icap in all subjects. This 30-item questionnaire was then assessed the VHI to a specific group of patients with voice dis- for test-retest stability in total as well as the three sub. where he ‘‘always’’ felt this to be the case. and was validated against the SF-36.22 Part I: Voice questionnaire using a five-point response scale from 0. A recent addition to functional assessment is the Voice Activity and Participation Profile (VAPP). The Voice Handicap Index compared them with a control group of 369 nonsingers.2) than for the recreational singers. Moreover. Their sub- jects consisted primarily of unilateral vocal fold paralysis patients and showed a significant change from pre. This 28-item tool examines five areas: self- perceived severity of the voice problem. the patients with vocal fold gomery examined outcomes in patients with vocal fold paralysis initially began with the highest pretreatment paralysis (Hogikyan and Sethuraman. Overall. Pre. e¤ect on the job. there was a 50% Other measures of voice outcome have been proposed or greater improvement in the mean VHI for the com. The in- VHI and remained with the highest VHI after treatment. Recently. Figure 1 shows that subjects with liability data on a revised 10-question VHI. and studied.

and Martin. and Sethuraman. via Jacobson. area. American Jour.. ynology. 33–34. treatment for these handi. In P. E. Voice Handicap Index the impact of an intervention for patients who use their results in singers. 152–158. 1981). Earle. (2001). Dejonckere caps can also be assessed in terms of e¤ectiveness for the (Ed. The MOS 36-item short form health survey For many years. both of which List. 485–494. E. Assessing outcomes for dysphonic patients. 540–550. 25– Glicklich. C.. W. 15. Validation of a voice outcome survey for unilateral vocal fold paralysis. A per. 12.. H. Lu. 111. 31. 440–447. A. 430–433. Occupational voice dis- be identified. C.. 14. M. Journal —Thomas Murry and Clark A. Journal of Voice. E. K. are highly valuable in the assessment of vocal function. R. handicap.. Disabilities and Handicaps: A manual of ica. Neurology. The study of functional voice assessment to identify the McHorney. 823–828. A. the degree of handicap can Murry. 44. (1990). M. H. A. 564–569. (1993).. M. fined squamous cell head and neck cancer. 31–37. Unfortunately. C. Electroglottographic Assessment of Hartl. M.. The inverse filtering. via ultrasonography (Baken and Orliko¤. or disease type. and Hug. J. pation profile: Assessing the impact of voice disorders on conditioned. N. M.. A. 12. and Yiu. consuming way in which these signals must be acquired. The Hague. A. F. D. F... Sharon. investigators have focused on acoustic (SF-36): II. S. C. S. G.). T. References aerodynamic and videostroboscopic features of bilateral vocal fold lesions.. Jr. Rosen of Voice. the routine application of these tech- 66. Riquet. 480–488. (2001). Frequency of voice problems among teachers nal of Clinical Oncology. W. et al. E. P. T. Voice activity and partici. 13. and Laryngology. Madassu. 33. and Rosen... P. (1997). et al.. Benninger. Montgomery. Geneva: World Health Organization. 11.. and New. Kirchner.. Objective voice analysis after autologous fat injection for Voice unilateral vocal fold paralysis. also allows investigators to make valid comparisons of Murry. (1998). M. and VR-QOL have demonstrated that regardless cer. Aggarwal. S. Journal of Speech... Validation of are called glottographic waveforms or glottograms (Titze an instrument to measure voice-related quality of life (V. Weinstein. of age. Ware. and Weymuller. G. 109. Electroglottographic Assessment of Voice 23 Summary daily activities. and analyzed. G. formance status scale for head and neck patients. glottal width. L. A number of instruments can be used to help character- Hassan.. 229–235. have not shed significant light on patients’ per- ity of life following intraarterial chemoradiation for organ ception of their disorder. (2000). Folia Journal of Voice. 44. Assessment of voice based on a patient’s perceived se. M. A. Acoustic. A. M. verity and the need to recover vocal function may be Picarillo. via photoglottography. E. J. Otolaryngology Clinics of North Amer. T. S. preservation in patients with advanced head and neck can- VOS. Such Jacobson. 43). Head and Neck Surgery. including the glottal open quotient Hospital Headache Disability Inventory (HDI). Medical change in voice following treatment. R. Cancer. Ramadan. Rosen. 2000). niques has been hampered by the cumbersome and time- Ma. 120.. voices in di¤erent environments and the patients’ per. C. J. S.. B. . 292–299. J. E. 837–842. Perceptual and laboratory assess. A. and Robbins. Assessment of ize the behavior of the glottis and vocal folds during quality of life in head and neck cancer patients. Journal of Voice. and Hearing Research. adequacy and audiometric correlates. (1998). R. L. T. Patients’ self-assessment of perceived severity 128). 540–550. degree of handicap is novel for benign voice disorders.. 113– patient.. and Lansky. and Ho¤man. T. D. 764–769. and Sherbourne.. Lemke. J. (1993). and Grywalski. International Classification ment of dysphonia. and other occupations. and the maximum flow declination rate. the Netherlands: Kugler Publications. Rosen.. Acoustic measures C. (1994).. Ritter-Sterr.. Atiuja. N. C... Jacobson. T. D. E. Glovsky. C.. C. grams are those that track change in glottal flow. glottal Voice Handicap Index (VHI): Development and validation. V. of dysphonic severity across and within voice types.. C. A. and Rosen. 511–524. J. These measures. World Health Organization. Rhinol- ogy. Among the more common glotto- RQOL). phonation. the most appropriate manner to assess severity of voice Otolaryngology–Head and Neck Surgery. Ear and Hearing. (1998). and Murry. B. The signals derived from these instruments Hogikyan.. D.. 110. P. sex. H. (1980). Long-term results after chemoradiotherapy of locally con. Occupational voice disorders: Care and cure (pp. (in press). 370–377.. Dejonckere. 13.. 20. Johnson. Language. The VHI 10: An out- come measure following voice disorder treatment.. signals can be used to obtain several di¤erent physio- man. Otolaryngology–Head and Neck Surgery. orders and the voice handicap index. Furthermore.. The development of the Henry Ford logical measures. (1994). G. Care. M.. Head and Neck Surgery. Annals of Otology.. 557–559. and Murry. of Impairments. W. Annals of Otology Rhinology and Lar- Adelstein. D. Journal of Voice. Psychometric and clinical tests of validity in and aerodynamic measures of voice production to assess measuring physical and medical health constructs. Martin. Acute and chronic changes in swallowing and qual- e‰cacy. et al. J. via kymography. although extremely useful in understanding treatment Murry. The hearing handicap inventory for adults: Psychometric ception of the treatment from a functional perspective. G. Smith. (1990). and vocal fold movement. Vaissiere. Gardner. Fitch. 12. One glottographic method.. (2000).. Wolfe. 49. A. Grywalski. J. Phoniatrica. and Talkin. S. Measures such as the VHI. S. (1998). 247–263. Newman. Hans. B. (1999). classification relating to the consequences of disease (pp. Taylor. (1998).. Outcome research and otolaryngology.. C. Journal of Voice. (2000).. V. (1999). (2001). Lombard.

. which contemporary theory suggests is a critical element in the assessment of voice production. such that their inferior margins ap. The glottal region. mechanics. The result is a waveform—sometimes The numbered points on the trace correspond approximately to designated Lx—that varies chiefly as a function of vocal the points of the cycle depicted above. Below it is a normal changes and amplified to boost the laryngeal contribu. consequence of several factors. laryngeal height variation induced by respiration and articulation. Electrical impedance is thus highest when the current path must completely bypass an open glottis and progressively decreases as greater contact be- tween the vocal folds is achieved. however. and the erated greatly in the 1980s with the advent of personal anatomy and orientation of the medial surfaces. supplement the evaluation and treatment of vocal pa. When the vocal folds separate. Because increasing and decreasing vocal fold contact has a relatively small e¤ect on the overall Figure 1. including bilateral vocal ics for vocal fold vibration was confirmed. forming the basis of the EGG signal. fold contact area (Gilbert. it is not surprising that e¤orts to formulate Instead of a simple mediolateral oscillation. most of the changes in transcervical impedance are due to strap muscle activity. 1). requiring no probe placement within the vocal tract. the electroglottogram is both high-pass fil. is that a valid is far from perfectly understood. Despite these e¤orts. pathology. Interest in EGG increased quite well (Fig. and accel. An imperceptible low-amplitude. At the top is shown a schematic representation of a impedance. tion to the signal. and pulsatile blood vol- ume changes. however. possibilities for abnormality of tissue structure or bio- tions of the technique. The clinical challenge. tissue and body fluids are relatively good conductors of elec- tricity. 1984). whereas air is a particularly poor conductor. is quite small compared with the total region through which the current is flowing. the current path is forced to circumvent the glottal air space. Contact between the vocal folds a¤ords a con- duit through which current can take a more direct route across the neck. Con- computers and commercially available EGGs that were siderable research has been devoted to establishing the technologically superior to previous instruments. especially in the face of and reliable EGG assessment demands a firm under. the clinical potential of EGG was the pattern of vocal fold vibration can be characterized recognized by the mid-1960s. the vocal simple rules relating abnormal details to specific pathol- folds engage in a quite complex undulatory movement ogies have not met with notable success. important features of the EGG and how they relate EGG has a worldwide reputation as a useful tool to to specific aspects of vocal fold status and behavior. the contact area function thology. In short. In fact. decreasing e¤ective voltage. clinical value of EGG rests in documenting the vibratory proximate before the more superior margins make con. (2) it is easy to acquire. Today. The contact phases of the vibratory cycle are shown beneath the electroglottogram. the voltage across the neck is modulated by the contact of the vocal folds. electroglottogram depicting relative vocal fold contact area. approximating the level of the vocal folds. Potter. Because EGG tracks e¤ective medial contact area. medial compression. The contact pattern will vary as a in the 1970s as the importance of mucosal wave dynam. Electroglottography (known as electrolaryngography in the United Kingdom) is a plethysmographic technique that entails fixing a pair of surface electrodes to each side of the neck at the thyroid lamina. for several reasons: (1) it is noninvasive. the during phonation. First proposed by Fabre in 1957 as a means to assess laryngeal physiology. and (3) it o¤ers unique information about the mucoundulatory behavior of the vocal folds. 1981). pathology itself. however. high-frequency current is then passed between these electrodes. fold mass and tension. alone or in conjunc- tion with other speech signals. consequence of pathology rather than in diagnosing the tact. single cycle of vocal fold vibration viewed coronally (left) and tered to remove the far slower nonphonatory impedance superiorly (right) (after Hirano. In this way. Given the complexity of the ‘‘rolling and standing of normal vocal fold vibratory behavior along peeling’’ motion of the glottal margins and the myriad with recognition of the specific capabilities and limita. Because of their electrolyte content. and Hoodin. has emerged as the most commonly used technique.24 Part I: Voice electroglottography (EGG).

Electroglottographic Assessment of Voice 25

Using multiple glottographic techniques, Baer,
Löfqvist, and McGarr (1983) demonstrated that, for
normal modal-register phonation, the ‘‘depth of closure’’
was very shallow just before glottal opening and quite
deep soon after closure was initiated. Most important,
they showed that the instant at which the glottis first
appears occurs sometime before all contact is lost, and
that the instant of glottal closure occurs sometime after
the vocal folds first make contact. Thus, although the
EGG is sensitive to the depth of contact, it cannot be
used to determine the width, area, or shape of the glottis.
For this reason, EGG is not a valid technique for the
measurement of glottal open time or, therefore, the open
quotient. Likewise, since EGG does not specify which
parts of the vocal folds are in contact, it cannot be used
to measure glottal closed time, nor can it, without addi-
tional evidence, be used to determine whether maximal
vocal fold contact indeed represents complete oblitera-
tion of the glottal space. Identifying the exact moment
when (and if ) all medial contact is lost has also proved
particularly problematic. Once the vocal folds do lose
contact, however, it can no longer be assumed that the
EGG signal conveys any information whatsoever about
laryngeal behavior. During such intervals, the signal
may vary solely as a function of the instrument’s auto-
matic gain control and filtering (Rothenberg, 1981).
Although the EGG provides useful information only
about those parts of the vibratory cycle during which
there is some vocal fold contact, these characteristics
may provide important clinical insight, especially when
paired with videostroboscopy and other data traces.
EGG, with its ability to demonstrate contact change in
both the horizontal and vertical planes, can quite e¤ec-
Figure 2. Typical electroglottograms obtained from a normal
tively document the normal voice registers (Fig. 2) as
man prolonging phonation in the low-frequency pulse,
well as abnormal and unstable modes of vibration (Fig. moderate-frequency modal, and high-frequency falsetto voice
3). However, to qualitatively assess EGG wave charac- registers.
teristics and to derive useful indices of vocal fold contact
behavior, it may be best to view the EGG in terms of
a vibratory cycle composed of a contact phase and a tween 1 for a contact phase maximally skewed to the
minimal-contact phase (see Fig. 1). The contact phase left and þ1 for a contact phase maximally skewed to the
includes intervals of increasing and decreasing contact, right. For normal modal-register phonation, CI varies
whereas the peak represents maximal vocal fold contact between 0.6 and 0.4 for both men and women, but,
and, presumably, maximal glottal closure. The minimal- as can be seen in Figure 2, it is markedly di¤erent for
contact phase is that portion of the EGG wave during other voice registers. Pulse-register EGGs typically have
which the vocal folds are probably not in contact. Much CIs in the vicinity of 0.8, whereas in falsetto it would
clinical misinterpretation can be avoided if no attempt not be uncommon to have a CI that approximates zero,
is made to equate the vibratory contact phase with the indicating a symmetrical or nearly symmetrical contact
glottal closed phase or the minimal-contact phase with phase.
the glottal open phase. Another EGG measure that is gaining some currency
For the typical modal-register EGG, the contact in the clinical literature is the contact quotient (CQ).
phase is asymmetrical; that is, the increase in contact Defined as the duration of the contact phase relative to
takes less time than the interval of decreasing contact. the period of the entire vibratory cycle, there is evidence
The degree of contact asymmetry is thought to vary not from both in vivo testing and mathematical modeling to
only as a consequence of vocal fold tension but also as a suggest that CQ varies with the degree of medial com-
function of vertical mucosal convergence and dynamics pression of the vocal folds (see Fig. 3) along a hypo-
(i.e., phasing; Titze, 1990). A dimensionless ratio, the adducted ‘‘loose’’ (or ‘‘breathy’’) to a hyperadducted
contact index (CI), can be used to assess contact sym- ‘‘tight’’ (or ‘‘pressed’’) phonatory continuum (Rothen-
metry (Orliko¤, 1991). Defined as the di¤erence between berg and Mahshie, 1988; Titze, 1990). Under typical
the increasing and decreasing contact durations divided vocal circumstances, CQ is within the range of 40%–
by the duration of the contact phase, CI will vary be- 60%, and despite the propensity for a posterior glottal

26 Part I: Voice

intonation, voicing, and fluency characteristics. In fact,
EGG has, for many, become the preferred means by
which to measure vocal fundamental frequency and jitter.
In summary, EGG provides an innocuous, straight-
forward, and convenient way to assess vocal fold vibra-
tion through its ability to track the relative area of
contact. Although it does not supply valid information
about the opening and closing of the glottis, the tech-
nique a¤ords a unique perspective on vocal fold be-
havior. When conservatively interpreted, and when
combined with other tools of laryngeal evaluation, EGG
can substantially further the clinician’s understanding of
the malfunctioning larynx and play an e¤ective role in
therapeutics as well.
See also acoustic assessment of voice.
—Robert F. Orliko¤

References
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vibrations: A comparison between high-speed filming and
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Hirano, M. (1981). Clinical examination of voice. New York:
Figure 3. Electroglottograms representing di¤erent abnormal Springer-Verlag.
modes of vocal fold vibration. Kakita, Y. (1988). Simultaneous observation of the vibratory
pattern, sound pressure, and airflow signals using a physical
model of the vocal folds. In O. Fujimura (Ed.), Vocal
chink in women, there does not seem to be a significant physiology: Voice production, mechanisms, and functions
sex e¤ect. This is probably due to the fact that EGG (pp. 207–218). New York: Raven Press.
(and thus the CQ) is insensitive to glottal gaps that are Orliko¤, R. F. (1991). Assessment of the dynamics of vocal
not time varying. Unlike men, however, women tend fold contact from the electroglottogram: Data from normal
to show an increase in CQ with vocal F0. It has been male subjects. Journal of Speech and Hearing Research, 34,
conjectured that this may be the result of greater medial 1066–1072.
compression employed by women at higher F0s that Orliko¤, R. F. (1995). Vocal stability and vocal tract configu-
serves to diminish the posterior glottal gap. Nonetheless, ration: An acoustic and electroglottographic investigation.
a strong relationship between CQ and vocal intensity has Journal of Voice, 9, 173–181.
Rothenberg, M. (1981). Some relations between glottal air flow
been documented in both men and women, consistent
and vocal fold contact area. ASHA Reports, 11, 88–96.
with the known relationship between vocal power and Rothenberg, M., and Mahshie, J. J. (1988). Monitoring vocal
the adductory presetting of the vocal folds. Because fold abduction through vocal fold contact area. Journal of
vocal intensity is also related to the rate of vocal fold Speech and Hearing Research, 31, 338–351.
contact (Kakita, 1988), there have been some prelimi- Titze, I. R. (1990). Interpretation of the electroglottographic
nary attempts to derive useful EGG measures of the signal. Journal of Voice, 4, 1–9.
contact rise time. Titze, I. R., and Talkin, D. (1981). Simulation and interpreta-
Because EGG is relatively una¤ected by vocal tract tion of glottographic waveforms. ASHA Reports, 11, 48–55.
resonance and turbulence noise (Orliko¤, 1995), it al-
lows evaluation of vocal fold behavior under conditions Further Readings
not well-suited to other voice assessment techniques. For Abberton, E., and Fourcin, A. J. (1972). Laryngographic
this reason, and because the EGG waveshape is a rela- analysis and intonation. British Journal of Disorders of
tively simple one, the EGG has found some success both Communication, 7, 24–29.
as a trigger signal for laryngeal videostroboscopy and as Baken, R. J. (1992). Electroglottography. Journal of Voice, 6,
a means to define and describe phonatory onset, o¤set, 98–110.

Functional Voice Disorders 27

Carlson, E. (1993). Accent method plus direct visual feedback Functional Voice Disorders
of electroglottographic signals. In J. C. Stemple (Ed.), Voice
therapy: Clinical studies (pp. 57–71). St. Louis: Mosby–
Year Book. The human voice is acutely responsive to changes in
Carlson, E. (1995). Electrolaryngography in the assessment
emotional state, and the larynx plays a prominent role as
and treatment of incomplete mutation (puberphonia) in
adults. European Journal of Disorders of Communication, an instrument for the expression of intense emotions
30, 140–148. such as fear, anger, grief, and joy. Consequently, many
Childers, D. G., Hicks, D. M., Moore, G. P., and Alsaka, regard the voice as a sensitive barometer of emotions
Y. A. (1986). A model of vocal fold vibratory motion, con- and the larynx as the control valve that regulates the re-
tact area, and the electroglottogram. Journal of the Acousti- lease of these emotions (Aronson, 1990). Furthermore,
cal Society of America, 80, 1309–1320. the voice is one of the most individual and characteristic
Childers, D. G., Hicks, D. M., Moore, G. P., Eskenazi, L., and expressions of a person—a ‘‘mirror of personality.’’
Lalwani, A. L. (1990). Electroglottography and vocal fold Thus, when the voice becomes disordered, it is not un-
physiology. Journal of Speech and Hearing Research, 33, common for clinicians to suggest personality traits,
245–254.
psychological factors, or emotional or inhibitory pro-
Childers, D. G., and Krishnamurthy, A. K. (1985). A critical
review of electroglottography. CRC Critical Review of Bio- cesses as primary causal mechanisms. This is especially
medical Engineering, 12, 131–161. true in the case of functional dysphonia or aphonia,
Colton, R. H., and Conture, E. G. (1990). Problems and pit- in which no visible structural or neurological laryngeal
falls of electroglottography. Journal of Voice, 4, 10–24. pathology exists to explain the partial or complete loss of
Cranen, B. (1991). Simultaneous modelling of EGG, PGG, voice.
and glottal flow. In J. Gau‰n and B. Hammarberg (Eds.), Functional dysphonia, which may account for more
Vocal fold physiology: Acoustic, perceptual, and physiologi- than 10% of cases referred to multidisciplinary voice
cal aspects of voice mechanisms (pp. 57–64). San Diego, clinics, occurs predominantly in women, commonly fol-
CA: Singular Publishing Group. lows upper respiratory infection symptoms, and varies
Croatto, L., and Ferrero, F. E. (1979). L’esame elettro-
glottografico appliato ad alcuni casi di disodia. Acta Pho-
in its response to treatment (Bridger and Epstein, 1983;
niatrica Latina, 2, 213–224. Schalen and Andersson, 1992). The term functional
Fourcin, A. J. (1981). Laryngographic assessment of phona- implies a voice disturbance of physiological function
tory function. ASHA Reports, 11, 116–127. rather than anatomical structure. In clinical circles,
Gleeson, M. J., and Fourcin, A. J. (1983). Clinical analysis of functional is usually contrasted with organic and often
laryngeal trauma secondary to intubation. Journal of the carries the added meaning of psychogenic. Stress, emo-
Royal Society of Medicine, 76, 928–932. tion, and psychological conflict are frequently presumed
Gómez Gonzáles, J. L., and del Cañizo Alvarez, C. (1988). to cause or exacerbate functional symptoms.
Nuevas tecnicas de exploración funcional ları́ngea: La Some confusion surrounds the diagnostic category
electroglotografı́a. Anales Oto-Rino-Otoları́ngologica Ibero- of functional dysphonia because it includes an array of
Americana, 15, 239–362.
Hacki, T. (1989). Klassifizierung von Glottisdysfunktionen mit
medically unexplained voice disorders: psychogenic,
Hilfe der Elecktroglottographie. Folia Phoniatrica, 41, 43–48. conversion, hysterical, tension-fatigue syndrome, hyper-
Hertegård, S., and Gau‰n, J. (1995). Glottal area and vibra- kinetic, muscle misuse, and muscle tension dysphonia.
tory patterns studied with simultaneous stroboscopy, flow Although each diagnostic label implies some degree of
glottography, and electroglottography. Journal of Speech etiologic heterogeneity, whether these disorders are
and Hearing Research, 38, 85–100. qualitatively di¤erent and etiologically distinct remains
Kitzing, P. (1990). Clinical applications of electroglottography. unclear. When applied clinically, these various labels
Journal of Voice, 4, 238–249. frequently reflect clinician supposition, bias, or pref-
Kitzing, P. (2000). Electroglottography. In A. Ferlito (Ed.), erence. Voice disorder taxonomies have yet to be
Diseases of the larynx (pp. 127–138). New York: Oxford adequately operationalized; consequently, diagnostic
University Press.
Motta, G., Cesari, U., Iengo, M., and Motta, G., Jr. (1990).
categories often lack clear thresholds or discrete boun-
Clinical application of electroglottography. Folia Phonia- daries to determine patient inclusion or exclusion. To
trica, 42, 111–117. improve precision, some clinicians prefer the term psy-
Neil, W. F., Wechsler, E., and Robinson, J. M. (1977). Elec- chogenic voice disorder, to put the emphasis on the psy-
trolaryngography in laryngeal disorders. Clinical Otolaryn- chological origins of the disorder. According to Aronson
gology, 2, 33–40. (1990), a psychogenic voice disorder is synonymous with
Nieto Altazarra, A., and Echarri San Martin, R. (1996). Elec- a functional one but o¤ers the clinician the advantage
troglotografı́a. In R. Garcı́a-Tapia Urrutia and I. Cobeta of stating confidently, after an exploration of its causes,
Marco (Eds.), Diagnóstico y tratamiento de los transtornos that the voice disorder is a manifestation of one or more
de la voz (pp. 163–169). Madrid, Spain: Editorial Garsi. forms of psychological disequilibrium. At the purely
Orliko¤, R. F. (1998). Scrambled EGG: The uses and abuses
of electroglottography. Phonoscope, 1, 37–53.
phenomenological level there may be little di¤erence
Roubeau, C., Chevrie-Muller, C., and Arabia-Guidet, C. between functional and psychogenic voice disorders.
(1987). Electroglottographic study of the changes of voice Therefore, in this discussion, the terms functional and
registers. Folia Phoniatrica, 39, 280–289. psychogenic will be used synonymously, which reflects
Wechsler, E. (1977). A laryngographic study of voice disorders. current trends in the clinical literature (nosological im-
British Journal of Disorders of Communication, 12, 9–22. precision notwithstanding).

28 Part I: Voice

In clinical practice, ‘‘psychogenic voice disorder’’ without strain), breathiness, and high-pitched falsetto, as
should not be a default diagnosis for a voice problem well as voice and pitch breaks that vary in consistency
of undetermined cause. Rather, at least three criteria and severity.
should be met before such a diagnosis is o¤ered: symp- In conversion voice disorders, psychological factors
tom psychogenicity, symptom incongruity, and symp- are judged to be associated with the voice symptoms
tom reversibility (Sapir, 1995). Symptom psychogenicity because conflicts or other stressors precede the onset or
refers to the finding that the voice disorder is logically exacerbation of the dysphonia. In short, patients convert
linked in time of onset, course, and severity to an iden- intrapsychic distress into a voice symptom. The voice
tifiable psychological antecedent, such as a stressful life loss, whether partial or complete, is also often inter-
event or interpersonal conflict. Such information is preted to have symbolic meaning. Primary or secondary
acquired through a complete case history and psycho- gains are thought to play an important role in main-
social interview. Symptom incongruity refers to the ob- taining and reinforcing the conversion disorder. Primary
servation that the vocal symptoms are physiologically gain refers to anxiety alleviation accomplished by pre-
incompatible with existing or suspected disease, are venting the psychological conflict from entering con-
internally inconsistent, and are incongruent with other scious awareness. Secondary gain refers to the avoidance
speech and language characteristics. An often cited ex- of an undesirable activity or responsibility and the extra
ample of symptom incongruity is complete aphonia attention or support conferred on the patient.
(whispered speech) in a patient who has a normal throat Butcher and colleagues (Butcher et al., 1987; Butcher,
clear, cough, laugh, or hum, whereby the presence of Elias, and Raven, 1993; Butcher, 1995) have argued that
such normal nonspeech vocalization is at odds with there is little research evidence that conversion disorder
assumptions regarding neural integrity and function of is the most common cause of functional voice loss.
the laryngeal system. Finally, symptom reversibility Butcher advised that the conversion label should be re-
refers to complete, sustained amelioration of the voice served for cases of aphonia in which lack of concern and
disorder with short-term voice therapy (usually one or motivation to improve the voice coexists with clear evi-
two sessions) or through psychological abreaction. Fur- dence of a temporally linked psychosocial stressor. In the
thermore, maintaining the voice improvement requires place of conversion, Butcher (1995) o¤ered two alterna-
no compensatory e¤ort on the part of the patient. In tive models to account for psychogenic voice loss. Both
general, psychogenic dysphonia may be suspected when models minimized the role of primary and secondary
strong evidence exists for symptom incongruity and gain in maintaining the voice disorder. The first was
symptom psychogenicity, but it is confirmed only when a slightly reformulated psychoanalytic model that stated,
there is unmistakable evidence of symptom reversibility. ‘‘if predisposed by social and cultural bias as well as
A wide array of psychopathological processes con- early learning experiences, and then exposed to inter-
tributing to voice symptom formation in functional dys- personal di‰culties that stimulate internal conflict,
phonia have been proposed. These mechanisms include, particularly in situations involving conflict over self-
but are not limited to, conversion reaction, hysteria, expression or voicing feelings, intrapsychic conflict or
hypochondriasis, anxiety, depression and various per- stress becomes channeled into musculoskeletal tension,
sonality dispositions or emotional stresses or conflicts which physically inhibits voice production’’ (p. 472). The
that induce laryngeal musculoskeletal tension. Roy and second model, based on cognitive-behavioral principles,
Bless (2000) provide a more complete exploration of the stated that ‘‘life stresses and interpersonal problems in
putative psychological and personality processes involved an individual predisposed to having di‰culties express-
in functional dysphonia, as well as related research. ing feelings or views would produce involuntary anxiety
The dominant psychological explanation for dyspho- symptoms and musculoskeletal tension, which would
nia unaccounted for by pathological findings is the con- center on and inhibit voice production’’ (p. 473). Both
cept of conversion disorder. According to the DSM-IV, models clearly emphasized the inhibitory e¤ects of excess
conversion disorder involves unexplained symptoms or laryngeal muscle tension on voice production, although
deficits a¤ecting voluntary motor or sensory function through slightly di¤erent causal mechanisms.
that suggest a neurological or other general medical Recently, Roy and Bless (2000) proposed a theory
condition (American Psychiatric Association, 1994). The that links personality to the development of functional
conversion symptom represents an unconscious simula- dysphonia. The ‘‘trait theory of functional dysphonia’’
tion of illness that ostensibly prevents conscious aware- shares Butcher’s (1995) theme of inhibitory laryngeal
ness of emotional conflict or stress, thereby displacing behavior but attributes this muscularly inhibited voice
the mental conflict and reducing anxiety. When the la- production to specific personality types. In brief, the
ryngeal system is involved, the condition is referred to as authors speculate that the combination of personality
conversion dysphonia or aphonia. In aphonia, patients traits such as introversion and neuroticism (trait anxiety)
lose their voice suddenly and completely and articulate and constraint leads to predictable and conditioned la-
in a whisper. The whisper may be pure, harsh, or sharp, ryngeal inhibitory responses to certain environmental
with occasional high-pitched squeaklike traces of pho- signals or cues. For instance, when undesirable punish-
nation. In dysphonia, phonation is preserved but dis- ing or frustrating outcomes have been paired with pre-
turbed in quality, pitch, or loudness. Myriad dysphonia vious attempts to speak out, this can lead to muscularly
types are encountered, including hoarseness (with or inhibited voice. The authors contend that this conflict

Functional Voice Disorders 29

between laryngeal inhibition and activation (with origins complaints, and (4) introversion in the functional dys-
in personality and nervous system functioning) results in phonia population. Patients have been described as
elevated laryngeal tension states and can give rise to in- inhibited, stress reactive, socially anxious, nonassertive,
complete or disordered vocalization in a structurally and and with a tendency toward restraint (Friedl, Friedrich,
neurologically intact larynx. and Egger, 1990; Gerritsma, 1991; Roy, Bless, and Hei-
As is apparent from the foregoing discussion, the ex- sey, 2000a, 2000b).
quisite sensitivity and prolonged hypercontraction of the In conclusion, the larynx can be a site of neuromus-
intrinsic and extrinsic laryngeal muscles in response to cular tension arising from stress, emotional inhibition,
stress, anxiety, depression, and inhibited emotional ex- fear or threat, communication breakdown, and certain
pression is frequently cited as the common denominator personality types. This tension can produce severely dis-
underlying the majority of functional voice problems. ordered voice in the context of a structurally normal
Nichol, Morrison, and Rammage (1993) proposed that larynx. Although the precise mechanisms underlying and
excess muscle tension arises from overactivity of auto- maintaining psychogenic voice problems remain unclear,
nomic and voluntary nervous systems in individuals the voice disorder is a powerful reminder of the intimate
who are unduly aroused and anxious. They added that relationship between mind and body.
such overactivity leads to hypertonicity of the intrinsic See also psychogenic voice disorders: direct
and extrinsic laryngeal muscles, resulting in muscle ten- therapy.
sion dysphonias sometimes associated with adjustment
or anxiety disorders, or with certain personality trait —Nelson Roy
disturbances.
Finally, some researchers have noted that their ‘‘psy- References
chogenic dysphonia and aphonia’’ patients had an
abnormally high number of reported allergy, asthma, American Psychiatric Association. (1994). Diagnostic and sta-
or upper respiratory infection symptoms, suggesting a tistical manual of mental disorders—Fourth edition. Wash-
ington, DC: American Psychiatric Press.
link between psychological factors and respiratory and
Aronson, A. E. (1990). Clinical voice disorders: An interdisci-
phonatory disorders (Milutinovic, 1991; Schalen and plinary approach (3rd ed.). New York: Thieme.
Andersson, 1992). They have speculated that organic Aronson, A. E., Peterson, H. W., and Litin, E. M. (1966).
changes in the larynx, pharynx, and nose facilitate the Psychiatric symptomatology in functional dysphonia and
appearance of a functional voice problem; that is, these aphonia. Journal of Speech and Hearing Disorders, 31, 115–
changes direct the somatization of psychodynamic con- 127.
flict. Likewise, Rammage, Nichol, and Morrison (1987) Bridger, M. M., and Epstein, R. (1983). Functional voice dis-
proposed that a relatively minor organic change such as orders: A review of 109 patients. Journal of Laryngology
edema, infection, or reflux laryngitis may trigger func- and Otology, 97, 1145–1148.
tional misuse, particularly if the individual is exceedingly Butcher, P. (1995). Psychological processes in psychogenic
voice disorder. European Journal of Disorders of Communi-
anxious about his or her voice or health. In a similar cation, 30, 467–474.
vein, the same authors felt that anticipation of poor Butcher, P., Elias, A., Raven, R. (1993). Psychogenic voice
voice production in hypochondriacal, dependent, or disorders and cognitive behaviour therapy. San Diego, CA:
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lance over sensations arising from the throat (larynx) Butcher, P., Elias, A., Raven, R., Yeatman, J., and Littlejohns,
and respiratory system that may lead to altered voice D. (1987). Psychogenic voice disorder unresponsive to
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Research evidence to support the various psycho- behaviour therapy. British Journal of Disorders of Commu-
logical mechanisms o¤ered to explain functional voice nication, 22, 81–92.
problems has seldom been provided. A complete review Friedl, W., Friedrich, G., and Egger, J. (1990). Personality and
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Roy et al. (1997). The empirical literature evaluating the Gerritsma, E. J. (1991). An investigation into some personality
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and Litin, 1966; Kinzl, Biebl, and Rauchegger, 1988; social characteristics of patients with functional dysphonia.
Gerritsma, 1991; Roy, Bless, and Heisey, 2000a, 2000b), Journal of Psychosomatic Research, 3, 483–490.
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Milutinovic, Z. (1991). Inflammatory changes as a risk factor
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ological di¤erences, these studies have identified a gen- Interdisciplinary approach to functional voice disorders:
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anxiety, (2) depression, (3) somatic preoccupation or Surgury, 108, 643–647.

30 Part I: Voice

Pfau, E. M. (1975). Psychologische Untersuchungsergegnisse Hypokinetic Laryngeal Movement
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Roy, N., and Bless, D. M. (2000). Toward a theory of the dis- most often in individuals diagnosed with the neuro-
positional bases of functional dysphonia and vocal nodules: logical disorder, parkinsonism. Parkinsonism has the
Exploring the role of personality and emotional adjustment. following features: bradykinesia, postural instability,
In R. D. Kent and M. J. Ball (Eds.), Voice quality mea- rigidity, resting tremor, and freezing (motor blocks)
surement (pp. 461–480). San Diego, CA: Singular Publish- (Fahn, 1986). For the diagnosis to be made, at least two
ing Group. of these five features should be present, and one of the
Roy, N., Bless, D. M., and Heisey, D. (2000a). Personality and
two features should be either tremor or rigidity. Parkin-
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Roy, N., Bless, D. M., and Heisey, D. (2000b). Personality and Parkinson’s disease (PD) (i.e., symptoms of unknown
voice disorders: A multitrait-multidisorder analysis. Journal cause); secondary (or symptomatic) PD, caused by a
of Voice, 14, 521–548. known and identifiable cause; or parkinsonism-plus syn-
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and Ford, C. N. (1997). Psychological correlates of func- by a known gene defect or have a distinctive pathology.
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Sapir, S. (1995). Psychogenic spasmodic dysphonia: A case tests. No single feature is completely reliable for di¤er-
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entiating among the di¤erent causes of parkinsonism.
and treatment of psychogenic voice disorder. Clinical Oto- Idiopathic PD is the most common type of parkin-
laryngology, 17, 225–230. sonism encountered by the neurologist. Pathologically,
White, A., Deary, I. J., and Wilson, J. A. (1997). Psychiatric idiopathic PD a¤ects many structures in the central
disturbance and personality traits in dysphonic patients. Euro- nervous system (CNS), with preferential involvement
pean Journal of Disorders of Communication, 32, 121–128. of dopaminergic neurons in the substantia nigra pars
compacta (SNpc). Lewy bodies, eosinophilic intra-
Further Readings cytoplasmatic inclusions, can be found in these neurons
(Galvin, Lee, and Trojanowski, 2001). Alpha-synuclein
Deary, I. J., Scott, S., Wilson, I. M., White, A., MacKenzie, is the primary component of Lewy body fibrils (Galvin,
K., and Wilson, J. A. (1998). Personality and psychological Lee, and Trojanowski, 2001). However, only about 75%
distress in dysphonia. British Journal of Health Psychology, of patients with the clinical diagnosis of idiopathic PD
2, 333–341. are found at autopsy to have the pathological CNS
Friedl, W., Friedrich, G., Egger, J., and Fitzek, I. (1993). Psy-
changes characteristic of PD (Hughes et al., 1992).
chogenic aspects of functional dysphonia. Folia Phoniatrica,
45, 10–13. Many patients and their families consider the reduced
Green, G. (1988). The inter-relationship between vocal and ability to communicate one of the most di‰cult aspects
psychological characteristics: A literature review. Australian of PD. Hypokinetic dysarthria, characterized by a soft
Journal of Human Communication Disorders, 16, 31–43. voice, monotone, a breathy, hoarse voice quality, and
Gunther, V., Mayr-Graft, A., Miller, C., and Kinzl, H. (1996). imprecise articulation (Darley, Aronson, and Brown,
A comparative study of psychological aspects of recurring 1975; Logemann et al., 1978), and reduced facial ex-
and non-recurring functional aphonias. European Archives pression (masked facies) contribute to limitations in
of Otorhinolaryngology, 253, 240–244. communication in the vast majority of individuals with
House, A. O., and Andrews, H. B. (1988). Life events and dif- idiopathic PD (Pitcairn et al., 1990). During the course
ficulties preceding the onset of functional dysphonia. Jour-
of the disease, approximately 45%–89% of patients will
nal of Psychosomatic Research, 32, 311–319.
Koufman, J. A., and Blalock, P. D. (1982). Classification and report speech problems (Logemann and Fisher, 1981;
approach to patients with functional voice disorders. Annals Sapir et al., 2002). Repetitive speech phenomena (Benke
of Otology, Rhinology, and Laryngology, 91, 372–377. et al., 2000), voice tremor, and hyperkinetic dysarthria
Morrison, M. D., and Rammage, L. (1993). Muscle misuse may also be encountered in individuals with idiopathic
voice disorders: Description and classification. Acta Oto- PD. When hyperkinetic dysarthria is reported in idio-
laryngologica (Stockholm), 113, 428–434. pathic PD, it is most frequently seen together with other
Moses, P. J. (1954). The voice of neurosis. New York: Grune motor complications (e.g., dyskinesia) of prolonged
and Stratton. levodopa therapy (Critchley, 1981).
Pennebaker, J. W., and Watson, D. (1991). The psychology of Logemann et al. (1978) suggested that the clusters of
somatic symptoms. In L. J. Kirmayer and J. M. Robbins
speech symptoms they observed in 200 individuals with
(Eds.), Current concepts of somatization. Washington, DC:
American Psychiatric Press. PD represented a progression in dysfunction, beginning
Roy, N., and Bless, D. M. (2000). Personality traits and psy- with disordered phonation in recently diagnosed patients
chological factors in voice pathology: A foundation for and extending to include disordered articulation and
future research. Journal of Speech, Language, and Hearing other aspects of speech in more advanced cases. Recent
Research, 43, 737–748. findings by Sapir et al. (2002) are consistent with this

Hypokinetic Laryngeal Movement Disorders 31

suggestion. Sapir et al. (2002) observed voice disorders in reduced and variable single motor unit activity in the
individuals with recent onset of PD and low Unified thyroarytenoid muscle of individuals with idiopathic PD
Parkinson Disease Rating Scale (UPDRS) scores; in (Luschei et al., 1999) are consistent with a number of
individuals with longer duration of disease and higher hypotheses, the most plausible of which is reduced cen-
UPDRS scores, they observed a significantly higher in- tral drive to laryngeal motor neuron pools.
cidence of abnormal articulation and fluency, in addition Although the origin of the hypophonia in PD is cur-
to the disordered voice. Hypokinetic dysarthria of par- rently undefined, Ramig and colleagues (e.g., Fox et al.,
kinsonism is considered to be a part of basal ganglia 2002) have hypothesized that there are at least three
damage (Darley, Aronson, and Brown, 1975). However, features underlying the voice disorder in individuals with
there are no studies on pathological changes in the PD: (1) an overall neural amplitude scaledown (Penny
hypokinetic dysarthria of idiopathic PD. A significant and Young, 1983) to the laryngeal mechanism (reduced
correlation between neuronal loss and gliosis in SNpc amplitude of neural drive to the muscles of the larynx);
and substantia nigra pars reticulata (SNpr) and severity (2) problems in sensory perception of e¤ort (Berardelli et
of hypokinetic dysarthria was found in patients with al., 1986), which prevents the individual with idiopathic
Parkinson-plus syndromes (Kluin et al., 2001). Speech PD from accurately monitoring his or her vocal output;
and voice characteristics may di¤er between idiopathic which results in (3) the individual’s di‰culty in inde-
PD and Parkinson-plus syndromes (e.g., Shy-Drager pendently generating (through internal cueing or scaling)
syndrome, progressive supranuclear palsy, multisystem adequate vocal e¤ort (Hallet and Khoshbin, 1980) to
atrophy). In addition to the classic hypokinetic symp- produce normal loudness. Reduced neural drive, prob-
toms, these patients may have more slurring, a strained, lems in sensory perception of e¤ort, and problems scal-
strangled voice, pallilalia, and hypernasality (Country- ing adequate vocal output e¤ort may be significant
man, Ramig, and Pawlas, 1994) and their symptoms factors underlying the voice problems in individuals with
may progress more rapidly. PD.
Certain aspects of hypokinetic dysarthria in idio-
pathic PD have been studied extensively. Hypophonia —Lorraine Olson Ramig, Mitchell F. Brin, Miodrag
(reduced loudness, monotone, a breathy, hoarse quality) Velickovic, and Cynthia Fox
may be observed in as many as 89% of individuals with
idiopathic PD (Logemann et al., 1978). Fox and Ramig
References
(1997) reported that sound pressure levels in individuals Aronson, A. E. (1990). Clinical voice disorders. New York:
with idiopathic PD were significantly lower (2–4 dB Thieme-Stratton.
[30 cm]) across a variety of speech tasks than in an age- Baker, K. K., Ramig, L. O., Luschei, E. S., and Smith, M. E.
and sex-matched control group. Lack of vocal fold clo- (1998). Thyroarytenoid muscle activity associated with
sure, including bowing of the vocal cords and anterior hypophonia in Parkinson disease and aging. Neurology, 51,
and posterior chinks (Hanson, Gerratt, and Ward, 1984; 1592–1598.
Benke, T., Hohenstein, C., Poewe, W., and Butterworth, B.
Smith et al., 1995), has been implicated as a cause of this (2000). Repetitive speech phenomena in Parkinson’s dis-
hypophonia. Perez et al. (1996) used videostroboscopic ease. Journal of Neurology, Neurosurgery, and Psychiatry,
observations to study vocal fold vibration in individuals 69, 319–324.
with idiopathic PD. They reported abnormal phase clo- Berardelli, A., Dick, J. P., Rothwell, J. C., Day, B. L., and
sure and symmetry and tremor (both at rest and during Marsden, C. D. (1986). Scaling of the size of the first ago-
phonation) in nearly 50% of patients. Whereas reduced nist EMG burst during rapid wrist movements in patients
loudness and disordered voice quality in idiopathic PD with Parkinson’s disease. Journal of Neurology, Neuro-
have been associated with glottal incompetence (lack of surgery, and Psychiatry, 49, 1273–1279.
vocal fold closure—e.g., bowing; Hanson, Gerratt, and Countryman, S., Ramig, L. O., and Pawlas, A. A. (1994).
Ward, 1984; Smith et al., 1995; Perez et al., 1996), the Speech and voice deficits in Parkinsonian Plus syndromes:
Can they be treated? Journal of Medical Speech-Language
specific origin of this glottal incompetence has not been Pathology, 2, 211–225.
clearly defined. Rigidity or fatigue secondary to rigidity, Critchley, E. M. (1981). Speech disorders of Parkinsonism: A
paralysis, reduced thyroarytenoid longitudinal tension review. Journal of Neurology, Neurosurgery, and Psychiatry,
secondary to cricothyroid rigidity (Aronson, 1990), and 44, 751–758.
misperception of voice loudness (Ho, Bradshaw, and Darley, F. L., Aronson, A. E., and Brown, J. B. (1975). Motor
Iansek 2000; Sapir et al., 2002) are among the explana- speech disorders. Philadelphia: Saunders.
tions. It has been suggested that glottal incompetence Fahn, S. (1986). Parkinson’s disease and other basal ganglion
(e.g., vocal fold bowing) might be due to loss of muscle disorders. In A. K. Asbury, G. M. McKhann, and W. I.
or connective tissue volume, either throughout the entire McDonald (Eds.), Diseases of the nervous system: Clinical
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Fox, C., Morrison, C. E., Ramig, L. O., and Sapir, S. (2002).
fold. Recent physiological studies of laryngeal function Current perspectives on the Lee Silverman voice treatment
in idiopathic PD have shown a reduced amplitude of (LSVT) for individuals with idiopathic Parkinson’s disease.
electromyographic activity in the thyroarytenoid mus- American Journal of Speech-Language Pathology, 11, 111–
cle accompanying glottal incompetence when compared 123.
with both aged-matched and younger controls (Baker Fox, C., and Ramig, L. (1997). Vocal sound pressure level and
et al., 1998). These findings and the observation of self-perception of speech and voice in men and women with

32 Part I: Voice

idiopathic Parkinson disease. American Journal of Speech- Conner, N. P., Abbs, J. H., Cole, K. J., and Gracco, V. L.
Language Pathology, 6, 85–94. (1989). Parkinsonian deficits in serial multiarticulate move-
Galvin, J. E., Lee, V. M., and Trojanowski, J. Q. (2001). Syn- ments for speech. Brain, 112, 997–1009.
ucleinopathies: Clinical and pathological implications. Contreras-Vidal, J., and Stelmach, G. (1995). A neural model
Archives of Neurology, 58, 186–190. of basal ganglia-thalamocortical relations in normal and
Hallet, M., and Khoshbin, S. (1980). A physiological mecha- parkinsonian movement. Biological Cybernetics, 73, 467–
nism of bradykinesia. Brain, 103, 301–314. 476.
Hanson, D., Gerratt, B., and Ward, P. (1984). Cinegraphic DeLong, M. R. (1990). Primate models of movement disorders
observations of laryngeal function in Parkinson’s disease. of basal ganglia origin. Trends in Neuroscience, 13, 281–
Laryngoscope, 94, 348–353. 285.
Ho, A. K., Bradshaw, J. L., and Iansek, T. (2000). Volume Forrest, K., Weismer, G., and Turner, G. (1989). Kinematic,
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Hughes, A. J., Daniel, S. E., Kilford, L., and Lees, A. J. of the Acoustical Society of America, 85, 2608–2622.
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181–184. Jurgens, U., and von Cramon, D. (1982). On the role of
Kluin, K. J., Gilman, S., Foster, N. L., Sima, A., D’Amato, the anterior cingulated cortex in phonation: A case report.
C., Bruch, L., et al. (2001). Neuropathological correlates Brain and Language, 15, 234–248.
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Neurology, 58, 265–269. stem structure involved in vocalization. Journal of Speech
Logemann, J. A., and Fisher, H. B. (1981). Vocal tract control and Hearing Research, 28, 241–249.
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articulations. Journal of Speech and Hearing Disorders, 46, tween perceptual ratings and acoustic measures of hypo-
348–352. kinetic speech. In M. R. McNeil, J. C. Rosenbek, and A. E.
Logemann, J. A., Fisher, H. B., Boshes, B., and Blonsky, E. Aronson (Eds.), Dysarthria of speech: Physiology-acoustics-
(1978). Frequency and concurrence of vocal tract dysfunc- linguistics-management. San Diego, CA: College-Hill Press.
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Journal of Speech and Hearing Disorders, 43, 47–57. and weakness in parkinsonian dysarthria. Journal of Speech
Luschei, E. S., Ramig, L. O., Baker, K. L., and Smith, M. E. and Hearing Disorders, 40, 170–178.
(1999). Discharge characteristics of laryngeal single motor Sarno, M. T. (1968). Speech impairment in Parkinson’s dis-
units during phonation in young and older adults and in ease. Journal of Speech and Hearing Disorders, 49, 269–275.
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81, 2131–2139. Deficits in orofacial sensorimotor function in Parkinson’s
Penny, J. B., and Young, A. B. (1983). Speculations on the disease. Annals of Neurology, 19, 275–282.
functional anatomy of basal ganglia disorders. Annual Re- Solomon, N. P., Hixon, T. J. (1993). Speech breathing in Par-
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Perez, K., Ramig, L. O., Smith, M., and Dromey, C. (1996). 36, 294–310.
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ings. Journal of Voice, 10, 354–361. function in early Parkinson’s disease. Movement Disorders,
Pitcairn, T., Clemie, S., Gray, J., and Pentland, B. (1990). 10, 562–565.
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Sapir, S., Pawlas, A. A., Ramig, L. O., Countryman, S., et al. Infectious Diseases and Inflammatory
(2002). Speech and voice abnormalities in Parkinson dis-
ease: Relation to severity of motor impairment, duration of Conditions of the Larynx
disease, medication, depression, gender, and age. Journal of
Medical Speech-Language Pathology, 9, 213–226.
Smith, M. E., Ramig, L. O., Dromey, C., et al. (1995). Inten- Infectious and inflammatory conditions of the larynx
sive voice treatment in Parkinson disease: Laryngostrobo- can a¤ect the voice, swallowing, and breathing to
scopic findings. Journal of Voice, 9, 453–459. varying extents. Changes can be acute or chronic and
can occur in isolation or as part of systemic processes.
Further Readings The conditions described in this article are grouped by
etiology.
Ackerman, H., and Ziegler, W. (1991). Articulatory deficits
in Parkinsonian dysarthria. Journal of Neurology, Neuro- Infectious Diseases
surgery, and Psychiatry, 54, 1093–1098.
Brown, R. G., and Marsden, C. D. (1988). An investigation of
Viral Laryngotracheitis. Viral laryngotracheitis is the
the phenomenon of ‘‘set’’ in Parkinson’s disease. Movement
Disorders, 3, 152–161. most common infectious laryngeal disease. It is typically
Caliguri, M. P. (1989). Short-term fluctuations in orofacial associated with upper respiratory infection, for example,
motor control in Parkinson’s disease. In K. M. Yorkson by rhinoviruses and adenoviruses. Dysphonia is usually
and D. R. Beukelman (Eds.), Recent advances in clinical self-limiting but may create major problems for a pro-
dysarthria. Boston: College-Hill Press. fessional voice user. The larger diameter upper airway in

Infectious Diseases and Inflammatory Conditions of the Larynx 33

adults makes airway obstruction much less likely than in ness and odynophagia, typically out of proportion to the
children. size of the lesion. However, these symptoms are not
In a typical clinical scenario, a performer with mild universally present. The vocal folds are most commonly
upper respiratory symptoms has to carry on performing a¤ected, although all areas of the larynx can be
but complains of reduced vocal pitch and increased ef- involved. Laryngeal tuberculosis is often di‰cult to dis-
fort on singing high notes. Mild vocal fold edema and tinguish from carcinoma on laryngoscopy. Chest radi-
erythema may occur but can be normal for this patient ography and the purified protein derivative (PPD) test
group. Thickened, erythematous tracheal mucosa visible help establish the diagnosis, although biopsy and histo-
between the vocal folds supports the diagnosis. logical confirmation may be required. Patients are treated
Hydration and rest may be su‰cient treatment. with antituberculous chemotherapy. The laryngeal symp-
However, if the performer decides to proceed with the toms usually respond within 2 weeks.
show, high-dose steroids can reduce inflammation, and Leprosy is rare in developing countries. Laryngeal
antibiotics may prevent opportunistic bacterial infection. infection by Mycobacterium leprae can cause nodules,
Cough suppressants, expectorants, and steam inhala- ulceration, and fibrosis. Lesions are often painless but
tions may also be useful. Careful vocal warmup should may progress over the years to laryngeal stenosis.
be undertaken before performing, and ‘‘rescue’’ must be Treatment is with antileprosy chemotherapy (Soni, 1992).
balanced against the risk of vocal injury.
Other Bacterial Infections. Laryngeal actinomycosis
Other Viral Infections. Herpes simplex and herpes zos- can occur in immunocompromised patients and follow-
ter infection have been reported in association with vocal ing laryngeal radiotherapy (Nelson and Tybor, 1992).
fold paralysis (Flowers and Kernodle, 1990; Nishizaki Biopsy may be required to distinguish it from radio-
et al., 1997). Laryngeal vesicles, ulceration, or plaques necrosis or tumor. Treatment requires prolonged anti-
may lead to suspicion of the diagnosis, and antiviral biotic therapy.
therapy should be instituted early. New laryngeal muscle Scleroma is a chronic granulomatous disease due to
weakness may also occur in post-polio syndrome (Rob- Klebsiella scleromatis. Primary involvement is in the
inson, Hillel, and Waugh, 1998). Viral infection has also nose, but the larynx can also be a¤ected. Subglottic
been implicated in the pathogenesis of certain laryn- stenosis is the main concern (Amoils and Shindo, 1996).
geal tumors. The most established association is between
human papillomavirus (HPV) and laryngeal papil- Fungal Laryngitis. Fungal laryngitis is rare and typi-
lomatosis (Levi et al., 1989). HPV, Epstein-Barr virus, cally occurs in immunocompromised individuals. Fungi
and even herpes simplex virus have been implicated in include yeasts and molds. Yeast infections are more fre-
the development of laryngeal malignancy (Ferlito et al., quent in the larynx, with Candida albicans most com-
1997; Garcia-Milian et al., 1998; Pou et al., 2000). monly identified (Vrabec, 1993). Predisposing factors in
nonimmunocompromised patients include antibiotic and
Bacterial Laryngitis. Bacterial laryngitis is most com- inhaled steroid use, and foreign bodies such as silicone
monly due to Hemophilus influenzae, Staphylococcus voice prostheses.
aureus, Streptococcus pneumoniae, and beta-hemolytic The degree of hoarseness in laryngeal candidiasis may
streptococcus. Pain and fever may be severe, with air- not reflect the extent of infection. Pain and associated
way and swallowing di‰culties generally overshadowing swallowing di‰culty may be present. Typically, thick
voice loss. Typically the supraglottis is involved, with the white exudates are seen, and oropharyngeal involvement
aryepiglottic folds appearing boggy and edematous, can coexist. Biopsy may show epithelial hyperplasia with
often more so than the epiglottis. Unlike in children, a pseudocarcinomatous appearance. Potential complica-
laryngoscopy is usually safe in adults and is the best tions include scarring, airway obstruction, and systemic
means of diagnosis. Possible underlying causes such as a dissemination.
laryngeal foreign body should be considered. Treatment In mild localized disease, topical nystatin or clo-
includes intravenous antibiotics, hydration, humidifica- trimazole are usually e¤ective. Discontinuing antibiotics
tion, and corticosteroids. Close observation is essential or inhaled steroids should be considered. More severe
in case airway support is needed. Rarely, infected mu- cases may require oral antifungal azoles such as keto-
cous retention cysts and epiglottic abscesses occur (Stack conazole, fluconazole, or itraconazole. Intravenous
and Ridley, 1995). Tracheostomy and drainage may be amphotericin is e‰cacious but has potentially severe side
required. e¤ects. It is usually used for invasive or systemic disease.
Less common fungal diseases include blastomycosis,
Mycobacterial Infections. Laryngeal tuberculosis is histoplasmosis, and coccidiomycosis. Infection may be
rare in industrialized countries but must be considered in confused with laryngeal carcinoma, and special histo-
the di¤erential diagnosis of laryngeal disease, especially logical stains are usually required for diagnosis. Long-
in patients with AIDS or other immune deficiencies term treatment with amphotericin B may be necessary.
(Singh et al., 1996). Tuberculosis can infect the larynx
primarily, by direct spread from the lungs, or by hema- Syphilis. Syphilis is caused by the spirochete Trepo-
togenous or lymphatic dissemination (Ramandan, nema pallidum. Laryngeal involvement is rare but may
Tarayi, and Baroudy, 1993). Most patients have hoarse- occur in later stages of the disease. Secondary syphilis

34 Part I: Voice

may present with laryngeal papules, ulcers and edema 50% of cases. Dapsone, corticosteroids, and immuno-
that mimic carcinoma, or tuberculous laryngitis. Ter- suppressive drugs have been used to control the disease.
tiary syphilis may cause gummas, leading to scarring Repeated attacks of laryngeal chondritis can cause sub-
and stenosis (Lacy, Alderson, and Parker, 1994). Sero- glottic scarring, necessitating permanent tracheostomy
logic tests are diagnostic. Active disease is treated with (Spraggs, Tostevin, and Howard, 1997).
penicillin.
Cicatricial Pemphigoid. This chronic subepithelial
Inflammatory Processes bullous disease predominantly involves the mucous
membranes. Acute laryngeal lesions are painful, and
Chronic Laryngitis. Chronic laryngeal inflammation examination shows mucosal erosion and ulceration.
can result from smoking, gastroesophageal reflux Later, scarring and stenosis may occur, with supraglottic
(GER), voice abuse, or allergy. Patients often complain involvement (Hanson, Olsen, and Rogers, 1988). Treat-
of hoarseness, sore throat, a globus sensation, and throat ment includes dapsone, systemic or intralesional ste-
clearing. The vocal folds are usually thickened, dull, and roids, and cyclophosphamide. Scarring may require laser
erythematous. Posterior laryngeal involvement usually excision and sometimes tracheostomy.
suggests GER. Besides direct chemical irritation, GER
can promote laryngeal muscle misuse, which contributes Amyloidosis. Amyloidosis is characterized by deposi-
to wear-and-tear injury (Gill and Morrison, 1998). tion of acellular proteinaceous material (amyloid) in
Although seasonal allergies may cause vocal fold tissues (Lewis et al., 1992). It can occur primarily or
edema and hoarseness (Jackson-Menaldi, Dzul, and secondary to other diseases such as multiple myeloma or
Holland, 1999), it is surprising that allergy-induced tuberculosis. Deposits may be localized or generalized.
chronic laryngitis is not more common. Even patients Laryngeal involvement is usually due to primary local-
with significant nasal allergies or asthma have a low ized disease. Submucosal deposits may a¤ect any part of
incidence of voice problems. The severity of other aller- the larynx but most commonly occur in the ventricular
gic accompaniments helps the clinician identify patients folds. Treatment is by conservative laser excision.
with dysphonia of allergic cause. Recurrences are frequent.
Treatment of chronic laryngitis includes voice rest Sarcoidosis. Sarcoidosis is a multiorgan granulomatous
and elimination of irritants. Dietary modifications and disease of unknown etiology. About 6% of cases involve
postural measures such as elevating the head of the bed the larynx, producing dysphonia and airway obstruction.
can reduce GER. Proton pump inhibitors can be e¤ec- Pale, di¤use swelling of the epiglottis and aryepiglottic
tive for persistent laryngeal symptoms (Hanson, Kamel, folds is characteristic (Benjamin, Dalton, and Crox-
and Kahrilas, 1995). son, 1995). Systemic or intralesional steroids, anti-
lepromatous therapy, and laser debulking are all possible
Traumatic and Iatrogenic Causes. Inflammatory pol- treatments.
yps, polypoid degeneration, and contact granuloma can
arise from vocal trauma. Smoking contributes to poly- Wegener’s Granulomatosis. Wegener’s granulomatosis
poid degeneration, and intubation injury can cause con- is an idiopathic syndrome characterized by vasculitis
tact granulomas. GER may promote inflammation in all and necrotizing granulomas of the respiratory tract and
these conditions. Granulomas can also form many years kidneys. The larynx is involved in 8% of cases (Wax-
after Teflon injection for glottic insu‰ciency. man and Bose, 1986). Ulcerative lesions and subglottic
stenosis may occur, causing hoarseness and dyspnea.
Rheumatoid Arthritis and Systemic Lupus Erythe- Treatment includes corticosteroids and cyclophospha-
matosus. Laryngeal involvement occurs in almost a mide. Laser resection or open surgery is sometimes
third of patients with rheumatoid arthritis (Lofgren and necessary for airway maintenance.
Montgomery, 1962). Patients present with a variety of
symptoms. In the acute phase the larynx may be tender —David P. Lau and Murray D. Morrison
and inflamed. In the chronic phase the laryngeal mucosa
may appear normal, but cricoarytenoid joint ankylosis References
may be present. Submucosal rheumatoid nodules or Amoils, C., and Shindo, M. (1996). Laryngotracheal manifes-
‘‘bamboo nodes’’ can form in the membranous vocal tations of rhinoscleroma. Annals of Otology, Rhinology, and
folds. If the mucosal wave is severely damped, micro- Laryngology, 105, 336–340.
laryngeal excision can improve the voice. Corticosteroids Benjamin, B., Dalton, C., and Croxson, G. (1995). Laryngo-
can be injected intracordally following excision. Other scopic diagnosis of laryngeal sarcoid. Annals of Otology,
autoimmune diseases such as systemic lupus erythe- Rhinology, and Laryngology, 104, 529–531.
matosus can cause similar laryngeal pathology (Woo, Ferlito, A., Weiss, L., Rinaldo, A., et al. (1997). Clinicopatho-
logic consultation: Lymphoepithelial carcinoma of the
Mendelsohn, and Humphrey, 1995). larynx, hypopharynx and trachea. Annals of Otology, Rhi-
nology, and Laryngology, 106, 437–444.
Relapsing Polychondritis. Relapsing polychondritis is Flowers, R., and Kernodle, D. (1990). Vagal mononeuritis
an autoimmune disease causing inflammation of carti- caused by herpes simplex virus: Association with unilateral
laginous structures. The pinna is most commonly af- vocal cord paralysis. American Journal of Medicine, 88,
fected, although laryngeal involvement occurs in around 686–688.

Instrumental Assessment of Children’s Voice 35

Garcia-Milian, R., Hernandez, H., Panade, L., et al. (1998). Further Readings
Detection and typing of human papillomavirus DNA in
benign and malignant tumours of laryngeal epithelium. Badaracco, G., Venuti, A., Morello, R., Muller, A., and Mar-
Acta Oto-Laryngologica, 118, 754–758. cante, M. (2000). Human papillomavirus in head and neck
Gill, C., and Morrison, M. (1998). Esophagolaryngeal reflux in carcinomas: Prevalence, physical status and relationship
a porcine animal model. Journal of Otolaryngology, 27, 76– with clinical/pathological parameters. Anticancer Research,
80. 20, 1305.
Hanson, D., Kamel, P., and Kahrilas, P. (1995). Outcomes of Cleary, K., and Batsakis, J. (1995). Mycobacterial disease of
antireflux therapy for the treatment of chronic laryngitis. the head and neck: Current perspective. Annals of Otology,
Annals of Otology, Rhinology, and Laryngology, 104, 550– Rhinology, and Laryngology, 104, 830–833.
555. Herridge, M., Pearson, F., and Downey, G. (1996). Subglottic
Hanson, R., Olsen, K., and Rogers, R. (1988). Upper aero- stenosis complicating Wegener’s granulomatosis: Surgical
digestive tract manifestations of cicatricial pemphigoid. repair as a viable treatment option. Journal of Thoracic and
Annals of Otology, Rhinology, and Laryngology, 97, 493–499. Cardiovascular Surgery, 111, 961–966.
Jackson-Menaldi, C., Dzul, A., and Holland, R. (1999). Aller- Jones, K. (1998). Infections and manifestations of systemic
gies and vocal fold edema: A preliminary report. Journal of disease in the larynx. In C. W. Cummings, J. M. Fre-
Voice, 13, 113–122. drickson, L. A. Harker, C. J. Krause, D. E. Schuller, and
Lacy, P., Alderson, D., and Parker, A. (1994). Late congenital M. A. Richardson (Eds.), Otolaryngology—head and neck
syphilis of the larynx and pharynx presenting at endo- surgery (3rd ed., pp. 1979–1988). St Louis: Mosby.
tracheal intubation. Journal of Laryngology and Otology, Langford, C., and Van Waes, C. (1997). Upper airway ob-
108, 688–689. struction in the rheumatic diseases. Rheumatic Diseases
Levi, J., Delcelo, R., Alberti, V., Torloni, H., and Villa, L. Clinics of North America, 23, 345–363.
(1989). Human papillomavirus DNA in respiratory papil- Morrison, M., Rammage, L., Nichol, H., Pullan, B., May, P.,
lomatosis detected by in situ hybridization and polymerase and Salkeld, L. (2001). Management of the voice and its dis-
chain reaction. American Journal of Pathology, 135, 1179– orders (2nd ed.). San Diego, CA: Singular Publishing Group.
1184. Raymond, A., Sneige, N., and Batsakis, J. (1992). Amyloidosis
Lewis, J., Olsen, K., Kurtin, P., and Kyle, R. (1992). Laryngeal in the upper aerodigestive tracts. Annals of Otology, Rhi-
amyloidosis: A clinicopathologic and immunohistochemical nology, and Laryngology, 101, 794–796.
review. Otolaryngology–Head and Neck Surgery, 106, 372– Richter, B., Fradis, M., Kohler, G., and Ridder, G. (2001).
377. Epiglottic tuberculosis: Di¤erential diagnosis and treat-
Lofgren, R., and Montgomery, W. (1962). Incidence of laryn- ment. Case report and review of the literature. Annals of
geal involvement in rheumatoid arthritis. New England Otology, Rhinology, and Laryngology, 110, 197–201.
Journal of Medicine, 267, 193. Ridder, G., Strohhacker, H., Lohle, E., Golz, A., and Fradis,
Nelson, E., and Tybor, A. (1992). Actinomycosis of the larynx. M. (2000). Laryngeal sarcoidosis: Treatment with the anti-
Ear, Nose, and Throat Journal, 71, 356–358. leprosy drug clofazimine. Annals of Otology, Rhinology, and
Nishizaki, K., Onada, K., Akagi, H., Yuen, K., Ogawa, T., Laryngology, 109, 1146–1149.
and Masuda, Y. (1997). Laryngeal zoster with unilateral Satalo¤, R. (1997). Common infections and inflammations and
laryngeal paralysis. ORL: Journal for Oto-rhino-laryngology other conditions. In R. T. Satalo¤ (Ed.), Professional voice:
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36 Part I: Voice

these procedures should take into account the devel- Sex di¤erences in f0 emerge especially strongly during
opmental features of the larynx and special problems adolescence. The overall f0 decline from infancy to
associated with a pediatric population. adulthood is about one octave for girls and two octaves
An important starting point is the developmental for boys. There is some question as to when the sex
anatomy and physiology of the larynx. This background di¤erence emerges. Lee et al. (1999) observed that f0
is essential in understanding children’s vocal function as di¤erences between male and female children were sta-
determined by instrumental assessments. The larynx of tistically significant beginning at about age 12 years, but
the infant and young child di¤ers considerably in its Glaze et al. (1988) observed di¤erences between boys
anatomy and physiology from the adult larynx (see and girls for the age period 5–11 years. Further, Hacki
anatomy of the human larynx). The vocal folds in an and Heitmuller (1999) reported a lowering of both the
infant are about 3–5 mm long, and the composition of habitual pitch and the entire speaking pitch range be-
the folds is uniform. That is, the infant’s vocal folds are tween the ages of 7 and 8 years for girls and between the
not only very short compared with those of the adult, ages of 8 and 9 years for boys. Sex di¤erences emerge
but they lack the lamination seen in the adult folds. The strongly with the onset of mutation. Hacki and Heit-
lamination has been central to modern theories of pho- muller (1999) concluded that the beginning of the muta-
nation, and its absence in infants and marginal develop- tion occurs at age 10–11 years. Mean f0 change is
ment in young children presents interesting challenges to pronounced in males between the ages of about 12 and
theories of phonation applied to a pediatric population. 15 years. For example, Lee et al. (1999) reported a 78%
An early stage of development of the lamina propria decrease in f0 for males between these ages. No signifi-
begins between 1 and 4 years, with the appearance of the cant change was observed after the age of 15 years,
vocal ligament (intermediate and deep layers of the which indicates that the voice change is e¤ectively com-
lamina propria). During this same interval, the length of plete by that age (Hollien, Green, and Massey, 1994;
the vocal fold increases (reaching about 7.5 mm by age Kent and Vorperian, 1995).
5) and the entire laryngeal framework increases in size. Other acoustic aspects of children’s voices have not
The di¤erentiation of the superficial layer of the lamina been extensively studied. In apparently the only large-
propria apparently is not complete until at least the age scale study of its kind, Campisi et al. (2002) provided
of 12 years. normative data for children for the parameters of
Studies on the time of first appearance of sexual the Multi-Dimensional Voice Program (MDVP). On the
dimorphism in laryngeal size are conflicting, ranging majority of parameters (excluding, of course, f0 ), the
from 3 years to no sex di¤erences in laryngeal size ob- mean values for children were fairly consistent with
servable during early childhood. Sexual dimorphism of those for adults, which simplifies the clinical application
vocal fold length has been reported to appear at about of MDVP. However, this conclusion does not apply to
age 6–7 years. These reported anatomical di¤erences the pubescent period, during which variability in ampli-
do not appear to contribute to significant di¤erences in tude and fundamental frequency increases in both girls
vocal fundamental frequency ( f0 ) between males and and boys, but markedly so in the latter (Boltezar, Bur-
females until puberty, at which time laryngeal growth ger, and Zargi, 1997). It should also be noted voice
is remarkable, especially in boys. For example, in boys, training can a¤ect the degree of aperiodicity in children’s
the anteroposterior dimension of the thyroid cartilage voices (Dejonckere et al., 1996) (see acoustic assess-
increases threefold, along with increases in vocal fold ment of voice).
length.
Aerodynamic Studies of Children’s Voice. There are
Acoustic Studies of Children’s Voice. Mean f0 has been only limited data describing developmental patterns
one of the most thoroughly studied aspects of the pedi- in voice aerodynamics. Table 1 shows normative data
atric voice. For infants’ nondistress utterances, such as for flow, pressure, and laryngeal airway resistance from
cooing and babbling, mean f0 falls in the range of 300– three sources (Netsell et al., 1994; Keilman and Bader,
600 Hz and appears to be stable until about 9 months, 1995; Zajac, 1995, 1998). All of the data were collected
when it begins to decline until adulthood (Kent and during the production of /pi/ syllable trains, following
Read, 2002). A relatively sharp decline occurs between the procedure first described by Smitheran and Hixon
the ages of 12 months and 3 years, so that by the age of 3 (1981). Flow appears to increase with age, ranging from
years, the mean f0 in both males and females is about 75–79 mL/s in children aged 3–5 years to 127–188 mL/s
250 Hz. Mean f0 is stable or gradually falling between 6 in adults. Pressure decreases slightly with age, ranging
and 11 years, and the value of 250 Hz may be taken as from 8.4 cm H2 O in children ages 3–5 years to 5.3–6.0
a reasonable estimate of f0 in both boys and girls. Some cm H2 O in adults. Laryngeal airway pressure decreases
studies report no significant change in f0 during this with age, ranging from 111–119 cm H2 O/L/s in children
developmental period, but Glaze et al. (1988) reported aged 3–6 years to 34–43 cm H2 O/L/s in adults. This
that f0 decreased with increasing age, height, and weight decrease in laryngeal airway pressure occurs as a func-
for boys and girls ages 5–11 years, and Ferrand and tion of the rate of flow increase exceeding the rate of
Bloom (1996) observed a decrease in the mean, maxi- pressure decrease across the age range.
mum, and range of f0 in boys, but not in girls, at about Netsell et al. (1994) explained the developmental
7–8 years of age. changes in flow, pressure, and laryngeal airway pressure

because of di¤erences in procedures across studies Dejonckere. and Pelland-Blais. T. and Susser. International Journal of Pediatric Otorhino- mental procedures change relatively little from child. J.3 (1. J. and Hacki. 1995. and Z (Zajac. M. Schloss. Acoustic characteristics of children’s voice.. These values are reasonably similar to values troglottography in the pediatric population. R. Burger. D. closing 156–160.. The maintenance of rather stable values across of Pediatric Otorhinolaryngology. L. J. these breathing with age.3) 77 (23) K 13–15 F&M 5. Aerodynamic normative data from three sources: N (Netsell et al. R. procedures may play a valuable role in the objective as- dynamic parameters were observed between female and sessment of voice in children.97 (2. Nuss. and Zargi.1% (3. Milenkovic. Therefore. International Journal question. and Sadeghi. 130.3 (2. although caution should be observed Otolaryngology–Head and Neck Surgery. to maintain normal voice quality in the face of consid.. in singing. 2. K (Keilman & Bader.. 185– 190.29) N 9–12 F 10 121 (21) 7. T.4) 34 (9) F ¼ female.1% Cheyne. genesis and diagnosis. S311–S314.. Dejonckere.3).4) K 8–12 F&M 6. Apparently. erable variation between children of similar ages (see —Ray D..81 (2. with standard deviations in parentheses Age Flow Pressure LAR Reference (yr) Sex N (mL/s) (cm H2 O) (cm H2 O/L/s) N 3–5 F 10 79 (16) 8.. With the mutation. C. H. Journal of the distinct advantage for clinical application. 96. except for f0 and the ics in voices of normal children. Gender di¤erences in of the major changes that are observed in laryngeal children’s intonational patterns. erable alteration in the apparatus of voice production. closing quotient. graphic assessment of voice). 1999).. 79 girls and 85 boys.4) 119 (20) K 4–7 F&M 7. Tewfik.8% (3.. the values obtained from instru. H.4 (2.3 (24. International Journal of Pediatric Otorhinolaryngology. Bloemenkamp. Glaze. open quotient. G. Instability of 164 children. D. (1999). 1994). E. as secondary to an increasing airway size and decreasing that instrumental procedures can be used successfully dependence on expiratory muscle forces alone for speech with children as young as 3 years of age. P.82 (62. hood to adulthood.4 (1. (1994). I. 1995). E. 284– anatomy and physiology.. H.2) 43 (10) N Adult M 10 188 (51) 6. P. S. and Bloom. 1975) (see electroglotto. L. P. stability is challenged. and Massey. Voice problems in children: Patho- (Takahashi and Koike. Values shown are means. Bless.3) 111 (26) N 3–5 M 10 75 (20) 8. N ¼ number of participants. This stability is remarkable in view Ferrand. Elec- (4. and opening quotient—31. (in parentheses) for these measures were as follows: jit. R. High standard deviations reflect consid. S141–S144. Computer- opening quotient. Manoukian. (1999). and Hillman. References though EGG data on children’s voice are not abun- dant.4 (1.. mutation. laryngology. T. open quotient—54. (1999). Al. Archives of Otolaryngology–Head and Neck Surgery. 128. 35. and One of the most striking features of the instrumental Lebacq. Journal of Voice. (1997). See also voice disorders in children. Green. Wieneke. with and without education aerodynamic measures.95) N Adult F 10 127 (29) 5. quotient—14.. Cheyne et al. R. It is also clear Acoustical Society of America. 312–319. however. The means and standard deviations assisted voice analysis: Establishing a pediatric database. 125. (1988). A. 107–115. M. Archives of reported for adults.07) K 4–15 F&M 100 50–150 87.1 (1. 2646–2654. ter—0.46 (2.. P. K. Instrumental Assessment of Children’s Voice 37 Table 1.4 (1. and Heitmuller.. and Hillman. 1998). . 1).. Journal of Voice.2) 59 (7) N 9–12 M 10 115 (42) 7.. D. a substantial period of childhood (from about 5 to 12 Hollien. L.0) 97 (39) Z 7–11 F&M 10 123 (30) 11. H. (1996). Kent and Nathan V.5) 89 (25) N 6–9 M 9 101 (42) 8. M ¼ male... 49(Suppl.3) 95.61). E. R. Nuss.0 (1. 49(Suppl. male children. Development of the the suitability of published normative data is open to child’s voice: Premutation. (1996). ages 3–16 years of voice in adolescence: Pathologic condition or normal (Cheyne. N. 1). (2002). sures of jitter. C. Longitudinal years) for many acoustic and EGG parameters holds a research on adolescent voice change in males.9 (1. Welham aerodynamic assessment of voice). H. Electroglottographic Studies of Children’s Voice. 1105–1108. H. F0 -perturbation and f0 -loudness dynam- studies of children’s voice is that. No consistent di¤erences in aero.26) N 6–9 F 10 86 (19) 7. 10. M... developmental variation? Journal of Pediatrics. R. children are able 291. All data were collected using the methodology described by Smitheran and Hixon (1981). LAR ¼ laryngeal airway resistance.8). one study provides normative data on a sample Boltezar. Z. reported no significant e¤ect of age on the EGG mea- Campisi.1).76% (0.

Otolaryngolica Supplement (Stockholm). and Vorperian.. (1998). isolation.. 2001).. J. and is endocytosed into nerve endings. tremor. sonants (p. Muscular tension dysphonia may be confused Zajac. 1994). dysphonia was renamed ‘‘spasmodic’’ dysphonia to de. Some perceptual dimen. which form the basis for diagnosis. CA: Singular/Thompson intervals in the abductor type. L. BTX-A injection. Ford. which are perceived as breathy Developmental patterns of laryngeal and respiratory func. A clinical method for es- timating laryngeal airway resistance during vowel produc. (1995). and Narayanan. 123–131. sometimes with an associated head ment of the craniofacial-oral-laryngeal systems: A review.. and Hixon. (1995).. 138–146. 1455–1468. D. In adductor denervating the muscle. do not involve intermit- Smitheran. tent spasmodic changes in the voice. Such persons may respond to sions and acoustical correlates of pathological voices. 1999). ‘‘spastic’’ tion of the thyroarytenoid muscle for up to 4 months.. When acetylcholine release is cricothyroid muscle in some persons (Nash and Ludlow. and Bader. muscle spasms are injected in that muscle. E¤ects of a pressure target on laryngeal Some patients with voice tremor may also develop mus- airway resistance in children. A 5-Hz tremor can be heard on prolonged namic aspects in children’s voice. tremor (Koda and Ludlow. A. 138–144. and Koike. in ABSD. S.. although not unilateral injection produces a partial chemodenerva- in all patients (Cyrus et al. J. di¤uses. 31. E. All of these Botulinum toxin type A (BTX-A) is e¤ective in conditions are idiopathic and all have distinctive symp. Lee. voice breaks during cle. 1991) and in multiple case both ADSD and ABSD (Deleyiannis et al. R. In the 1980s. Acta manual laryngeal manipulation (Roy. R. 3. Anatomic develop. and Bless. The vowels are associated with involuntary spasmodic mus. either small bilateral injections or a tenoid muscle is often involved in ABSD. however. D. Kent. In ADSD. 1–24. Acoustics Intermittent voice breaks are specific to the spasmodic of children’s speech: Developmental changes of temporal dysphonias. San Diego. Reductions in spasmodic muscle bursts relate to voice note the intermittent aspect of the voice breaks and was improvement (Bielamowicz and Ludlow. ing during voiceless consonants. series (Ludlow et al. instability. (2002). Blit- cating a reduction in the normal central suppression zer. h). (1975). The laryngeal dystonias include spasmodic dysphonia. as (Blitzer and Brin. J.). BTX-A is less e¤ective in of laryngeal sensorimotor responses in these disorders. Rammage. blocked. k. 1991. 31. the original end-plates (de Paiva et al. A variety of muscles may be involved in voice Journal of Medical Speech-Language Pathology.. and Read.. This classified as a task-specific focal laryngeal dystonia therapy is e¤ective in least 90% of ADSD patients. 105. new nerve endings sprout. 8. 46. improvements occur in 60% of cases (Ludlow et al. Ludlow. either prolonged glottal stops and intermit- and spectral parameters. Laryngeal airway resistance in children with spasmodic dysphonia when ADSD patients develop with cleft palate and adequate velopharyngeal function. Similarly. producing voice breaks in vowels or breathy of speech (2nd ed. In transmission and some reduction in muscle weakness. Journal of Speech and Hearing Disorders. muscle vated. (1981). and Smith. The posterior cricoary. 212–213. during voice production. Other idiopathic voice disorders. Lotz. indi.. 1999). instability. with adduc- tory movements of the vocal folds during inspiration Laryngeal Movement Disorders: that remit during sleep (Marion et al. which may provide synaptic ryngeal muscles (Van Pelt. Journal of Voice.. W. Zajac. resulting in symptoms of both disorders. 1992). although bursts can also occur in the junction (Aoki. ABSD. Voice tremor occurs more Learning. Potamianos.. S. during vowels in ADSD or prolonged voiceless con- Netsell. 145–190. Y. the abductor type of spasmodic dysphonia (ABSD). which is usually intermit- tent and often coincides with irritants a¤ecting the upper airway (Christopher et al. H. t. The toxin is injected into mus- spasmodic dysphonia (ADSD). Rather.38 Part I: Voice Keilman. T. 1988. significant nia. s. C. increased muscle tension in an e¤ort to overcome vocal Cleft Palate–Craniofacial Journal. 32. owing to intensity and frequency modulation. K. 2001). a vesicle-docking protein essen- cle bursts in the thyroarytenoid and other adductor la. such tion for speech production. two-thirds of ABSD patients obtain patients with ADSD or ABSD and can also occur in some degree of benefit from posterior cricoarytenoid . treating a myriad of hyperkinetic disorders by partially toms. These nerve endings are later replaced by restitution of breathy breaks are due to prolonged vocal fold open. 1998). Blitzer and Brin. 1992). (1999). 338. and Schulte. tremor. abnormal hypertense laryngeal postures are maintained Takahashi. Vocal tremor is present in at least one-third of 1991). Tremor can a¤ect either or both the adductor or abduc- Kent. H.. D. R. and Stewart. 2000). When voice breaks are absent. The e¤ect is reversible: within a few weeks activation is normal in both adductor and abductor la. Pediatric Otorhinolaryngology. International Journal of vowels. 183–190. Journal of the Acoustical Society of tent intervals of a strained or strangled voice quality America. It di¤ers Treatment with Botulinum Toxin from vocal fold dysfunction. 1996). 1983. the other 15% have ABSD. The acoustic analysis tor muscles. Brin. Journal of Communication cular tension dysphonia in an e¤ort to overcome vocal Disorders. Paradoxical breathing dystonia is rare. K. as muscular tension dysphonia.. often in women. f. tial for acetylcholine release into the neuromuscular ryngeal muscles. (1994). Morrison. Abnormalities in laryngeal has been demonstrated in a small randomized con- adductor responses to sensory stimulation are found in trolled trial (Truong et al... C. D. and Emami. A. toxin cleaves SNAP 25.. 1991). J.. the muscle fibers become temporarily dener- 1996). and paradoxical breathing dystonia. Peters. (1995). consistent tion. When only ABSD patients with cricothyroid ADSD a¤ects 85% of patients with spasmodic dyspho. 1999). Development of aerody. breaks.

.. M. jection in persons with ADSD are similar.. 100. and Laryngology. and toxin injections in patients with abductor spasmodic dys- phonia. Blitzer. and Stewart. New England Journal of A in laryngeal dystonia likely di¤er with the di¤erent Medicine. A. 1992). the force- et al. usually toxin management of spasmodic dysphonia (laryngeal dys- occurring over a period of about 2 months during end. F. C. Rhinology. sensory feedback may also have a role in the treatment culty swallowing liquids may occur and occasionally of laryngeal dystonia. 1 to 3 months in other disorders such as ABSD and Rhinology. L.... Annals of Otology. S. whether the 1999). K. S. A. C. Aviv. Brin. To maintain symptom control. Annals of Otology.. L. Aoki. and Laryngology. and Brin. Annals of Otology. 2000). causing changes in sensory feedback account for the longer pe- progressive denervation. Central control muscle BTX-A injections. 2000). it is more e¤ective in some C. however. The breathiness resolves some..... R. although voice loudness is also change with reductions in adductory force between not yet reduced.. resulting in lower motor neuron used successfully to treat paradoxical breathing dystonia pool activity for all the laryngeal muscles. returning 2 or more years later for reinjection. Brin. K. Laryngeal Movement Disorders: Treatment with Botulinum Toxin 39 injections (Blitzer et al. and it activity levels (Bielamowicz and Ludlow. Journal of Neurology. and Laryngology. 108. and Ludlow. injection. A few persons re. although larger doses are sometimes more e¤ec.. Bielamowicz. Blager. Perhaps diminish as BTX-A di¤uses through the muscle. and Fahn. Abductor laryngeal dystonia: A series treated with botulinum toxin. M. The benefit is greatest between 1 and 3 months after Bielamowicz... 1988). tor system than on muscle fiber innervation (On et al. in addition to e¤erent denervation results in aspiration. 1992. In all cases BTX-A causes partial dener- were measured in blinded fashion before and after teat. in persons with were used (Warrick et al. larynx.. covery of swallowing. while the side ment disorders. Ludlow side between the first and second weeks after an injection (Ludlow. pathophysiologies: although BTX-A is beneficial in Cyrus.. during the period when axonal 3–10. tion. B. plate reinnervation. Grillone et al. This benefit period di¤ers among the dis. C. (1998).. 102. which reduces the force that can be exerted by ment. Future approaches to altering culties increase over the 3–5 days after injection. C. F. (2001). R. by sipping through a straw.. Either tenoid muscle injections were unilateral. S. when the patient’s voice is close to normal (2001). for treating muscle tone (measured in microvolts) and maximum tremor than it is in ADSD (Warrick et al. BTX-A was less e¤ective in ABSD (Bielamowicz a muscle following injection. et al. Vocal-cord dys- The mechanisms responsible for benefit from BTX. J. speech is more fluent. Adductor muscle activity abnormalities in . A. Rhew. Squire. K. Because Bielamowicz. weeks after injection.. (1983). E¤ects of botu- improvements in voice volume seem independent of re. F. 1999). Voice loudness and breaks gradually the vocal folds following BTX-A injection. maintain benefit for more than a year following injec. however.. BTX-A injection was ADSD following BTX-A injection.. riod of benefit in ADSD than in other laryngeal move- fits become apparent the second day. Stewart. by BTX-A. B. Some individuals. Pharmacology and immunology of botu- what later.. Laryngeal dystonia: A orders. 1998). Wood.. (1992). lasting from 3 to 5 months in ADSD but from series with botulinum toxin therapy. voice breaks are significantly reduced. Christopher. Laryngoscope.. 1). and Nash. Eckert. 194– lie recovery of these functions. R. The di‰culties with swallowing gradually sub. many hyperkinetic disorders. S. and there were also reductions in overall levels of tive. most Laryngoscope. however. 203. L. Patients are advised to ingest liq.. tremor. 2000). tonia): A 12-year experience in more than 900 patients. then. Raney. Assessment of posterior cricoarytenoid botulinum volume. 1994).. Bidus. 2001) than in ADSD (Ludlow et al. logical e¤ects of BTX-A may be greater on the fusimo- Changes in laryngeal function following BTX-A in. L. E. vation. possibly as patients References learn to compensate. Such is rarely helpful in patients with abductor tremor. J. 163–167. and Ludlow. with reduced hoarseness (Ludlow 110. arytenoid muscle may contain muscle spindles (Sanders port a sense of reduction in laryngeal tension within 8 et al. mucosal mechanoreceptor feedback will hours following injection. When thyroary- beneficial in 50% of patients with voice tremors. Evans. 109. Di‰. Although only one portion of the human thyro- injection was unilateral or bilateral. Most people report that bene. C. 306. di¤erent mechanisms may under. (2001). A. When speech symptoms than in others. J. patients return for injection about 3 months before the Blitzer. uids slowly and in small volumes. R. M. spasmodic unilateral or bilateral thyroarytenoid injections can be bursts were significantly reduced on both sides of the used. linum toxin on pathophysiology in spasmodic dysphonia. fulness of vocal fold hyperadduction is reduced and Patients with adductor tremor confined to the vocal patients are less able to produce voice breaks even folds often receive some benefit from thyroarytenoid if muscle spasms continue to occur. F. F. 248(Suppl. 406–412. BTX-A is much less e¤ective. F. although the duration of side e¤ects is e¤ects of progressive breathiness and swallowing di‰. S. The physio- (Marion et al. —Christy L. 1566–1570. Botulinum The return of symptoms in ADSD is gradual. reductions in muscle activity and spasms may be the BTX-A administered as either unilateral or bilateral result of reductions in muscle spindle and mechano- injections into the thyroarytenoid muscle has been receptor feedback. similar in all disorders. Rhinology. (1991).. and Ludlow. (2000). 1994).. full return of symptoms. In ADSD. 85–89. function presenting as asthma. 1988). and Souhrada. sprouting may occur (de Paiva et al. reaching normal loudness levels as late as 3–4 linum toxin serotypes.. Blitzer. C. 1435–1441. When objective measures changes also appear to occur.

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Functional repair of motor endplates tification of symptoms for spasmodic dysphonia and vocal after botulinum neurotoxin type A poisoning: Biphasic tremor: A comparison of expert and nonexpert judges. Dyspnea in dystonia: A functional evaluation. 23–30.. Wang. placebo-controlled study. A. Dystonia and tremor Stridor and focal laryngeal dystonia. and Diamond. and Rhew. Neurology. Rhinology. Annals of Otology. Treatment of speech and voice disorders Mechanisms of action of phenol block and botulinus toxin with botulinum toxin. A. (1987). L. J. T. C. 14. and Brin. and Ludlow. Neurology. J.. and Jankovic.. Ford. J. R. 96. Neurology. W. Botu- Voice. C. and Smith. (1994). E. M. A. The 1519. Lange. (1999). I. C.... Kirazli. rology.. C. (1988). R. (1998). N. of Neurology. S.. 113. laryngology–Head and Neck Surgery. (1992). C. linum toxin injection of the vocal fold for spasmodic dys- Truong. C. and Bless. U. Cranial-cervical dyskinesias: An overview. (1994).... Brin. 619. Sedory. treatment. and Emami. Laryngoscope. (1998). Muscle and Nerve. Otolaryngology–Head and Further Readings Neck Surgery. Rolnick. 630–634. K. Stewart. dystonia (spastic dysphonia). J. tremor and dystonia: Categorization of occupational tion. H. toxin (pp.. D. 78. B. A. of the voice with multiple anatomical sites of tremor: A Rosenbaum. Ludlow. 106. Electromyographic findings in focal laryngeal Deleyiannis. Laryngoscope. Pathophysiology of the spasmodic dys- and Rehabilitation. Fahn.. 7–16.. M. (1995). E.. (1990). M. 34. Rapheal (Eds.. B. and Biller. (1985).. Ludlow. Character- 856.. 1366–1374. switch of synaptic activity between nerve sprouts and their Journal of Communication Disorders.. D. movement disorders. 51. 572– 1220–1225. 94. Meunier. C.). Yamashita. R. 105. 2262–2266. tion and follow-up.. Brin. Annino. Fiedler. New York: Marcel Dekker. Mosko- Nash. 591–594. technique for injection of botulinum toxin through the Warrick. 616–623. T. Advances in Neurology.. Bielamowicz.. Warden. (1988). Lovelace. P. Journal of Voice. 127–134. Y. (1995). Cannito. R. A.. Sedory. Botulinum A toxin for cranial-cervical Ludlow. (1991). Kang. 30. VanPelt. and phonia. 101. Braun. and Laryngology. 1512– Morrison. and Ludlow. Blitzer. J. M. muscle activation in patients with voice tremor. E. Case. 484–489. B. J. 38. 344–349. Task-specific focal crossover design study of unilateral versus bilateral injec... and Fink. L. Y. 24.. of Physics. A. L. Oto- tor spasmodic dysphonia using botulinum toxin injection. single fiber EMG changes. Klap. M.. Dromey.. Annals of Otology. Muscle lation in humans. L. and Ludlow.. V. Neurosurgery. Archives of Otolaryngology–Head and Neck Mistura. L. Archives of Otolaryngology–Head and Neck ison of muscle activation patterns in adductor and abductor Surgery. 111.. D.. L. Woodson. (1989). An evaluation of laryngeal Brin... and Ludlow.

. posterior division supplies the only abductor of the .. M. Hallett (Eds. Therapy with botulinum toxin (pp. 106. P. Subplatysmal flaps are (see also anatomy of the human larynx). New York: Marcel Dekker. 502–520. 1999). and Martinkosky. swallowing. The nerve in question is identified pathways that include the SLN (supraglottic larynx) and through a transcervical approach. Weissler. 95–103. The external fine-tuned permutations of laryngeal opening and clo. and its design is still being elucidated. The nerve Indications for laryngeal reinnervation include func. B. This nerve approaches the larynx as well as microsurgical instrumentation and technique. Sensation by Horsley. and Ludlow. K. Witsell. F. the 1991. Speech functions are nates in the supraglottic submucosal receptors. Jankovic and M. (motor) branch terminates in the cricothyroid muscle. L.. Laryngoscope. Autonomic fibers also skin incision is placed into a neck skin crease at about innervate the larynx. E. Howard. Laryngeal Reinnervation Procedures 41 Sapienza. prevention of immediately splits into an anterior and a posterior divi- denervation atrophy. L. nique of reinnervation is similar for both sensory and mucosal and intramuscular receptors and travel along motor systems. M. S. but these are poorly understood the level of the cricoid cartilage. and Woodson. and speech. The internal (sensory) branch pierces the thyrohyoid membrane and termi- a tight sphincter during swallowing. until the last 30 years that reinnervation techniques were The motor innervation of the larynx is somewhat more refined and became performed with relative frequency. The most primitive responsibilities include functioning as a con- duit to bring air to the lungs and protecting the respiratory tract during swallowing. (1997). who described reanastomosis of a severed to the supraglottic mucosal is supplied via the internal RLN. This structure is easily identified as it literature over the next several decades. restoration of laryngeal sensation. J. V. C. C. The swallow- ing side e¤ects of botulinum toxin type A injection in spas- modic dysphonia. Journal of Voice. E. 2). (1994). S. 14. In J. Responses of stutterers and vocal tremor patients to treatment with botulinum toxin. but it was not pierces the thyrohyoid membrane on either side (Fig. (2000). gan is complex.. laryngeal adductors except the cricothyroid muscle. Innervation of this or.). Stylized left lateral view of the left SLN. J. C. 250. Adductor spasmodic dysphonia and muscular tension dysphonia: Acoustic analysis of sustained phonation and reading. Stewart. The anterior division supplies all of the and modification of pathological innervation (Crumley.. Laryngoscope. All of the intralaryngeal muscles are inner- Surely this is associated with advances in surgical optics vated by the RLN. Diamond. 11. G. and Ludlow. (1994). 271–276. T. Murry. 86–92. 104. Tureen. The larynx is further exposed Reinnervation of the larynx was first reported 1909 after splitting the strap muscles in the midline.. Aviv et al. elevated and retracted. Adductor spasmodic dys- phonia: Standard evaluation of symptoms and severity.. 1997. Berke et al. Donovan. F.. L. 481–490). S. Sedory-Holzer. T. 8–11.. C. M. enters the larynx from deep to the cricothyroid joint and tional reanimation of the paralyzed larynx. These duties are physiologically opposite. Journal of Voice. and Murry. (1993).. E. 1). E. and Brin. A. A¤erent fibers emanate from intra. The tech- nerves (RLNs).. Reports of laryngeal reinnervation spotted the branch of the SLN. Allen. E¤erent fibers to the larynx from the brainstem motor nuclei travel by way of the vagus nerve to the superior laryngeal nerve (SLN) and the recurrent laryngeal Anatomy and Technique of Reinnervation. Laryngeal Reinnervation Procedures The human larynx is a neuromuscularly complex organ responsible for three primary and often opposing func- tions: respiration. Blit- zer. sion (Fig. from below in the tracheoesophageal groove. ing of the SLN occurs proximally as it exits the carotid sheath. L. (1996).. A comparison of bilateral and unilateral botulinum toxin treatments for spasmodic dysphonia.. Usually a horizontal the RLN (subglottic larynx). C.. European Archives of Otorhinolaryngology. Walton. Measurement of laryngeal resistance in the evaluation of botulinum toxin injection for treatment of focal laryngeal dystonia.. the larynx must form a wide caliber during respiration but also be capable of forming Figure 1. Branch- sure against pulmonary airflow. complicated. D. Stager... F. Zwirner. P. S.

The posterior division travels to the posterior cricoarytenoid (PCA) muscle. geal tasks. The ante. more common and is characterized by a lateralized vocal plasty. The ansa cervicalis is a good example of an ac- SLN and the main trunk of the RLN can be approached ceptable motor donor nerve (Crumley. Although many patients are successfully treated with various static pro- larynx. 1991. The anastomosis must be tension- free. the posterior cricoarytenoid muscle. The posterior division is approached by rotation of the larynx. and McMicken. aspiration or cough during swallowing. similar to an external approach to the arytenoid. The anterior divi- larynx is described as unilateral or bilateral. The etiology is commonly idiopathic. the inferior cord that prevents complete glottic closure during laryn- cornu of the thyroid cartilage protects the RLN’s posterior di. Sensory reinnervation is less clear. Berke et without opening the larynx.42 Part I: Voice the thyroid cartilage. 1999). it is severed sharply with a single cut of a sharp instrument. Identification and dissection of the fine distal nerve branches is usually carried out under louposcopic or mi- croscopic magnification using precision instruments. while the other Izdebski. Once the cartilage is opened the anterior branch can be seen coursing obliquely toward the termi- nus in the midportion of the thyroarytenoid muscle. cedures. The diag- sion gives o¤ branches at the interarytenoid (IA) and lateral nosis is made on the basis of history and physical exam- cricoarytenoid (LCA) muscles and then terminates in the mid. one can hope to prevent muscle atrophy and help restore muscle bulk. The new motor or sensory nerve is brought into the field under zero tension and then anastomosed with several epineural sutures of fine microsurgical material (9-0 or 10-0 nylon or silk). the best results rior division further arborizes to innervate each of the would restore the organ to its preexisting physiological intrinsic adductors in a well-defined order: the interary. 1988). Selection of the appropriate donor nerve is discussed subsequently. ination including laryngoscopic findings. end-to-end nerve-nerve anas- tomosis with epineural suture fixation is a superior and Figure 2. With modern techniques. but the condition may be due to inflammatory neuropathy. 1983. This is important to avoid crushing trauma to the nerve stump. The donor nerve is still connected to its proximal (motor) or distal (sensory) cell bodies. most reinnervation procedures of the larynx were carried out with nerve- muscle pedicle implantation into the a¤ected muscle. A large inferiorly based window is made in the thyroid lamina and centered over the infe- rior tubercle. theoretically. relatively few reports have demonstrated true voli- tional movement. The branches to on the basis of laryngeal electromyography or radio- the TA and LCA are easily seen through a large inferiorly graphic imaging. The interarytenoid muscle is ioned by Crumley (Crumley. The external with unilateral vocal cord paralysis were treated with branch of the SLN innervates the only external adductor anastomosis of the distal RLN trunk to the ansa cervi- of the larynx—the cricothyroid muscle. The far more reliable technique of reinnervation. Although physiological reinnervation is the goal. The patient seeks care for dysphonia and vision and the IA branch during further dissection. and lastly interest in physiological restoration. thought to receive bilateral innervation. state. A series of patients muscles all receive unilateral innervation.. Over the past 20 years there has been increased tenoid followed by the lateral cricoarytenoid. Although the calis. Paralysis of the deep to the cricothyroid joint. This nerve normally supplies motor neurons RLN can only be successfully approached after opening to the strap muscles (extrinsic accessory muscles of . Over the next 3–9 months healing occurs. Prior to the microsurgical age. If preserved during an anterior approach. 1991. Crumley. Once the damaged nerve is identified. Stylized left lateral view of the left RLN. the adductor branches of the al. The RLN divides into an anterior and a posterior division just Reinnervation for Laryngeal Paralysis. one can argue that. a concept champ- the thyroarytenoid muscles. Typically. and sometimes portion of the thyroarytenoid (TA) muscle. The unilaterally paralyzed larynx is based cartilage window reminiscent of those done for thyro. or neo- plastic invasion of the recurrent nerve. iatrogenic trauma. 1984. branching pattern is quite consistent from patient to patient. with neurontization of the motor end-plates or the sensory receptors.

many have had trouble repeating them. Sensory Palsy. Spasmodic dysphonia is an small amount of sensory and autonomic) fibers.. one may hypothesize that mass firing of of patients have the adductor variety. (combination with arytenoid adduction) or to avoid the the e¤ect of Botox is temporary. Unfortunately. A laryngeal denervation and of the donor nerve to the anterior branch of the recur. Studies ponents of other techniques have argued that the ansa performed in the laboratory demonstrated that reanas- cervicalis may not have enough axons to properly tomosis of the internal branch of the SLN restored regenerate the RLN. Voicing issues are usually considered secondary to the airway concerns. success has been reliably 1978). Laryngeal Transplantation. In the facial nerve.. how. for example. reflexive movement of the reinnervated vocal cord. A fasci- would be more appropriate because of increased axon cle of the ansa cervicalis is then suture-anastomosed bulk and little donor morbidity. Berke. Evaluation of these patients. one may see successfully used to restore sensation to the larynx (Aviv mass movement of the face with volitional movement et al. 2001). with this technique have demonstrated volitional and Reinnervation maintains tone of the thyroarytenoid. reinnervation. and mucosal anastomosis has been well aphragm and normally fires with inspiration. micro- et al. 1989). anastomosis or an easily identifiable fascicle for connec.. Recent work has highlighted the im- Chhetri et al. The phrenic nerve innervates the di- vascular. Lee. 1999).. or tracheotomy to improve their airway. this disorder is botulinum toxin (Botox) injections into tion with another static procedure to augment results the a¤ected laryngeal adductor muscles. Blumin and Gerald S. 1999). 1986. the patient does not have notice. After development of ever. with about 95% of patients achieving freedom cheotomy dependent. 1997). With idiopathic focal dystonia of the larynx. 1993) and pothesis. reinnervation procedure has been designed to provide a rent nerve (Green et al. Therapy is directed at restoring from further therapy. He suggests that the hypoglossal nerve the larynx to avoid spontaneous reinnervation. portance of laryngeal sensation. some have recommended combining reinnerva.. cular physiology. the distalmost branches of the Paniello has proposed that the ansa cervicalis is not laryngeal adductors are severed from their muscle inser- the best donor nerve to the larynx (Paniello. Lee. an air-pulse quantification system to measure sensation. when the ansa coarytenoid muscle (Maniglia et al. physiological restoration would be preferred. These patients are troubled una¤ected by the dystonia. 1999). In this procedure. ary- Hemilaryngeal reinnervation with the ansa cervicalis tenoidectomy. whose function is to elevate and lower the use of the SLN as a motor source for the posterior cri- larynx during swallowing. 1998).. Synkinesis refers to well. Most tech- cervicalis is sacrificed. European groups have studied phrenic nerve Current research has been aimed at preventing trans- to posterior branch of the RLN transfers (van Lith-Bijl plant rejection. Tucker advocated reinnervation of the would be anastomosed—bilateral anterior and posterior posterior cricoarytenoid with a nerve muscle pedicle of branches of the RLN and bilateral external and internal the sternohyoid muscle and ansa cervicalis (Tucker. For a fully functional larynx. Clinically. The RLN contains both abductor and adductor (as well as a Modification of Dystonia. it has been worked out in the animal model. To date. 1999). 1992. 1994. 1997. Fortunately. This approach has had great by a fixed small airway and often find themselves tra. shown that one of its nerve roots can be sacrificed with- out paralysis of the diaphragm. success.. branches of the SLN. have a high incidence of laryngosensory deficit. anastomosis of the greater auric- mass firing of a motor nerve that can occur after rein. it was shown that patients with stroke and dysphagia but volitional movement typically is not restored. and tion. Laryngeal Reinnervation Procedures 43 the larynx).. Others have suggested —Joel H. The mainstay of treatment for mind. niques of reinnervation for bilateral vocal cord paralysis able disability. More partially achieved in one human (Strome et al. does not demonstrate restoration of normal mus. and repeated injections potential for synkinesis by performing the anastomosis are needed indefinitely. and Black- (Paniello. has been shown to improve voicing in those patients undergoing the procedure (Crumley and Izdebski. ysis undergo a static procedure such as cordotomy. ular nerve to the internal branch of the SLN has been nervation. With this concept in during connected speech. Chhetri permanent alternative to Botox treatment (Berke et al. because all the braches are essentially acting as one. The a¤ected vocal cord has good bulk. characterized by all fibers cancels the firings of individual fibers out and intermittent and paroxysmal spasms of the vocal cords thus produces a static vocal cord.. and Dahm. airway caliber while avoiding aspiration. Berke . Nasri et al. 1999). Animal experiments to the distal thyroarytenoid branch for reinnervation. or that synkinesis has occurred protective laryngeal reflexes (Blumin. eight nerves In the 1970s. Pro. These ‘‘bad’’ nerve stumps are then sutured outside Dahm. et al. Transplantation of a phys- Although most practitioners currently treat with static iologically functional larynx is the sought-after grail of techniques. The technique of microneural. 1999). recently.. The majority of patients with bilateral vocal cord paral- tion to the anterior branch. thus preventing atrophy and theoretically protecting that Neurological bilateral vocal cord paralysis is often muscle by occupying the motor end-plates with neurons post-traumatic or iatrogenic. The majority reinnervation. The size match to the RLN is excellent still have not enjoyed the success of unilateral reinner- when using either the whole nerve bundle for main trunk vation and are only performed by a few practitioners. Although his results were supportive of his hy- achieved in the canine model (Berke et al.

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structures of the peripheral speech mechanism. Blunt laryngeal trauma is most commonly changes in speech may be variable and ultimately de- reported in persons less than 30 years old. Because of the observed. H. Laryngeal Trauma and Peripheral Structural Ablations 45 Zheng. 1979). 1991). and velum. and radical dissection ment (Schaefer. causes include motor vehicle collisions. articulatory. possibility of disease spread. and swallowing may exist. such injuries or their medical treatment may have a significant impact on speech. An Injuries to the intrinsic structures of the oral cavity experimental comparison of di¤erent kinds of laryngeal are also rare. Zhou. Because of vari- ability in the extent of traumatic injuries. Trauma to the Laryngeal Trauma and Peripheral mandible also can directly impact verbal communica- Structural Ablations tion. emergency tracheotomy is common.g. nasal cavity.. In some instances. vidual. In contrast to peripheral structural changes due to trau- letic injuries. and auditory-perceptual components is essen- subsystems (e. hard palate. the lowing. and swelling of the the Speech System. additional surgical treatment ment may have negative consequences on vocal and may be warranted. partial or com. appropriate (e. systems (Netsell and Daniel. alveolus.000 emer.000 to 1 in 42. Information from each of these areas is valuable in related structures necessary for competent and e¤ective identifying the problem. cent tissue. deglutition. pain. pend on the structures treated. the primary presenting symptoms are hoarseness. they may invade adja- the voice are of secondary importance. (1998). the potential adequate airway through emergency airway manage. dysphagia. in Alterations of the vibratory. ath. whereas vocal disturbances are speech functions. lacerations of soft tissues. or resonance addressing any type of traumatic injury to the peripheral system consequent to traumatic injury or the treatment structures of the speech mechanism. the literature in this area is sparse.g. or larynx. In other instances these changes may result in dramatic alteration of one or more anatomical structures Speech Considerations. the clinical literature is meager in relation to injuries of the lip. Estimates in the literature indicate that acute laryngeal trauma accounts for 1 in 15. Unfortunately. maintaining an have the potential to be invasive. assessment methods of disease can significantly alter the functions of both typically employed with the dysarthrias may be most voice and speech.. Because laryngeal trauma. when necessary. and the consequent reduction surgical treatment for disease also may a¤ect isolated in speech intelligibility and communicative proficiency. Injuries may cinoma may occur in the epithelial tissue of the mouth. Tumors of the head plete dislocations.. 2000). pharynx. medical intervention is first directed at determining cancers involve squamous epithelial tissue. holds real potential to a¤ect breath. e¤ectiveness. Laryn. tongue. Head and neck squamous cell car- tissues of the neck (cervical emphysema). Y. These tumors airway patency and. developing management strat- verbal communication. In this regard. In cases of blunt trauma to the larynx. and this treat- When injuries are severe. falls. A large number of such traumatic Surgical Ablation injuries are the result of accidental blunt trauma to the neck. such as shooting or for oral cancer also result in alterations in functions stabbing. and the like.. articulatory. and neck account for approximately 5% of all malig- bined types of injury. the airway is of primary concern. 540–547. The majority of head and neck ing. or com. but in the neck. Speech management initially necessary for normal voice and speech production. Peripheral Structural Changes Resulting from gency room visits. egies. which may result in penetrating injuries not necessary for speech or swallowing. S. and information on speech outcomes following injuries of this type is frequently anecdotal. structural changes due to surgical ablation injuries are the result of violence. Z.. When airway compromise is of regional lymphatics is often required. radiation therapy is com- geal trauma is truly an emergency medical condition. in focuses on identifying which subsystems are impaired. S. and monitoring patient progress. Another portion of these matic injury. have more widespread influences on entire speech acoustic. floor of the mouth. although when they do occur. However. Dworkin.. Although gery. which frequently requires more extensive . 1992). The treatment itself only of the larynx but also of other critical structures has clear potential to a¤ect speech production.. 119. or may A comprehensive evaluation that involves aerodynamic. the literature Laryngeal Trauma on the dysarthrias often provides a useful framework for establishing clinical goals and evaluating treatment Trauma to the larynx is a relatively rare clinical entity. Traumatic injury and the severity of impairment. Li. no nancies in men and 2% of all malignancies in women matter how minor. for spread of disease is substantial. involve fractures of laryngeal cartilages. speech. therefore. subsequent changes to the point-place system may provide essential information larynx and oral peripheral system may be relatively on the extent and degree of impairment of speech sub- minor and without substantial consequence to the indi. (Franceschi et al. and Cuan. Chen. Otolaryngology–Head and Neck Sur. changes to As tumors increase in size. dyspnea Malignant Conditions A¤ecting Peripheral Structures of (shortness of breath). Thus. and potentially deglutition and swal. addition to other oral functions. velopharyngeal) and the tial. changes in muscle reinnervation. possible. monly used to eliminate occult disease.

stop-plosive sounds). Such Isolated mandibular tumors are rare. Extended lesions involving extirpation of maxillary tumors may involve extensive the mandible often require surgical resection.46 Part I: Voice treatment because of the threat of distant spread of dis. damaged bone. respiration. or di‰culty breathing. substantial. Johnson. if the lesion is extensive and quire a fixed position for continuous generation or oral destructive. others report pain. changes to the lip and alveolus may certainly limit the 1983a.. more significant surgical resections of the hard and soft tures of the tongue or floor of mouth to become fixed. For example.g. but regional procedures vary in the extent of resection and may be spread of cancer to the mandible from other oral struc- performed transorally or transfacially.. which may result in tumors of the maxilla. a significant reduction in the essential struc. an- Once primary medical treatment (surgery. tissue lowing and speech production. The on tumor location. radiotherapy. and quality of life. thus reducing tissue damage and related literature in this area is scant to nonexistent. Floor of Mouth. Because resection. the integrity of the oral valve structures of the peripheral speech mechanism include for articulatory shaping and the subsequent demands of surgery. Mandible.. 2000). disease stage. ciated with a range of side e¤ects. when decreased if the radiation exposure is limited to less larger resections are performed on the tongue (partial or than 60 cGy (Thorn et al. the tumor may encroach on the production. the goals of rehabilitation are (e. portions of the Kline. or sounds that re- logical function. di‰culty swallowing (dys. Although defects of the phagia). swallowing. Osteoradio. the potential for metastatic spread of disease is the nasal cavity (Brown et al. Surgical re- ease. and soft palates may occur. radiotherapy is commonly asso. cancer has invaded bone. Large resections and reconstructions also increase the Hyperbaric oxygen therapy is sometimes used to reduce potential for speech disruption because of limited mo- the degree of osteoradionecrosis (Marx. inate the ability to e¤ectively seal the oral cavity from stances. and hu. which is likely to result in loss of sensa. 1985). geal incompetence due to structural defects that elim- tion (paresthesia). Radiation delivered to the head and neck a¤ects both abnormal and normal Defects of the Tongue. The mandible and tongue are dental caries following radiation treatment. among ment is contraindicated. Healing and other e¤ects of treatment also deformities. with distant spread. However. Lip.. In many instances. 1983b). radiother. palate frequently have a dramatic influence on speech In other situations. during which the post- changes that may directly alter speech and swallowing. such defects following surgical treatment. cosmesis. paralysis. The choice of modality usually depends with profound influences on oral communication. these types of problems maintaining some level of nutrition. which in turn improves variable e¤ects on speech and general oral function.g. and floor of the mouth (xerostomia). airway turbulence (e. and attain some level of functional ture.g. however. Surgery for traumatic injury or tumors that ing decrease in salivary flow leading to a dry mouth invade the mandible. or chemotherapy. terior sounds in which the lip is an active articulator apy) has been completed. Surgery is the pre. The destructive nature of alveolus may be augmented quite well prosthetically. Palliative care focuses on pain control and structures. Salivary glands may be damaged. When considerable portions of both the hard and the Current treatment protocols for tumors involving soft palate are removed. and subsequent treat.g.. Alveolus. movable structures that are intricately involved in swal- necrosis may result in the exposure of bone. Some individuals are asymptomatic at the time of duction of the gum ridge (alveolus) as well as the hard diagnosis. resections are often substan- . However. a malignant tumor may cause adjacent muscular struc. cell type. speech. with a result. Similarly. and tissues. function. Osteoradionecrosis may be in deglutition. build-up (e. need to be addressed during this period. drink. Slowing the speech rate may help to augment articulatory precision in the presence of Defects of the Maxilla and Velum. surgical anatomy changes and the prosthesis is changed while at the same time creating significant cosmetic in tandem. may be altered by surgical ablation of these instead. tongue. 2000). which usually cause significant not result in any significant level of noticeable change discomfort to the individual. and bility of the reconstructed areas (e. In some cases. labiodental sounds). Because surgical tures is not uncommon. In both circum. surgery total glossectomy) or floor of the mouth. The vascularity. or pain. ferred method for treating cancer of the maxilla. Defects in the alveolar ridge or lip may have in blood and related tissues. Surgery car. This decrease in saliva may then challenge is frequently more radical than surgery for injuries or normal oral hygiene and health. production of specific speech sounds. The primary deficit observed is velopharyn- nerve supply. Each treatment modality is associated with some fect through prosthetic management so that the individ- additional morbidity that can significantly a¤ect struc. or speech. often combination. This therapy facilitates oxygen uptake tongue). lingual-alveolar sounds). Rehabilitation involves a multidisciplinary team ries a clear potential for anatomical and physiological and occurs over several months.. osteoradionecrotic changes following extractions (Marx. tures for speech may exist post-treatment. Focal excisions may changes. can be addressed using methods commonly employed man dignity. or infection. alone or in the resonance system are substantially a¤ected. ual can eat. sounds that rely on pressure to maintain or restore anatomical structure and physio. palliative care may be initiated others. with a subsequent need for grafting. and other goals of rehabilitation include reducing the surgical de- factors. reconstruction may be necessary to debride infected tissue or to remove with one of a variety of flap procedures is necessary. for articulation therapy.

laryngeal. 1999). 1993. Although some minor Subsystem evaluation may entail instrumentally based adjustments to the definitive prosthesis are not uncom.g. helping to reduce velopharyngeal defects. assessments (speech aerodynamics and acoustics).. Anderson et al. speech-language pathologist. with the first obturator being placed in situ at the time of surgery.. However. amplitude. as this creates relative e‰ciency for speech and swallowing movements. This may be which supplements lingual inability by bringing the new compounded by di‰culties in chewing food or by dys. sensory system. Total or partial removal early prostheses can be modified throughout the course of the tongue (glossectomy) or resection of the anterior of treatment to facilitate swallowing and speech. including evaluate the motor capacity as well as the capacity of the a dentist. Leonard and Gillis. 1978. Together. In order for speech improvement to occur. ripheral oral mechanism. particularly 1989). Sills. the devices must be created so ment. intelligibility (e. keeps food and other debris in the mobility of the mandible pose a risk for changes in from entering the wound. such surgical defects reduce contacts to improve articulatory precision and speech articulatory precision and change the acoustic struc. certain factors may alter the man. However. the expertise of multiple professionals. reduce velopharyngeal orifice area. prosthodontist. 1982. is of clinical value (Gillis and Leonard. permits eating. including the oral and nasal cavities as separate entities and to evaluation of formant frequency. Early oral speech or voice parameters. and radiologist. speech assessment must patient. changes packing of the wound site. Acoustic considerations relative to speech intelli. When the jaw is dis- literature. As such. 1989). subsequently requiring reconstruction with donor speech concerns. respiration is paramount. which Again. to enhancing residual speech capabilities. 1982. and articulatory. Most individuals use respiratory. and spec. 1990). so that nutritional problems must always be may then have greater ability to make the necessary oral considered. after treatment. intraoral prostheses for those with surgical methods recommended for treatment of the dysarthrias defects of peripheral oral structures seek to maintain (e. Acoustic analysis. velopharyngeal. and Charles. including both a¤erent and e¤erent compo- Prosthetic Management. The Systematic assessment of the peripheral speech mecha- initial obturator is maintained for 1–2 weeks. which mon. Gillis and ture of speech because of changes in the volume of the Leonard. for reasons that go beyond telligibility (Leeper. changes to the peripheral oral structures will almost cer. Tobey and Lincks. changes in symmetry may emerge that may in- fluence chewing and swallowing. 1983). rupted. Surgical treatment of maxillary tumors can proximate superior structures of the oral cavity exist result in a variety of problems postsurgically. usually anywhere contributions to the overall speech deficits observed can from 3 to 6 months after surgery. At this time a final or be better defined for purposes of treatment monitoring. Prosthetic adaptations air through the nasal cavity). the surgical defect must be augmented with a prosthe.. auditory-perceptual evaluations of Prosthetic Management of Surgical Defects. the oral speech system are best addressed using the In general. this area is not well documented in the clinical may result in secondary problems. For ex. However. cally induced velopharyngeal incompetence is essential 1982. 1999. drinking. This is typically a multistage process. Leeper and resulting from injury or malignancy is essential (Adis.. and allows im- oral resonance. problems in fitting and retention of the prosthesis. Leeper and . following larger resections of the maxilla. 1992). munication. these types of of this type may also benefit eating and swallowing. Such a prosthesis is useful in patients vocal tract as well as resultant hypernasality and who have healed after undergoing a maxillectomy or nasal emission (abnormal and perhaps excessive flow of maxillary-mandibular resection. The results of peripheral structural ablations of that they do not impede normal breathing. 1977. Prosthetic rehabilitation for jaw defects mediate oral communication (Doyle. The surgical obturator allows careful bone or plate reconstruction methods. significantly disrupts eating and drinking. 1989). Reduction of surgi- tral moments. and measures of speech in- rehabilitation is essential. 1964).. Additionally. this obturator will be maintained permanently elicit information on the aeromechanical relationship (Desjardins. In addition to gibility should also be addressed in this population using the obvious defects in the structural integrity of the pe- tools developed for the dysarthrias (Kent et al. hard palate inferior in the oral cavity. attempts to facilitate this ability may be ample. leakage of food or drink into the nasal cavity achieved by constructing a ‘‘palatal drop’’ prosthesis. Laryngeal Trauma and Peripheral Structural Ablations 47 tial. Kent et al. at which nism includes formal evaluation of all subsystems— time an interim device is fabricated. to oral port size and tongue–hard palate valving (Warren and DuBois. head and neck surgeon. Gratton. Speech Assessment sis. definitive obturator is fabricated. pros. For soft palate defects. the interim device until complete healing has occurred As each component of the system is assessed. is When reductions in the ability of the tongue to ap- necessary.. thetist. mandibular reconstructions may course of rehabilitation. its relative and related treatments are completed. Aramany et al. Because maxilla or mandible results in significant speech impair. To optimize the care of each nents of the system. The individual phagia. treatment may disrupt neural processes. Oral Articulatory Evaluation. These devices serve both speech and swallowing by tainly result in decreased speech intelligibility and com. Fabrication of a prosthesis is permit the individual to manipulate the mandible with more di‰cult when teeth are absent. and the overall acoustic structure of speech due to changes in swallowing without a nasogastric tube.g.

T. Maxillofacial Desjardins. M.. Sills. P. R.. Journal of Speech. External laryn- Contemporary concerns in clinical care. Osteoradionecrosis of the jaws: Clinical characteristics and relation to the field of irradiation. Gooen. Archives of Otolaryngology–Head and seek to improve intelligibility. (1978). 107. improving intelli- Medicine and Rehabilitation. D. Leeper. and Lincks. S. (1990). L. Gillis. M. J. Shockley. 25–29. S. J.. E. In J. (1996). Early rehabilitative management of of the head and neck: Clinical and pathological consid- the maxillectomy patient. Comparison of cancers of the oral cavity and pharynx Gussack. D. tation following laryngeal cancer (pp. (1982).. and related tasks that laryngeal trauma. (1985). E¤ects of a prosthetic physiological model allows the clinician to identify the tongue on vowel intelligibility and food management in relative contribution of each speech subsystem and to a patient with total glossectomy.. spontaneous speech. Pro-Ed. 125. H. J. Johnson. Cleft Palate Journal. D. Zlotolow. J.. N. A. H. Bidoli. R. R. and Raman. erations (2nd ed. E. R. D. P. C. I.. B. Shah. 22. Acoustic analyses of References speech changes after maxillectomy and prosthodontic man- agement. Further Readings Aramany. R. 598–604. J. Lerner. 34. J. 82.48 Part I: Voice Gratton. 54. V. Brown. 449–455. 15. R. N. Archives of Physical compensation of sound substitutions). B. E. mandible: A review. cal trial of hyperbaric oxygen vs. D. T. M. 265–284. cavity and the oropharynx. and Marunick. Squamous cell carcinomas of the oral fect. and Rutledge. J. L.. N. 78–81. determining and maintain. Starr (Eds. J.. (1993). H. 1999). Leeper. (1979). 13. Q. F. Tobey. and Sills. D. S. Laryngoscope. (1994). 117–133. Schaefer. R.. J. 49–54. Foundations of voice and speech rehabili- guide. Journal of Prosthetic Dentistry. Severe laryngeal injury cased by blunt tomy.. D. Louis: Ishiyaki EuroAmerica. A.. R. A. and Rosenbek. J. (1979). and DuBois. R. Journal of Oral and —Philip C. (1999). (1983). 1088–1093. San Diego.. Downs. 50. 47. C. R. A. J. R. Kavarana. A pressure-flow defects.). 23. R. P. Ex- dontic management of maxillofacial and palatal defects.. lary defects. chims. (1993). V. P.. 485–496. B. Kent. P. P. St. 877–880. 38. American Journal of Otolaryngology. R. 48. Assessment of review of current practice. Osteoradionecrosis: A new concept of its optimize the system. (1964). 660–665.). and Bastholt. 1174–1176. E.. S. H. R. A. H. Louis: Mosby. 119–124... (2000). Journal of Prosthetic Dentistry. and Kline.. 110–118. (1993). Leeper. and Ayslan. Prosthetic management of the head and neck cancer patient. T. Use of Netsell and Daniel’s (1979) Leonard. Prostho. The acute management of external tensity to improve oral resonance. Canadian Journal of Oncology. (1999). (1983). direct speech treatment goals Marx.. Treatment goals may best Neck Surgery. Herrero. N. 351–357. Haribhakti. Moller and C. Baltimore: Williams and Wilkins. (1993). 17–26. Hansen. St... G. Batsakis (Ed. G. (2000). 145). R. C. R. Strong. P. penicillin. 1. 41. I. 920–923. (1989). trauma to the neck: A case report. 23. (1992). Journal of Oral and Maxillofacial Sur- management.. J. S.. 97–122). ternal laryngeal trauma analysis of 392 patients. Austin. Head and Neck. W. Golz. for the dysarthrias (Dworkin. Obturator design for acquired maxil. Dworkin. Beumer. Journal of Oral and Maxillofacial Sur- permits continuous evaluation of each component in a gery. R. Jurkovich. (1989). W. Tumours Desjardins. A modified classification for the maxillectomy de.. Oral Oncology. J. and . D. be achieved by using the methods previously described Thorn.. Prosthodontic rehabilitation for glossectomy Balogh. gery. Archives of In K.. and Weymuller. and Charles. 106–115. S. (1999). G. 111. A. Marx.. CA: Singular Publishing Group. A. Specht. (1977). 118. Jewett.. P.. disciplinary issues and treatment (p. and Joa- for speech and swallowing in patients with total glossec. (1991). S. (1983a). P. gibility through overarticulation. and Leonard.. 62. S. 36. Beery. Laryngotracheal trauma. C. Once obturation occurs. W. D.). Spiro. E. technique for measuring velopharyngeal orifice area during Anderson. W. 482–499. worldwide: Etiological clues. 1991). E. Motor speech disorders: A treatment Doyle. 96.. Awde. A. S. Rogers. 111.. Such evaluations aid in fine-tuning prosthetic osteoradionecrosis. H. A. Dental Clinics of North America. F. Flax-Goldenberg. Cleft palate: Inter. Journal of Laryngology Kent.. E.. Neck.. 41. McNally. Toward phonetic intelligibility testing in dysarthria. R. Doyle.. B.... Dysarthria in adults: Physi- ologic approach to rehabilitation. specific sound production (or potentially the directed Netsell. Huryn.. quality of life in head and neck cancer patients. J. J. G. J. G. (1997). E.. Osteoradionecrosis of the patients. Preven- may include improving the control of the respiratory tion of osteoradionecrosis: A randomized prospective clini- support system for speech.. E. 58. Prosthesis serviceability for acquired jaw Warren. (1992). A new concept in the treatment of conditions.. Prosthetic treatment Goldenberg. (2000). Franceschi. and Sutherland. A. and Tibrewala. 808–814.. Journal of the ing the optimal speech rate. Doyle Maxillofacial Surgery. Journal of Prosthetic Dentistry. Journal of Speech-Language Pa. rehabilitation of individuals with head and neck cancer: A Hassan. and Otology. M. N.. S. and Boyle. A. comparative manner for prosthesis-in and prosthesis-out Marx. J. S. Oral prosthetic Head and Neck.. M. 15. J. Z. 311–318. Journal of Speech and target appropriate therapy techniques in an e¤ort to Hearing Disorders. (1986). Weismer. Journal of Prosthetic Dentistry. S. Journal of Prosthetic Dentistry. 52–71.. and Munoz. Adisman. G. Oral Journal of Speech and Hearing Disorders. 424–435. A. 39. rehabilitation: Prosthodontic and surgical considerations. 109–116. TX: Kornblith. J. and Luterman. Head and thology and Audiology. and Gillis. Postlaryngectomy speech rehabilitation: Cherian. increasing the accuracy of American Dental Association. T. The physiologic approach also pathophysiology. 2. J.. and Daniel. Batsakis. (1983b). D. A. cavity reconstruction: An objective assessment of function. modulating vocal in. Otolaryngology–Head and Neck Surgery. Journal of Laryngology Language Pathology and Audiology. geal trauma: Analysis of 30 cases. 283–288. and Gratton. (1982). Curtis. 502–508. and Otology.. 60.

relax psychogenic voice disorder is not associated with struc. and Close. D. The hypothesized physical nervous system pathology. 267–276. Roy and Leeper. or other psychological precursors palatal augmentation prosthesis. is then provided by the clinician. Carding...e. G.. Post- glossectomy deglutitory and articulatory rehabilitation with situational conflicts.. and Jacob. Wedel. Yontchev. Archives of Otolaryngol. L. Logemann. and Logemann. Journal of Prosthetic Dentistry. C. specific attention to the putative psychological dysfunc- Mahanna. A.. laryngeal pathology. Stemple. Andersson and Schalen. The fol- Logemann. D. Beukelman. J. A. Leeper. Davis. J. 36. B. (1993). Matz. that were identified during the interview.. 113. Once the larynx is within the brain. Psychogenic Voice Disorders: Direct Therapy 49 Holland. logical findings are reviewed with the patient. the precise mechanisms underly- patients using an obturator prosthesis. Carlsson. Journal of Oto- laryngology. visual and gology. Milutinovic.. and emotional inhibition (Case.. clinician provides brief information regarding the ther- Sandor. Carding and Horsley. 18. recently described a number of manual laryngeal repos- though numerous theories have been o¤ered to explain turing techniques that can stimulate improved voice . M. at reducing or rebalancing such tension (Boone and Masticatory function in patients with congenital and McFarlane. tional improvement in voice is said to follow. The management of acute she is reassured regarding the absence of any structural laryngeal trauma. 16. (1994). A. (1997). with associated pain and dis- comfort when the circumlaryngeal region is palpated. promote disequilibrium (Aronson. cancer surgery: An approach to speech outcome assessment. R. 18. B. and Carmichael. 303–308. the laryngo- Journal of Prosthetic Dentistry. Journal of Prosthetic Den. and lowing discussion considers voice therapy techniques Krugler. R. G. Aronson. ‘‘released’’ and range of motion is normalized.. Such ment in voice and reductions in pain and laryngeal dysregulated laryngeal muscle tension can interfere with height suggest a relief of tension (Roy and Ferguson. and relieve pain and discomfort asso- tural laryngeal changes or frank central or peripheral ciated with muscle spasms. tension is frequently o¤ered as the proximal cause of Schaefer. 1990). L. (1996). Before symptomatic therapy is begun. S. E. apy plan and the likelihood of a positive outcome. T. (1987).. as well as Therapy methods to relieve such tension during the diagnostic assessment and management session. C. PERCI: A method for rating palatal gressive relaxation. A. J. approach and emphasis vary among clinicians. A. fear. 1996)... (1989). E. ryngeal muscles is often associated with elevation of the tistry. the clinical voice literature is replete sus delayed obturator prosthesis placement. In its purest form. Bowman. tense muscles.. 279–285.. C. 1214–1218. the local circulation with removal of metabolic wastes. propor- lated musculoskeletal tension arising from stress. A. Hurst. J. P. Acute management of the psychogenic voice disorder. Robbins. G... R.. chewing therapy. (1997). E¤ects of intraoral prosthetics on swal. normal voice and give rise to complete aphonia (i. 79.. Speech and velopharyngeal function. W. and Taylor. S. (1998).. 1992. Horsley. 1993. R. Al.. M. 77. B. aimed at directly alleviating vocal symptoms without lowing in patients with oral cancer. Colangelo. and he or Myers. 1982. and circumlaryngeal massage aimed e‰ciency. F. 72. H. on voice production and its probable link to stress. 1999. (1987). 1998. R. C. List. fully elucidated (see functional voice disorders for a Lapointe. Baker. 2000). McConnel. A. Pauloksi.. 1–10. M. J. 448–452. Gunther et al. J. A.. 308–312. In a similar vein. Rademaker. Journal of Trauma. M. Roy and Bless (1998) also whispered speech) or partial voice loss (dysphonia). and Laryn. Annals of Otology. M. Lampe. 1990. 98. 118–120. and Iko. Marshall. Aronson (1990) and Roy and Bless (1998) have de- scribed manual techniques to determine the presence and Psychogenic Voice Disorders: Direct degree of laryngeal musculoskeletal tension. and Ow. D. J. Journal of Speech toward e¤ects of excess or dysregulated muscle tension and Hearing Research.. J. Roy Longitudinal assessments of quality of life in laryngeal can. and Sullivan. K. S.. O. and Docherty. The confident ogy–Head and Neck Surgery.. Functional assessment testing for maxillofacial psychogenic disorders can often result in rapid and dra- prosthetics. 310–316. Cardinale. G. 4.. Despite considerable controversy surrounding Comparison of maxillectomy patients with immediate ver- causal mechanisms. matic voice improvement (Koufman and Blalock. Cleft Palate Journal.. Head and Neck. While the specific Heiser. 9. K. 1997. Rhinology. Head and Neck. Prolonged hypercontraction of la- acquired maxillofacial defects. Speech and swal. K. It is asserted that the larynx. 2001). including yawn-sigh resonant voice therapy. Improve- flict. cer patients.. C. 2000). M. con. (1979). (1996). many voice therapies laryngeal trauma.. P. 4. Circumlaryngeal massage is one such treatment approach.. 147–165. et al. B. e¤ect of such massage is reduced laryngeal height and by virtue of its neural connections to emotional centers sti¤ness and increased mobility. 1990. is vulnerable to excess or poorly regu. Oral and Maxillofacial Because excess or dysregulated laryngeal muscle Surgery Clinics of North America. B. Ritter-Sterr. J. 25. Gaebler. J. Obturator prostheses after tion underlying the disorder. (1996). (1989). electromyographic biofeedback. P. 98–104. Dysphagia. A.. the dis- lowing function after anterior tongue and floor of mouth cussion typically includes some explanation of the un- resection with distal flap reconstruction. H. ing such psychologically based disorders have not been 323–334. et al. An explanation of the problem Pauloski. pro- Warren. 1996. H. systematic kneading of the extralaryngeal region that is a manifestation of some confirmed psychological is believed to stretch muscle tissue and fascia. Skillfully ap- Psychogenic voice disorder refers to a voice disorder plied.. review). 388–393. with evidence that symptomatic voice therapy for Light. Kahrilas. A. Quality of life of maxillectomy psychogenic voice loss. larynx and hyoid bone...

and the clini. hum. Carding. recovery of nor. Such preserved voicing for non. nate the abnormal symptoms. simple phrases. to mention only a few. sigh. mal voice can occur rapidly. In symptomatic therapy. Biebl. monitor the type and manner of voice produced. 1998). The anecdotal clinical literature suggests that the Certain patients with psychogenic dysphonia and prognosis for sustained removal of abnormal symptoms aphonia appear to have lost kinesthetic awareness in psychogenic aphonia or dysphonia may depend on and volitional control over voice production for speech several factors. or manual cueing. problem and the initiation of therapy may be important. the improved voice. 1994). the results regarding the durability of voice im- conversation about any topic and with anyone in the provement following direct therapy are mixed (Gunther clinical setting.50 Part I: Voice and briefly interrupt patterns of muscle misuse. the better the prognosis. 1990). Roy through phases of decreasing severity (Aronson. this may interfere with progress and trace of clearer voice so that it may be shaped toward contribute to a poorer treatment outcome. in administering the approach. the problem and the prognosis for maintaining normal nature of psychological dysfunction needs to be better voice. 1962. During this process. 1993. the foregoing observations have rarely cian provides immediate feedback regarding the positive been studied in any objective manner.. ally maintained without compensatory e¤ort and may 1998.. the voice symptoms. 1983. features that contributed to the development of the psy- genic voice disorders can produce rapid changes. If the situational. and Rammage. if normal quality or extended to longer utterances. and proprioceptive) to within the first session. not much laryngeal reposturing maneuvers are immediately iden. 1997. and tolerance. 1999). Therefore. For instance. and oral reading. If established. yet display normal voic. improvements in the patient’s emotional adjustment and den return of voice without necessarily transitioning voice function (Butcher. some The sooner voice therapy is initiated following the onset aphonic and severely dysphonic patients may be able to of the voice problem. balance. improvement during therapy for psychogenic voice dis. psychogenic voice disorders also has not been rigorously it is shaped and extended into sustained vowels. 1998. Once The long-term e¤ectiveness of direct voice therapy for this brief but relatively normal voice is reliably achieved. Digital cues can chogenic voice disorder is superior to another. cough. Andersson and Schalen. Fex et al. Of the few investigations that information and proceeds to brief narratives. yet others report more frequent post- casual conversation that begins with basic biographical treatment recurrences. evaluated (Pannbacker. Other patients will appear to experience sud. First.. and then exist.. chogenic voice disorder remain unchanged following ever. These the underlying psychological triggers are no longer e¤orts follow a trial-and-error pattern and require the active. caveat. 1997). 1988). It should improve further during conversation. Aphonia and extreme tension. 1996). . and review possible causes of the Kinzl. the some authorities. The mittent or mild dysphonia. therefore they are change. then. 1996. however. kinesthetic. it is instantly reinforced. direct symptomatic therapy for psycho. and Rauchegger. intensive treatment session or several sessions. any brief moments of clearer voice. Finally. some patients may need an maintain improved laryngeal positioning and muscle extended. the restored voice is usu. not the disturbance itself (Brodnitz. Most clinicians report that relapse is infrequent intervention is successful. and Raven. the patient is then engaged in and isolated. the more extreme normal voice quality. Finally. statements. be acknowledged that following direct voice therapy. the better the prognosis for im- speech purposes represents a clue to the capacity for provement. according to normal phonation. and patient motivation Once the larynx is correctly positioned. and Docherty. Andersson and Schalen. listening for and improvement should be sustained (Aronson. Elias. Second. Morrison. if significant second- goal of these voice maneuvers is to elicit even a brief ary gain is present. 1996. it would be logical to expect that and protracted experience for both clinician and patient such persistent factors would increase the probability of (Bridger and Epstein. Ramig and Verdolini. the time between the onset of voice and communication purposes. in some orders varies. or personality Certainly. in some cases voice therapy can be a frustrating behavioral treatment. Roy et al. When this phase of 1998). Case. As a voice is elicited. including the therapy voice during the therapy process can be dealt with by techniques selected. may be easier to modify than inter- patient is asked to produce such vocal behaviors. the patient needs to be an best regarded as clinical impressions rather than factual active participant and is encouraged to continually self. 1993. ing for vegetative or nonspeech acts. post-treatment referral to a psychiatrist or psy- various stages of dysphonia on their way to normal voice chologist may be necessary to achieve more enduring recovery. Therefore. The rate of future recurrences (Nichol. words. Colton and Casper. understood. When improved Du¤y. cian should debrief the patient regarding the cause of the only the symptom of psychological disturbance has been voice improvement. or years have elapsed. how. grunt. Any partial relapses or return of abnormal depending on several variables. Third. Although then be faded and the patient taught to rely on sensory signs of improvement should typically be observed feedback (auditory. it may be more di‰cult to elimi- or produce a high-pitched squeak with normal or near. clinician experience and confidence reassurance. 1990. Horsley. laugh. These Because there are few studies directly comparing the brief moments of voice improvement associated with e¤ectiveness of specific therapy techniques. discuss the patient’s feelings about removed. is known about whether one therapy approach for psy- tified for the patient and reinforced. emotional. If months clear the throat. the clini. Patients may progress gradually through cases. gargle. then normal voice should be established quickly seasoned clinician to be constantly vigilant. et al. et al. verbal reinstruction. 1995.

H. Research.). Di¤erential diagnosis Butcher. Nichol.. Psychogenic voice disorder unresponsive to laryngology. and body. McGrory. San Diego. Current Opinion in Otolaryngology and Head and Neck Surgery. L. Otolaryngology–Head and Neck some of the most severely disturbed voices encountered Surgery. 97. N. IL: Charles C Thomas. acoustic measures. 137–158. P. Baltimore: Williams and Wilkins. and Blalock.and long-term treatment outcomes. 225–230. and Casper. European Archives cies are determined by the vocal tract shape. 27.. Classification and Breathing. (1987)... Yeatman. of psychogenic voice disorder: Results of a follow-up study Journal of Voice. Psychogenic voice Multiphasic Personality Inventory. H. often represent Interdisciplinary approach to functional voice disorders: The psychiatrist’s role. (1988). belong to the personal voice characteristics. A. psychogenic voice disorders are power. Horsley. 81–92. Roy. M. Austin.. Stemple. St. A. P. Voice treatment techniques: A review hands. References Roy. M. British Journal of Disorders of Commu. Biebl. and Verdolini.. European Journal of Disorders of Communication. and Schalen. and Hirano. nication. New York: Thieme. 41(Suppl.. The functioning of the voice organ in singing is similar 72–104. N. (1990). Heisey.. R. a complex tone composed of a series of harmonic par- Acoustic analysis of functional dysphonia: Before and after tials of amplitudes decreasing by about 12 dB per octave voice therapy (Accent Method). and Docherty. D. R. Functional voice dis. Journal of Voice. O. H. (1998). Formant frequency Aronson.. voice therapy (6th ed. Schalen. Journal of Speech. In Roy. Springfield. speech therapy: Psychological characteristics and cognitive. (2000). and Ford. K. F. The voice source is Fex. Journal of Voice. Manual circumlaryngeal techniques in the assessment and treatment of voice dis- —Nelson Roy orders.. In an experienced clinician’s Pannbacker. 13. L. 49–64. Raven. M. to that in speech. 372–377. F. These frequen- A comparative study of psychological aspects of recurring and non-recurring functional aphonias. Journal of Voice.. (1983). Carding.. D. (1992). E¤ects of the manual Bridger.. J. Folia Phoniatrica. 12. 169–175. A. sence of structural laryngeal pathology. These control parameters determine vocal loudness.). TX: Pro-Ed. and treatment of psychogenic voice disorder. K. and Epstein.. (1998). (1996). S. 163– as measured in flow units. An evaluation study of voice therapy in non-organic dysphonia. respectively..). (1993). A. Annals ness and is therefore used for expressive purposes in of Otology.). K. L. 151–155. N. 11. Singular Publishing Group. 253. (1992). direct symptomatic therapy for psychogenic voice and recommendations for outcome studies. A. Voice and speech disorders: Medical D. H. and Rammage. Morrison. Voice therapy: Clinical studies (2nd ed. C. J. Functional disorders of the voice. 22. Motor speech disorders: Substrates.. 96–106. V. The Singing Voice 51 In summary.. Roy. Folia Phoniatrica. 321–331. Boston: Allyn and Bacon. laryngeal musculoskeletal tension reduction technique as orders: A review of 109 patients.. O. Shiromoto. Thus. Z.). Bless. Louis: Mosby. Colton. D. Du¤y.. of normal voice. Journal of Voice... K. (2000). (1996). J.. M. CA: 443–451. R. (1997). 91.. Subglottal pressure determines vocal loud- approach to patients with functional voice disorders. Clinical voice disorders: An interdisci. C. S. Treatment e‰cacy: the underlying bases of these disorders and the long-term Voice disorders.. Koufman. (2001). D. I. Levin (Ed. (1982). Understanding voice The voice source is mainly controlled by three physio- problems: A physiological perspective for diagnosis and logical factors. Etiology and treatment An evaluation of short. of thirty patients. (1997). Rhinology. Psychological correlates of aspects (pp. Elias. Elias. Miller. S. 108.. 11. L. 242–249. It propagates through the vo- 167. 7. Journal of Voice. Functional mine vowel quality. 17. (1995). (1990). while the higher formant frequencies aphonia: Psychosomatic aspects of diagnosis and therapy. Bless. Clinical Oto- D. For most of Otorhinolaryngology. D. G. N. J. cal tract and is thereby filtered in a manner determined Gunther. A study of the e¤ectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia. Mayr-Graft. Much remains to be learned regarding Ramig.. American Jour- disorders can produce rapid and remarkable restoration nal of Speech-Language Pathology. changes following manual circumlaryngeal therapy for func- plinary approach (3rd ed. A. Heisey. and Hearing e¤ect of direct therapeutic interventions. 453–481).. The voice and of Medical Speech-Language Pathology. M. tional dysphonia: Evidence of laryngeal lowering? Journal Boone. disorders and cognitive behaviour therapy. 42. A. di¤er. W. M.. Journal of Laryngology a treatment for functional voice disorders: Perceptual and and Otology. 6. of the vocal folds. behaviour therapy. L. and management. D. Milutinovic. subglottal pressure. functional dysphonia: An evaluation using the Minnesota Butcher. (1993).. (1999). 643–647.. N. and Ferguson. and Bless. and Laryngology. (1993). C. J. Results of vocal therapy for phono- ful examples of the intimate connection between mind neurosis: Behavior approach... These voice disorders. It is also varied with F0. M. and Kinzl. the origin of the sound is the Case. R.. San Diego. 7. 173–177. and Littlejohns. See also functional voice disorders. N. M. ential diagnosis. A. N.). singing. P. J. and Horsley. F0. M. Fex. by voice pathologists. and Rauchegger. (1962). N. by its resonance or formant frequencies. (1998). such that higher pitches . 9. Tasko. C. P. vowel sounds. (1994). 8.. and the degree of glottal adduction. 1145–1148.. The Singing Voice Carding. Clinical management of voice disorders (3rd voice source—the pulsating airflow through the glottis.. R. J.. D. and McFarlane. F. E. Language. length and sti¤ness treatment. and Raven. and Ford. S101–S116. and Andersson. Roy. which occur in the ab. 240–244. J. and Leeper. the two lowest formant frequencies deter- Kinzl. P. I. ed. R. Manual circumlaryngeal therapy for functional dysphonia: Andersson. (1996). (1998). CA: Singular Publishing Group. and mode of phonation. 40. S. 131–137. J. Brodnitz. M.

This type of phonation has been called flow phonation or resonant voice. The peak-to-peak modu- lation range is varied between nil and less than two semitones. 2). high lung volumes to inhalatory at low lung volumes. as hyperfunctional or pressed. Whereas in conversational exaggerated glottal adduction thus attenuates the fun- speech. This generates a source are used in singing than in speech. a firmer elasticity produces an exhalatory force that may amount adduction produces a smaller air volume in a pulse.52 Part I: Voice are sung with higher subglottal pressures than lower The acoustic significance of the waveform is straight- pitches. mostly between 5 and 7 Hz. This generates noise and produces a strong fundamental. The pitch perceived from a vibrato tone completely (Fig. frequently referred to as the maximum flow subglottal pressure is much more constant. Elasticity.5 or 2 kPa. lung volume is called the functional residual capacity In classical singing. on Voice Source. generated by the lungs and the rib and is strongly influenced by the overall glottal adduc- cage. adapting it to both loudness mainly by the negative peak of the di¤erentiated flow and pitch. varies with lung volume. for high. they reach an equilibrium at a certain lung volume. singers need to vary sub. The opposite extreme— age lung volume range that is more than twice as large that is. classically trained singers use an aver. while in loud speech subglottal pressure may be The amplitude gain of higher partials is greater than that raised to 1. no more than about 15%–20% of the total lung damental. At high lung volumes. It represents the main excitation of the therefore need to develop a virtuosic control of the vocal tract. Curiously enough. glottal pressure causes an SPL increase of about 10 dB. The airflow waveform of the voice the other hand. is generally referred to as the vibrato rate and is rather constant for a singer. pressed phonation is occasionally used source is characterized by quasi-triangular pulses. sound is increased by 10 dB. duced when the vocal folds open the glottis. brato. Typical flow glottogram showing transglottal airflow hand. it tends to increase some- what toward the end of tones. As a consequence. singers seem to strive to reduce glottal FRC. apparently for expressive purposes. 1). corresponds to its average F0. produced by the breathing muscles and passive forces The air volume contained in a flow pulse is decisive produced by gravity and the elasticity of the breathing to the amplitude of the source spectrum fundamental apparatus. mental. As the elasticity forces change from exhalatory at airflow escapes the glottis during the quasi-closed phase. pitch is perceived categorically. This steepness is linearly related to the sub- breathing apparatus. the habitual use of too faint adduction—is called and occasionally may vary from 100% to 0% of the total hypofunctional and prevents the vocal folds from closing vital capacity in long phrases. The modulation fre- quency. and fol. inhalations are started from avoided. Thus. these mus- cles cause a stretching of the vocal folds. singers’ vi- brato rates tend to decrease by about one-half hertz per decade of years. . In music. the glottis also during the vibratory cycle. The neural origin of this pulsation is not understood. and vibrato extent tends to increase by about 15 cent per decade. In nonclassical singing. The vibrato is generated by a rhythmical pulsation of the cricothyroid muscles. for a given subglottal pressure. pressed phonation is typically (FRC). Instead. singers may use pressures as high of lower partials. At low lung volumes. Thus. such that a continuous variation in F0 is heard as a continuous variation of pitch. or F0  2 1=6 . the partials near 3 kHz Subglottal pressure is determined by active forces typically increase by about 17 dB. forward. In both speech and singing. where the catego- versus time. which reduces the amplitude of the fundamental. In speech. Singers declination rate. In tidal breathing. if the sound level of a vowel as 4 or 6 kPa for loud tones sung at high pitches. As a result. It corresponds to a quasi-periodic modulation of produced when the folds close the glottis more or less F0 (Fig. In addition. elasticity con. This This phonation mode is often referred to as breathy. With increasing age. Thus. subglottal pressures in glottal pressure in such a way that a doubling of sub- singing are varied over a larger range than in speech. Because much higher lung volumes closure during the closed phase. A main characteristic of classical singing is the vi- lowed by horizontal portions near or at zero airflow. where waveform. When contracting. singers need to deal spectrum with strong high partials and a strong funda- with much greater exhalatory elasticity forces. and so raise F0. tion force. loud tones. pitch is perceived in a continuous fashion. ries are scale tones or the intervals between them. on the other Figure 1. This phonation mode is generally referred to capacity is used. The slope of the source spectrum is determined glottal pressure constantly. however. to 3 kPa or more. An tributes an inhalatory force. pro. Thus. This is in sharp contrast to speech. One possibility is that it emanates from a cocontraction of the cricothyroid and vocalis muscles. lung volumes above adduction to the minimum that will still result in glottal FRC are preferred.

7 cent. it is absent or much a wide pharynx. On average. If this resonance is appropriately tuned. and classically trained singers. apparently significantly to the characteristic voice qualities of these depending on the musical context. Spectra of the vowel [u] as spoken and sung by a classically trained baritone singer. tenors. The between voice classifications.5 kHz followed the vowel [i] is generally considerably lower in classical by a descent of about 9 dB per octave toward higher singing than in speech. the second formant of orchestra typically shows a peak near 0. each of which corresponds to a scale tone. Therefore. The to be to lower the larynx. it can all voiced sounds produced by classically trained male be regarded as a manifestation of vocal economy. tenors. a marked spectrum envelope peak the singer’s voice easier to perceive. and F5. the target F0 for a classifications.5 and 3 kHz. It does singers and altos (Fig. This corresponds The center frequency of the singer’s formant varies to less than one-tenth of a typical vibrato extent. Lowering the larynx lengthens the center frequency of a scale tone is 2 1=12 higher than the pharynx cavity. The singer’s formant spectrum peak is particularly prominent in bass and baritone singers. lower formant frequencies than tenors. The formant frequencies in classical sing. baritones. For example. and where the interval between adjacent scale tones corre. 4). The long-term-average spectrum of a symphonic found in speech. In tenors and Resonance. As F2 of the vowel [i] is mainly its lower neighbor. dependent on the pharynx length. it tends to be target F0 generally agrees with equal-tempered tuning. 2. or 0. it will provide a formant cluster. probably reflect di¤erences in vocal tract scale tone may deviate from its value in equal-tempered length. Experts generally find that a tone is out of tune speechlike formant frequencies are used. 3). Thus. such that the vowel quality frequencies (Fig. respectively. octaves. It is produced by a clustering not appear in nonclassical singing. This clustering seems to be achieved provided with a sound amplification system that takes by combining a narrow opening of the larynx tube with care of audibility problems. F4. who have a singer’s formant.5 and 3 kHz. However. whose voices are opening and the pharynx approximates 1 : 6 or less. where the soloist is of F3. such that individual singers’ voices larynx tube acts as a separate resonator in the sense that are di‰cult to discern. about 2.4. sopranos do not seem to produce lower formant frequencies than baritones. If the area ratio between the larynx tube less prominent among choral singers. its resonance frequency is rather insensitive to the cross. the sound level of an or- approaches that of the vowel [y]. These di¤erences. baritones. which is typically observed in width of each scale tone is approximately 6% wide. altos it is less prominent and in sopranos it is generally ing di¤er between voice classifications. As the singer’s for- between approximately 2. . chestra is comparatively low in the frequency region of These formant frequency deviations are related to the singer’s formant. it will be lowered by The demands for pitch accuracy are quite high in a lowering of the larynx.8 kHz for basses.6. Also. the supposed to blend. and 2. tuning by about a tenth of a semitone interval. basses have not observable. Typical ranges for basses. The Singing Voice 53 Figure 3. Thus. The approximate pitch range of a singer is about two sectional area in the remaining parts of the vocal tract. which contribute sponds to the F0 ratio of 1 : 2 1=12 .07 of a semitone interval. Example of vibrato. Figure 2. The enhancing the voice when accompanied by a loud or- formant frequencies also deviate from those typically chestra. Its resonance frequency can be somewhere between 2. In nonclassical singing. and no singer’s when it deviates from the target F0 by more than about formant is produced. so that the singer’s formant makes the singer’s formant. more singing. that appears in mant is produced mainly by vocal tract resonance. These di¤erences The singer’s formant seems to serve the purpose of probably reflect di¤erences in vocal tract length. the F0 continuum is divided logarithmically into a series A common method to achieve a wide pharynx seems of bins.

published in 1942. Long-term-average spectrum of an orchestra with In 1911. behavior. —Johan Sundberg In addition to the nature of the voice disorder. (1987). This disturbs the normal function of the tient education is understanding. giene programs regardless of the pathophysiology of See also voice acoustics. Englewood Cli¤s. J. they Luchsinger and Arnold (1965) stressed the need for at- increase F1 so that it is always higher than F0. An inappropriate vocal technique. Concern was raised about the e¤ects of tobacco. and sopranos are E2–E4 (82–330 Hz). the wider the jaw opening. Vocal hygiene. and C4–C6 (262–1047 Hz). NJ: Prentice Hall. however. glottal adduction or with singing in a too high pitch however. of the jaw opening when the e¤ect of this neutralization Subsequently. Singers. situation in which F0 is higher than F1. DeKalb. and resort to a widening professionals. a therapy program may be sometimes associated with a habitually exaggerated based completely on vocal hygiene. The authors. loud and excessive talking. until improved by consonants. they often need structure and function of the phonatory mechanism are medical attention. Instead. singers seem first to reduce the tongue this type of attention not only for teachers and voice constriction of the vocal tract. the higher the pitch. Most isolated vowel sounds can be take vocal hygiene to mean the science of vocal health correctly identified up to an F0 of about 500 Hz. late of vocal hygiene and preventive laryngeal medicine. faulty habits. alcohol. Another classic text was Diseases and Injuries (98–392 Hz).’’ Thus. edition of Dorland’s Medical Dictionary defines it as ‘‘the tion. which in apy program that also includes directed instruction in some cases may lead to developing vocal nodules. In it the author. quite recently. however. Above and the proper care of the vocal mechanism. More frequently. A frequent origin of their voice dis. but also for children in the classroom. issue of vocal hygiene. G2–G4 the voice. This and Jackson. most frequently discussed as constituting vocal hygiene. text intelligibility can be greatly the science on which these ideas are based was. the voice disorder. Because singers are extremely dependent to voice therapy. Despite this frequency. we can also at high F0. respectively. with detailed discussion of vocal hygiene. Titze. in 1886. Patient education and vocal hygiene are both integral Health Risks. these authors discussed the importance of other vowels. Also relevant would be their use of high other hand. identification deteriorates quickly and long-held beliefs about the value of certain activities remains low for most vowels at F0 higher than 700 Hz. I. hormones. also tends to cause voice disorders. that pathophysiology should dictate some specific di¤erences in the vocal hygiene approach. and diet on altos. focuses on changing an individual’s vocal subglottal pressures. C3–C5 (131–523 Hz). Persons who are educated about the on the perfect functioning of their voices. In some instances. and surgical Although there are commonalities among vocal hy- treatment is mostly considered inappropriate. Thus. Yet vowel identification is surprisingly successful science of health and its preservation. nodules generally disappear after voice rest. and cited rest and F1 in some vowels. Such voice production techniques. more implied and deduced than specific. a noted otolaryngologist. better able to grasp the need for care to restore it to orders is a cold. Principles of voice production. on the vocal folds. factors . to those expressed in the current literature. (1994). about vocal hygiene expressed in this book were similar sponding analysis of neutral speech at conversational loudness. virtually all voice texts have addressed the of the articulation fails to produce further increase of F1. For the tention to the physiological norm as the primary postu- vowel [a]. ous disciplines commonly use the term hygiene. the goal of pa- glottal mucosa. Because F1 and F2 are decisive to the perception of Both the general public and professionals in numer- vowels. The ideas The thin solid curve shows a rough approximation of a corre. Vocal Hygiene Vocal hygiene has been part of the voice treatment liter- ature continuously since the publication of Mackenzie’s The Hygiene of Vocal Organs. described many magical pre- scriptions used by famous singers to care for their voices. the substantial departures from the typical for. In reality.54 Part I: Voice References Sundberg. F3–F5 (175– of the Larynx. implicated various vocal abuses as the implies that F0 is often higher than the typical value of primary causes of voice disorders. vocal hygiene is but one spoke in a total ther- range. IL: Northern Illinois University Press. Figure 4. The science of the singing voice. seem to avoid the refraint from the behavior as the appropriate treatment. which typically causes dryness of the health and to maintain its health. The 29th mant frequency values in speech a¤ect vowel identifica. a German work by Barth included a chapter and without a tenor soloist (heavy solid and dashed curves). Jackson 698 Hz). this is achieved by widening the jaw opening. For Remarkably.

rapid removal of significant with long-term vocal use that involves increased im- amounts of body water increased PTP and was asso. Both environmental humidity and in exacerbating the symptoms of laryngopharyngeal surface hydration are important physiological factors reflux. Vocal Hygiene 55 such as timing of the program relative to surgery (i. Thus. vocal hygiene programs that address in determining the energy needed to sustain phona. radiation therapy. fried directly involved in the e¤ort required to initiate and foods. Many questions remain in this area. as iors. It is now common by-product of drinking large amounts of water. must also inform specific aspects of the are reducing vocal intensity by eliminating shouting or vocal hygiene program. . vocal nodules. stands alone or is but one aspect of a more extensive Other major components of vocal hygiene programs therapy process. A has been described by Titze (1994) as proportional to number of authors have studied the e¤ects of hydration vibrational amplitude and vibrational frequency. and eventual voice or tissue change. by which the hydration of vocal style modifications. repair. Although this is clearly a medical treat- the surface of the vocal folds. Both will probably ensue. prescribed protocol. 1994). chronic throat clearing. 1994) studied PTP in normal speakers threshold level in a predisposed individual. including chronic or inter- adequate fluid intake. and mucolytic agents may ment. list of laryngeal conditions. Lin. Viscosity is connection between viscosity and hydration. can cause vocal fold oscillations cease in a matter of minutes in vocal fold pathology. Thus. This lends support to the wide- PTP and self-perceived vocal e¤ort were lower after spread belief that loud and excessive voice use. both gastroesophageal and laryngopharyn- the surface of the vocal folds. and malignant tissue Thus. teachers and others in vocally demanding professions are Rehydration by dripping saline onto the folds restored prone to vibration overdose. Titze (1994) theor- and maintain vocal fold vibration. who showed that intraglottal contact increases is the minimum subglottal pressure required to initiate with increased vocal fold adduction. The greater the viscosity of vocal fold nation. (1990. there appear to be a number of mechanisms. 1991). Steam inhala. ication that will be continued through the postoperative tion and environmental humidification further hydrate healing stage. and Hanson ness and phonotraumatic vocalization are appropriately (2000) noted the presence of mucous glands in the tissue addressed in vocal hygiene programs and in directed of the vestibular folds and observed that these glands therapy approaches. healthy diet and lifestyle and that include reflux pre- tion. particularly patients undergoing dialysis. Treatment may include dietary changes. Clearly. a¤ects the health of the larynx and pharynx. should be a focus of all vocal hygiene programs. and surface moisture for lower PTP. viscosity is a measure of the resistance The complexity of vocal physiology suggests a direct to deformation of the vocal fold tissue. Environmental hydration geal. Jiang. pact stress on the tissues during collision and shearing ciated with symptoms of mild vocal dysfunction in some stresses (Jiang and Titze. mittent dysphonia. speaking above high ambient noise levels. ized that if a vibrational dose reaches and exceeds a dolini et al. Moreover. The force of collision (or impact) of the vocal folds such. The viscosity of secre. the necessary hydration of airway tissues. vocal fatigue. the stage is set for cyclic tissue injury. shearing forces. changes. issues of collision patients. and in- hydration. such as the pre or post). mainly be. with inadequate recovery the oscillations. External or superficial hydration may occur as a cautions appear to be well-founded. (PTP (1994). and whether the vocal hygiene training most e¤ective method of hydration. phona- increased by hydration and decreased by drying—hence tion threshold pressure. it appears that the body has robust tissue. Restoration of the body fluid reversed this and the impact forces associated with increased loud- trend (Fisher et al. which practice for patients scheduled for any laryngeal surgery increases the secretions in and around the larynx and to be placed on a preoperative course of antireflux med- lowers the viscosity of those secretions. Gastric acid and gastric pepsin. life- not yet fully understood.) For example. avoiding fre- Hydration and environmental humidification are quent throat clearing and other phonotraumatic behav- particularly important to the health of the voice. tions is thickened with ingestion of foods or medications Laryngopharyngeal reflux has been implicated in a long with a drying or diuretic e¤ect. duction in aging. nating. and excessive food intake have all been implicated maintain phonation. Thus. and. the information and supportive guidance through vocal lower the phonation threshold pressure. alcohol. tobacco. have been found in refluxed material. the speech-language pathologist should provide decrease the viscosity of the vocal folds. demonstrating the need for hydration time. the higher the PTP that is required and the greater cellular and neurophysiological mechanims to conserve is the internal friction or shearing force in the vocal fold.e. and the e¤ects of collision and the importance of vocal fold hydration to ease of pho. in. Ver. facilitates the vocal fold vibratory behavior. Jiang. Ca¤eine. and Hanson (1999) showed that deed other forms of harsh vocal productions. 2001). distribute a very important layer of lubricating mucus to Reflux. and medication.. Ng. the less air hygiene instruction to ensure that patients follow the pressure is required and the greater is the ease of pho. tissue injury subjected to hydrating and dehydrating conditions. This and dehydration of vocal fold mucosa and viscosity of was explored further in phonation by Jiang and Titze the folds on phonation threshold pressure (PTP). and the reduction in mucus pro. In a study of These e¤ects may explain vocal fold injuries. (Koufman. the latter implicated cause of the increased water content in this mucous layer in the delayed healing of submucosal laryngeal injury and in the superficial epithelium. reflux laryngitis. Surgery is usually a fold mucosa and the viscosity of the vocal folds are treatment of last resort. It also supports the view that fresh excised canine larynges deprived of humidified air. In one light..

Of note. I. J. J. D. I. (1942). however. Macmillan. The otolaryngologic manifestations musculature. tem can be understood within the theoretical framework Chan. J. V. D. J. amplification may have exceeded those of vocal hygiene instruction. R. experienced sig. 44. CA: Wadsworth. 51–59. Leipzig: functioning of the basic tetrapod vocal production sys- Thieme. or ‘‘buccal Jackson. C.. Phonation is typi- Jiang. It should be noted that the vocal two treatment approaches for teachers with voice disorders: hygiene program used in this study. (2001). and Arnold. K. J. W. Verdolini. Dependence disordered teachers. Roy Titze. ancestor of reptiles. J. of the myoelastic-aerodynamic and source/filter theories giene education? A study of some instrumental voice mea. (1994). Casper sound. C.. cally powered by passive deflation of the elastic lungs. Voice-speech- provement in a group of teachers with voice disorders language. 1–78. in the ogy. Simon.. K. Sobecks. An evaluation of the e¤ects of nificant improvement. H. (1994). Although the vocal hygiene group Verdolini-Marsten. E. Teachers who received a directed voice therapy program Roy. 1985). Journal of Speech. and requiring no activity on the part of the participants. and (3) a supralaryngeal vocal tract which filters this sound before emitting it into the environment. birds.. and Hearing Research. Journal of Speech. Corbin-Lewis. the lungs were inflated Speech. Does the voice improve with vocal hy. London: after a course of didactic training in vocal hygiene. This bears out the Vocal Production System: Evolution received wisdom that it is easier to take a pill—or wear an amplification device—than to change habits. M. 37. Englewood et al. J. birds. S. 8. and Jackson. Language. a wide variety of interesting mod- Barth. The hygiene of vocal organs. muscular diaphragm (Liem.. Journal of Speech. returning the air to the lungs. 1001–1007. and Titze. tion versus vocal hygiene instruction in a group of voice. K.. 101(Suppl. and mammals. (2001). Otolaryngologic Clinics of North America. S. (2001) found no significant im. comparing the e¤ects of the two approaches failed to Language.. (1991). 132–144. and Stemple. and Fennell. and Hearing Research. and Hearing Research. Diseases and injuries of pumping. vocal education and hygiene. sures in a group of kindergarten teachers. (1990).’’ and this system is still used by lungfish and the larynx. Phonatory e¤ects of body fluid removal. N. Although study results are mixed. Dove. The underlying rationale for vocal hygiene pods (nonfish vertebrates: amphibians. Laryngo- therapy program alone is adequate treatment for vocal scope. 13. Principles of voice production. Vocal fold physiol. Ligon.56 Part I: Voice An unanswered question is whether a vocal hygiene pepsin in the development of laryngeal injury. and Rose. This was Jiang. In primi- Fisher. and Druker. R. and Hearing Research. R. 4. Most pairwise contrasts directly of phonatory e¤ort on hydration level. G. (2002) examined the outcome of voice amplifica. amphibians (Brainerd and Ditelberg.. J. In another study. (1994). 1.. Einfuhrung in die Physiologie. In many frogs. Inspiration Jiang. A. V. The Hygiene der Menschlichen Stimme und Sprache. or in some cases by active compression of the hypaxial Koufman. 44. Weinrich. air expired from the lungs of gastroesophageal reflux disease: A clinical investigation during phonation is captured in an elastic air sac. Cli¤s.. I. Measurement of vocal fold intraglottal pressure and impact stress. 279–291... reptiles. 286–296. Journal of Voice. The lungs and attendant respiratory musculature 8. Gray. Belmont.. New York: Macmillan. et al. provide the air stream powering phonation. Mackenzie. Roy et al. and Hanson. 354–367. Journal of Voice. E.. by active expansion of the thorax evolved later. De- References spite this shared plan. D. Gray. Lin. (Vocal Function Exercises). M. Toledo. Journal of Voice. and Hanson. Language.. Roy. The e¤ects of rehy. 699–718. NJ: Prentice Hall. showed changes in the desired direction on all dependent Changes in phonation threshold pressure with induced con- measures. being purely didactic A prospective randomized clinical trial. Ng. Language. L. D... (2001).. C.. Titze. 53). might more appropriately be described as a patient edu. and often secondarily to produce —Janina K.. by rhythmic compression of the oral cavity. L. 286–296. This allows and an experimental investigation of the role of acid and frogs to produce multiple calls from the same volume .. powered originally by the intercostal muscles (as in liz- dration on phonation in excised canine larynges. reach significance. the study results suggest that the benefits of ditions of hydration. D. there is insu‰cient The human vocal production system is similar in broad evidence to suggest that vocal hygiene instruction be outline to that of other terrestrial vertebrates. 1993). K. All tetra- abandoned. R. Tanner. (2) a larynx that acts primarily as a quick-closing gate to protect the lungs. H. which of 225 patients using ambulatory 24 hr pH monitoring then deflates. familiar to speech scientists. problems. I. M. 142–151. is su‰ciently compelling that a vocal hygiene program and mammals) inherit from a common ancestor three should continue to be a component of a broad-based key components: (1) a respiratory system with lungs. (1911). Chan (1994) reported that a group Dove. K. (1965). (1994). Voice amplification versus vocal of non-voice-disordered kindergarten teachers did show hygiene instruction for teachers with voice disorders: A positive behavioral changes following a program of treatment outcome study. 44. E. Journal of tive air-breathing vertebrates. (1999). A... voice therapy intervention. Pathologie und ifications of the vocal production system are known. cation program. Luchsinger. the amplification group reported higher levels of extraclinical compliance with the pro- gram than the vocal hygiene group.. R. S. (1886). N. (2000).. Journal of ards or crocodilians) and later (in mammals only) by a Voice. D. Titze. W.

1989). 1991). the evolution Because the length of the vocal folds determines the of the human speech apparatus involved several impor- lowest frequency at which they could vibrate (Titze. and freed from the necessity of tracheal quencies provide a possible indicator of body size not protection.. Like any column of air. the significance of their loss in human evolution is hammerhead bat Hypsignathus monstrosus. However. 1973). However. During phonation. elongation can also be achieved by lowering the larynx. in nonpathological human voices. cal tract shared by all tetrapods. Fig. which sound is radiated into the environment (Gans. Vocal tract resonances are termed cords. all have formants. pushing the heart. simply vocal tract. How- mammal species. its primary function as a protective gate. they can be important Human speech is thus produced by the same conser- in animal vocal repertoires (Fitch. Again. Rice. 2000b). and nasal cavities. with long folds producing lower frequencies. Thus. hiss—perhaps the most primitive vocalization. to shape): they act as (geckos. Expiration Sounds created by the larynx must pass through the through the partially closed larynx creates a turbulent air contained in the pharyngeal. and trachea down into the ab- 1973). a novel phonatory structure called the syrinx rests within the confines of the head. 1960). Thus. one great apes posses large balloon-like sacs that open into might expect that a low fundamental would provide a the larynx directly above the glottis (Negus. mant frequencies are determined by the length and shape way appears to have constrained laryngeal anatomy. Kuhn. tant changes. vocal reptiles formants (from the Latin formare. Because larynx in these species can support a wide variety of all tetrapods have a vocal tract. 1A. which retract the larynx to the sternum during ter- mental frequency of the purr (Frazer Sissom. in howler pathological situations. Vocal Production System: Evolution 57 of air. A simi- The lungs are protected by a larynx in all tetrapods. it is possible to break the ana- cal folds (or syringeal membranes) into vibration. The airflow from the lungs sets the vo. 1C–E ). mass and elasticity and vibrates preferentially at certain vation of elastic membranes within the larynx. Dedicated to vocal body size are tightly linked (Fitch. limited. 1992. crocodilians). Because the vocal tract in mammals birds. Elongations that frequency. 2000). For- vocalizations. 1967). Together with demonstrations of formant Although our knowledge of animal phonation is still perception by nonhuman animals (Sommers et al. (Fitch. this air has phisticated vocalizations became possible after the inno. vative vocal production system of lungs. 1949). cat purring relies on an active tensing this is seen in extreme form in the red deer Cervus ela- of the vocal fold musculature at the 20–30 Hz funda. Vocal tract vocalizations at 40 kHz and higher (Suthers and Fattu. Vibration at a particular arisen to elongate the vocal tract (presumably resulting frequency does not typically require neural activity at from selection to sound larger. 1995). more so. and skull size and evolved at the base of the trachea. a laryngocele is a congenital or monkeys (genus Alouatta) the larynx and hyoid have acquired air sac that is attached to the larynx through grown to fill the space between mandible and sternum. a similar Peters. together (to seal the airway) (Negus. and tomical link between vocal tract length and body size. Large animals have long vocal tracts and (King. probably in response to selection for ever. domen (Schneider. All 1994). the movements of the change occurs in human males at puberty: the larynx vocal folds can be periodic and stable (leading to tonal descends slightly to give men a longer vocal tract and sounds) or highly aperiodic or even chaotic (e. which collectively termed the supralaryngeal vocal tract or virtually all tetrapods can produce. and Keleman. larynx. is observed in human males and is partially responsible tilages that can be separated (for breathing) or pushed for the voice change at puberty (Titze. the vocal resonant frequencies. air sacs are occasionally observed in humans in low-pitched voices (Fig. in lower formants than same-sized women (Fitch and screams). and mammals. However. oral. relatively normal phonation can of the nasal vocal tract are seen in the long nose of be obtained by blowing moist air through an excised male proboscis monkeys or the impressive nasal crests larynx. 1999). phus. and rodents and bats can produce ultrasonic of hadrosaur dinosaurs (Weishampel. and ritorial roaring (Fitch and Reby. this suggests that formants principles of the myoelastic-aerodynamic theory of hu. B). and Her. 1989). The most function of air sacs in ape vocalizations is not under- extreme example of laryngeal hypertrophy is seen in the stood. 1981). However. the size Ybarra. low formants. In of the vocal tract. The inflated sac also increases the e‰ciency with larynx of males expands to fill the entire thoracic cavity. a huge larynx has independently evolved in many which were subsequently lost in human evolution. For example. may have provided a cue to size in primitive vertebrates man phonation. 1997). However. . Because the low-pitched voices (Kelemen and Sade. ancestor of apes and humans also had such air sacs. 2001). Although the filters to shape the spectrum of the vocal output. formant fre- production. the avian syrinx is a remarkably diverse as easily ‘‘faked’’ as the laryngeal cue of fundamental structure underlying the great variety of bird sounds frequency. which are found in most frogs. lar though less impressive increase in larynx dimensions This structure primitively includes a pair of barlike car. 1949. Neubauer. while such aperiodic vocalizations are rare Giedd. and vo- zel. the laryngeal ventricle at precisely the same location as giving these small monkeys remarkably impressive and in the great apes (Stell and Maran. One was the loss of laryngeal air sacs. 2002). 1975). Parsimony suggests that the common of the larynx is not tightly constrained by body size.g. phonation in nonhumans appears to follow the Fitch and Kelley. in which the unknown. the rate of vibration is passively determined by the size and some intriguing morphological adaptations have and tension of these tissues.. Schön reliable indication of large body size. lungs.

102. berman. Journal of the Acoustical Society of trait initially arose to exaggerate size in early hominids America. may be associated with an increase in breathing control ing human evolution was the descent of the larynx from necessary for singing and speech in our own species. 1511–1522. Male red deer Cervus elaphus have a permanently de- scended larynx. 1969). 559–574. (1997). In particular. L. 57. T. Journal of the Acoustical Society of America. Phonetica. (2000b).. A second change in the vocal production system dur. a. T. u/ seem to be impossible to attain salamanders and the evolution of vertebrate air-breathing unless the tongue body is bent and able to move freely mechanisms. which could have served Fitch. Calls out of erectus (MacLarnon and Hewitt. In the 1960s. 2000a).. 205–218.58 Part I: Voice Figure 1. Neubauer. most mammals appear vocal tracts: Comparative cineradiographic observations of to lower the larynx during vocalization (Fitch. Given the existence 163–183. which together with the enlarged hyoid fills the space beneath the mandible (larynx and hyoid shown in gray). a lower position in the neck (Negus. 1999). Klatt. of these vowels in virtually all languages (Maddieson. (1993). Ethology. and Giedd. vocalizing animals. J. Zoology. (2000). 106. T. its normal mammalian position high in the throat to See also vocalization. 40–58. produce a diversity of sounds. and Ditelberg. E. Lung ventilation in ‘‘point vowels’’ /i. The existence of nonhuman mammals Fitch. lessening the gap between humans and other animals. which they lower to the sternum when roaring. Tecumseh Fitch speech scientists realized that this ‘‘descended larynx’’ allows humans to produce a wider variety of formant patterns than would be possible with a high larynx References (Lieberman. Fitch. (1999). T. the Brainerd. S. 49. W. Hammerheaded bat. Skull dimensions in relation to body size Despite these caveats. Examples of unusual vocal adaptations among vertebrates (not to scale). Perception of vocal tract 2001). and Wilson. H. B. P. of the thoracic intervertebral canal occurred during the 106. have the largest rela- tive larynx size among primates. Fitch. T. (2002). J. —W. This change chaos: The adaptive significance of nonlinear phenomena in . W. Finally. Howler monkeys Alouatta spp. Humans— Homo sapiens—have a descended larynx. and Kelley. (2000a). 1949). neural mechanisms of. C. within the oropharyngeal cavity. W. recent fossils suggest that an expansion resonances by whooping cranes. W. evolution of Homo some time after the earliest Homo Fitch. The phonetic potential of nonhuman a simpler speech system. quire a descended larynx.. 1984). E. J. speech typical of modern humans appears to re- caques. Also. J. Morphology and develop- with a descended larynx raises the possibility that this ment of the human vocal tract: A study using magnetic resonance imaging. T. the descended larynx is clearly an in nonhuman mammals: The causal bases for acoustic al- important component of human spoken language (Lie. Fitch. W. and was later coopted for use in speech (Fitch and Reby.. Of course. The now extinct duck- billed dinosaur Parasaurolophus had a hugely elongated nasal cavity (shown in gray) that filled the bony crest adorning the skull. has a huge larynx (gray) enlarged to fill the thoracic cavity. D. Vocal tract length and formant fre- quency dispersion correlate with body size in rhesus ma- 1984). 103. lometry.. resulting in an extremely elongated vocal tract (shown in gray). Grus americana. A. Hypsignathus monstrosus. and Herzel. resulting in an elongated ‘‘two-tube’’ vocal tract (shown in gray). W. Biological Journal of the Linnean Society. all mammals can 1213–1222.

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The perisylvian cortex also projects directly to the Output from the SMA to other vocalization motor areas medulla. The lateral and mesial surface of the human brain. 2000). ters (glutamate). Electrical and chemical stimulation of the PAG in into the cortex.and postcentral gyri is PAG in humans and animals lead to mutism (Jürgens. cortex is reciprocally connected to the ACG. Mutism seems to occur more frequently when the aqueductal gray (PAG) (Jürgens. and limbic system. Additional evidence linking the insula to vocal. Belin et al. 1988). which 1997). Du¤y. 1958). A variety of techniques have shown that 1982. propositional speech remains severely impaired but portant for vocalization. Lesions of the opercular region of the pre. counting) remains rela. Kirzinger. In some cases. a¤ecting the insula and possibly the many animal species elicits species-specific vocalizations basal ganglia (Jürgens. projects to midbrain mechanisms involved in vocaliza- as both are remembered and require proper sequencing. the insula during singing (Perry et al. activate or suppress coordinated groups ization comes from recent studies of apraxia in humans of oral.. 1994). tion. Newman. In specific cases. (Jürgens. along with expressive aphasia or apraxia superior temporal gyrus and Heschl’s gyrus. and Leiguarda. facial. 1995). and laryngeal muscles for (Dronkers. which are (Du¤y.g. and perhaps 1995). insula) are im. 1980). vocalization is less frequently preferentially active for perception of complex tones. Starkstein. However. known for its role in vocalization. where motor neurons controlling laryngeal is a subsequent stage in the execution of vocalization. Further 1994). it is necessary nonpropositional speech (e. The specific pattern of activation or suppression research is necessary to determine whether the opercular is determined by descending inputs from the ACG cortex alone or deeper structures (e. The perisylvian cortex also includes the right partial mutism. utilizing excitatory amino acid transmit- 1995). 1999. Berthier. respiratory. damaged bilaterally or when the damage extends deep 1994). a short time delay (13 ms) between stimulation of the and Jürgens. control of the voice by self-monitoring auditory feed- aphonia may arise from widespread damage. 1996). and recov. and the e¤ect is usually temporary. back (Perry et al. Speech and vocalization fall into these categories. and von Cramon. or psychogenic etiology (Sapir and Aronson. 1991.. singing. along with sensory feedback from the .g. The perisylvian the correct sequencing of motor acts (Picard and Strick. The other widely studied limbic system structure tional.. 1994). systems in primates suggest that the SMA is involved in The perisylvian cortex may control vocalization by selection and initiation of a remembered motor act or one or more pathways to the medulla. ery following therapy may suggest a di¤use. PAG neurons. 1996) and findings of increased blood flow in species-specific vocalization (Larson. to know whether mutism results from psychogenic or tively una¤ected (Brown. a¤ected than speech articulation or language (Du¤y. These neuro- The ACG is also connected with the perisylvian anatomical projections are supported by observations of cortex of the left hemisphere (Müller-Preuss. perception of one’s own voice. motiva.. is the midbrain peri- 1987). Studies of other motor physiological mechanisms. Damage to Broca’s area may cause total or Lou.60 Part I: Voice Figure 1. an area important for speech and cortex and excitation of laryngeal muscles (Ludlow and language. 1999). 1988. Jürgens. muscles are located (Kuypers..

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In J. sensory and motor components of the vagus complex in the 2197–2201. (1987). Brain Research.. Larson. Brain Research. J. (1997). Clinical voice disorders. In O. Projections from the ‘‘cingular’’ vocalization area in the squirrel monkey. M. and Lim.). H. R.. Park. Larson. Neural correlates of audio-vocal be. and Meyer. and Jürgens. In J. 116. Neuronal Davis. D. 71. Abbs mesial cortex related to faciovocal behavior in the awake (Eds. 8.. Unpublished doctoral dissertation. C. (1980). T. 35. L. The physiological control of search. R. rology. On the location and size of activity in the medulla oblongata during vocalization: A laryngeal motoneurons in the cat and rabbit. 157–222). and O’Leary. impairment of phonation: A case study. Whitaker and H. Experimental Brain Kirzinger.. The limbic system in human com- right insular lesion: A clinicopathological study. (1982).. Journal of Neurophysiology. Journal of single-unit recording study in the squirrel monkey. New York: Raven Press.. 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. That is. 423–425. corresponding to the discontinuity in Figure 1. (1951).e. The amplitudes of the harmonics at high fre. defined as the ratio Um ( f )=Us ( f ). In the time domain (Fig. then passes will cause the vocal folds to vibrate. in the frequency domain (Fig. For modal vocal fold 4pr vibration. the vocal tract transfer function Voice Acoustics T( f ). (1991). 1). in most cases it chiatry. is an all-pole transfer function. K. The cingular gyrus: Area 24. depicted in Figure 2. and during an utterance the shape For the ideal or modal volume-velocity waveform can be modified depending on the position within the (Fig. into the vocal tract from the glottis. Role of the right tem. vary with the speaker. . a put sound pressure can be considered to be the result of change in frequency is represented in the number of filtering Us0 (t) by the vocal tract transfer function T( f ). Thus we have between the pulses. J. 7.. and Jürgens.. jpr ( f )j ¼ jUs ( f )  2pf j jT( f )j  : (3) quencies decrease as 1= f 2 . Voice Acoustics 63 Penfield. 2403–2417. The frequency of this source The expression jUs ( f )  2pf j is the magnitude of the waveform varies from one individual to another and Fourier transform of the derivative Us0 (t). 13–23. a positive pressure below the glottis tion where the waveform is first positive. U. and the output sound pressure at a distance r poral neocortex in retention of pitch in auditory short-term from the lips is pr (t). Neurosciences and Biobehavior Review. During the open and (2) a second portion where the waveform returns phase of the cycle. 289–317. The supplementary motor is usually large compared with the impedance looking area of the cerebral cortex. and Lin. 1). D. 1985). Archives of Neurology and Psy. A. vibration. The sound pressure pr is related to Um by a radiation characteristic R( f ). the volume velocity is zero in the time interval where r ¼ density of air. The anterior cingu. at 4pr about 12 dB per octave. as Neurophysiology. Thus the out- within an utterance. pulses per second. A. 1B). Brain. velocity source that produces similar glottal pulses for late cortex and the phonatory control in monkey and man. 11. (1983). di¤erent vocal tract configurations. is reasonable to represent the glottal source as a volume- von Cramon. R. components of Us ( f ) and pr ( f ) are shown below the corresponding waveforms in Figure 2. 114. 1A). and then reaches a maximum negative value. through zero (corresponding to the peak of the pulse sectional area of the glottis changes during a cycle of in Fig. Ward. and Welch. Um (t). As the cross. the derivative Us0 (t) frequency is represented by the spacing between the can be viewed as the e¤ective excitation of the vocal harmonics. The volume velocity at the lips is Zatorre. the impedance of the glottal opening abruptly to zero. (1948). Journal of This source Us (t) is filtered by the vocal tract. The magnitudes of the spectral memory. i. The magnitude of this The basic acoustic source during normal phonation is radiation characteristic is approximately a waveform consisting of a quasi-periodic sequence of r  2pf pulses of volume velocity Us (t) that pass between the jR( f )j ¼ . W. the multiplied by a constant. The periodic nature of this waveform The magnitude of pr ( f ) can be written as is reflected in the harmonic structure of the spectrum r (Fig. S. where f ¼ frequency. (Fant. this derivative has the form shown in Figure 3A utterance and the prominence of the syllable. When a non- nasal vowel is produced. 66. B. 1A). (1) vibrating vocal folds (Fig. The shape of the individual pulses can also tract. and there is a relatively abrupt dis- continuity in slope at the time the volume velocity pr ( f ) ¼ Us ( f )  T( f )  R( f ): (2) decreases to zero. Liljencrants. Spectrum of waveform in A.. the airflow is modulated. Thus. A. Idealized waveform of glottal volume velocity Us (t) for modal vocal fold vibration for an adult male speaker. 1B). and Samson. Each pulse has a When the position and tension of the vocal folds are sequence of two components: (1) an initial smooth por- properly adjusted.

The principal acoustic excitation of 1963. folds come together. 1964. 1994. the vocal tract occurs at the time of this discontinuity. cartilaginous portions of the vocal folds relative to the trum (Fig.. One obvious attribute is glottis is never completely closed during a cycle of vi- the frequency f 0 of the glottal pulses. 1983). which is controlled bration. 1989). 3B) at high frequencies decreases as 1= f . particularly when the folds are relatively slack Us0 (t) is that the maximum negative value is reduced (Titze. Isshiki. Increasing or decreasing the subglottal (that is.) slope of the original waveform Us (t) at the time the vocal increases roughly as Ps3/2 (Ladefoged and McKinney. At the right is the waveform pr (t) and spectrum pr ( f ) of the sound pres- sure. B.e. or. vocal tract and the overall amplitude of the output are tude of the glottal pulses. in the decreased. there is continuing airflow through- magnitude of the discontinuity in slope at the time of out the cycle. Changes in the configuration of the membranous and For this ideal or modal derivative waveform. (Adapted with permission from Stevens. Second. Schema showing how the acoustic source at the glottis is fil- tered by the vocal tract to yield a volume velocity Um (t) at the lips. primarily by changing the tension of the vocal folds. Spectrum of wave- form in A. The magnitude of the glottal excitation supraglottal airways prevents the occurrence of the Figure 3. At the left of the figure both the source waveform Us (t) and its spectrum Us ( f ) are shown. Tanaka and Gould. modal configuration can lead to changes in the wave- at 6 dB/octave. A. the e¤ect on the derivative waveform quency.64 Part I: Voice Figure 2. form and spectrum of the glottal source. Derivative Us0 (t) of the modal volume-velocity waveform in Figure 1. which is radiated to obtain the sound pressure pr (t) at some distance from the lips. i. the speed with which the vocal folds approach the although the subglottal pressure also influences the fre. The inertia of the air in the glottis and glottal closure. it is less negative). midline is reduced. reflecting the discontinuity at closure. the vocal folds in which the glottal waveform can di¤er from the modal and arytenoid cartilages are configured such that the waveform (or its derivative). introducing several acoustic consequences. . the excitation of the pressure Ps causes increases or decreases in the ampli. For some For normal speech production. First. Thus. the spec. more specifically. there are several ways speakers and for some styles of speaking.

there is a non-zero return phase following ure 5A shows estimated spectra of the periodic and noise the maximum negative peak. causing a reduction in A1. the noise source has a spectrum that tilts upward with abrupt discontinuity in Us0 (t) that occurs at the time of increasing frequency. in the high-frequency spectrum amplitude of Us0 (t) rela. The corresponding waveform tion with a more abducted glottis of the type represented Us (t) is shown below the waveform Us0 (t). The spectral in Figure 4 leads to greater noise energy and reduced consequence of this non-zero return phase is a reduction high-frequency amplitude of the periodic component. At low frequencies. around 2–4 kHz (Stevens. there is an aspiration noise source with a contin- uous spectrum (Klatt and Klatt. 1985). A third component at high frequencies (Fig. the noise source is also modulated. It appears to have a broad peak at vocal fold closure in modal phonation (Rothenberg. components that would occur during modal phonation. the individual harmonics correspond- tion is an increased loss of acoustic energy from the ing to the periodic component may be obscured by the vocal tract through the partially open glottis and into noise component at high frequencies. the subglottal airways. With breathy- consequence of a somewhat abducted glottal configura. 1998). Still another consequence of glottal vibration with a partially open glottis is that there is increased average airflow through the glottis. 5B). voiced phonation. This increased flow causes an increased amplitude of noise generated by turbulence in the vicin- ity of the glottis. Schematized representation of spectra of the e¤ec. The spectrum of the noise is calculated with a modal vibration (A) and breathy voicing (B). apparent in the first formant range and results in an Figure 6 shows spectra of a vowel produced by a increased bandwidth of F1. Phona- schematized in Figure 4. and the noise component may dominate the periodic tive to the low-frequency spectrum amplitude. Thus. in addition to the quasi-periodic source. The three consequences just described lead to a vowel for which the spectrum ampli- tude A1 in the F1 range is reduced and the amplitudes of the spectral prominences due to higher formants are reduced relative to A1. as shown in the Us (t) wave- form in Figure 4. the periodic component is represented by the amplitudes of tive periodic and noise components of the glottal source for the harmonics. the harmonics are well defined. The spectrum of bandwidth of about 300 Hz. This type of phonation Figure 4. 1990). This energy loss a¤ects the vocal however. since the noise tract filter rather than the source waveform. ally returns to zero (Fant.’’ form Us (t) and its derivative Us0 (t) when the glottis is never The aspiration noise source can be represented as an completely closed within a cycle of vibration. 1997). Liljencrants. and is generated The derivative waveform Us0 (t) then has a shape that is only during the open phase of glottal vibration. . Fig- 1981). Schematized representation of volume velocity wave. Since the flow is modulated by the periodic fluctuation in glottal area. It is most component is weak in this frequency region. Rather. equivalent acoustic volume-velocity source that is added to the periodic source. high frequencies. during which Us0 (t) gradu. In contrast to the periodic source. has been called ‘‘breathy-voiced. Voice Acoustics 65 spectrum (Hanson. speaker with modal glottal vibration (A) and the same the amplitude of the first-formant prominence in the vowel produced by a speaker with a somewhat abducted Figure 5. The noise component is relatively weak. and Lin.

threshold pressure) increases. The spectra are from Hanson and Chuang of 600 Hz. during phonation. pressed frequency F3. B. Below the spec. 1990). speaker with approximately modal phonation. The waveforms below are as described in A. phonation-threshold pressure increases. As the vocal folds are adducted. with a bandwidth glottal pulses. vowel are evident. Therefore. These di¤erences lead to significant . See text. Comparison of the two spectra in Figure 6 The above description of the glottal vibration pattern also shows the greater spectrum tilt and the reduced for various degrees of glottal abduction and adduction prominence of the first formant peak associated with suggests that there is an optimum glottal width that an abducted glottis. (1998). quencies during phonation by a speaker with a breathy and may occur aperiodically (glottalization). The noise is also evident tion. in which the glottal pulses are nar- used to highlight the presence of noise at high fre. Spectrum of the vowel /e/ produced by a glottis (B). The noise in the trum are waveforms of this vowel before and after being fil.66 Part I: Voice Figure 6. 2002). rower and of lower amplitude than in modal phonation. This optimum configuration has been pressure required to maintain vibration (phonation examined experimentally by Verdolini et al. Below the spectra are waveforms of the vowel Adduction of the vocal folds relative to their modal before and after being filtered by a broad bandpass filter configuration can also lead to changes in the source (bandwidth of 600 Hz) centered on the third-formant waveform. for a given There are substantial individual and sex di¤erences in subglottal pressure an increase in the glottal area can the degree to which the folds are abducted or adducted lead to cessation of vocalfold vibration. A. the transglottal Stevens. waveform in the F3 region (and above) obscures the individual tered with a bandpass filter centered on F3. as already noted. Filtered waveforms of this type have been voicing occurs. Spectrum of the vowel /e/ produced by a male male speaker who apparently phonated with a glottal chink. Figure 6B. In addi- voice (Klatt and Klatt. The individual glottal pulses as filtered by F3 of the (1999). eventually in the spectrum at high frequencies for the speaker of reaching a point where the folds no longer vibrate. gives rise to a maximum in sound energy (Hanson and As the average glottal area increases.

G. synthesis. B.. istics of male speakers: Acoustic correlates and comparison there is airflow through the glottis. Note the substantial ranges of reflect the interactions between laryngeal anatomy and 20 dB or more within each sex. 1999). D. R. Q. sound reduction of the high-frequency spectrum relative to the low. Journal of the Acoustical Society of America.. 305–323). Regulatory mechanism of voice intensity variation. in H1 due to the possible influence of the first formant. M. One Society of America. J. Klatt. M.. 101. source. (1997). 1–13. Relationships between Hanson and Chuang. normal. Speech Transmission Lab. there is zero airflow. 4. 1999. Stevens and Helen M. M.) Stevens. A quasiarticulatory approach to controlling acoustic source parameters in a Klatt-type formant synthesizer using HLsyn. a measure that reflects the Ladefoged. H. San Diego. S.. E. and in A3 due to the influence of the frequencies of the Voice Disorders in Children first and second formants. (2002). (Vg) is an excellent indicator of whether the vocal Hanson. the amplitude of the third-formant spectrum promi. airflow through the glottis ciety of America. pressure. Laryngeal adduction in resonant voice. J. N. 1158–1182. Liljencrants. Cambridge. 85. 820–857. Glottal characteristics of female speakers: Acoustic correlates. S. other physiological events held constant.) Distributions of values of H1*-A3* are given in Figure 7 for a population of 22 female and 21 male speakers. Journal of the frequency spectrum. Glottal airflow and transglottal air pressure measurements for male and female speakers in soft. 106. 17– 29. Analysis. P. Airflow (rate of air movement or velocity) and air oratory Quarterly Progress and Status Report. Vocal fold physiology (pp. (1990). For Hanson. Investigations of voice using aerodynamic techniques pear to have a greater spectrum tilt on average. MIT Press. and when the vocal with female data. Voice Disorders in Children 67 Hanson. and Lin. H. but References careful control of stimuli and a good knowledge of laryngeal physiology make airflow and air pressure Fant. Hanson not always have a one-to-one correspondence with vocal tract physiology in a dynamic biological system. Similar observations have vocal intensity and noninvasively obtained aerodynamic also been made by Holmberg... In F.). (1998).. (1963). Tokyo: and A3. and Gould. 12. (Adapted with permission University of Tokyo Press. Glottal character. 7. 73. R. cal tract are good reflectors of vocal physiology. M. MA: of vowels generated by these sources (Hanson. Journal of the Acoustical Society of America. K. 1094–1077. 511– 529. and Perkell parameters in normal subjects. 112. A four.. Aerodynamic events do —Kenneth N. at a simple level. parameter model of glottal flow. Holmberg. Stevens and M. (1999). and loud voice. 84. N. Distributions of H1*-A3*. Investigators ing a somewhat less abrupt glottal closure during a cycle realized early on that voice production is an aero- and a greater tendency for lack of complete closure mechanical event and that vocal tract aerodynamics throughout the cycle. N. J.. When the vocal folds are open. Loudness. I. (1983). Journal of nence. Journal of the frequency spectrum amplitude is the di¤erence H1*-A3* Acoustical Society of America. 901–912. and subglottal pressure in speech. and consequently in the spectral characteristics Stevens. S. (1989). Palmer. acoustic measure that reflects the reduction of the Titze.). have been reported for more than 30 years. Acoustic phonetics. 315–327. (1985). and Chuang. and Stevens. Scientific substrates of speech produc- tion. H. D. Journal of the Acoustical (1988) using di¤erent measurement techniques. and Perkell. The female speakers ap. (The asterisks indicate that corrections are made Voice. 399–437). and perception of voice quality variations among female and male talkers. D. the amount of . Hillman.. (1981). 1316–1321. K. With America.. and Samawi. Journal of the Acoustical Society of America. N. (in dB) between the amplitude of the first harmonic and Verdolini. G. measurements invaluable tools. 454–460. Journal of the Acoustical So- example. In K. 35. 466–481. Tanaka. for male (black bars) and female (gray Acoustical Society of America. C. Introduction to communica- tion sciences and disorders (pp. CA: di¤erences in the waveform and spectrum of the glottal Singular Publishing Group. P. L. E. 1997. Journal of Speech and Hearing Research. Acoustic interaction between the glot- A3 is the amplitude of the strongest harmonic in the F3 peak. K. folds are open or closed. W. P. (1994). N. and fundamental frequency in phonation. bars) speakers. M. N. Drucker. Isshiki. Figure 7.. suggest. from Hanson and Chuang. complex physiological events. tal source and the vocal tract. G. H1 is the amplitude of the first harmonic and Rothenberg. (1998). and Klatt. H. Minifie (Ed. E. (1988). pressure (force per unit area of air molecules) in the vo- Stockholm: Royal Institute of Technology. Journal of the Acoustical Society of folds are completely closed. Hillman. and McKinney. (1964). K. H. as described in the text. 87. The asterisks indicate that corrections have been applied to H1 Hirano (Eds. On the relation between subglottal pressure high-frequency spectrum amplitude relative to the low.

subglottal pressure will decrease when the opening and closing of the vocal folds. Leden. V ¼ voltage. per- pressure (P) in a closed volume (V) of air must equal a mitting detailed. 1986). Rothenberg’s procedure allowed size of the subglottal air cavity. the amplitude of vibration. children produce lower average estimation of Rlaw o¤ers a more general interpretation airflow than adults. 1982. and laryngeal and articulatory config. and Perkell. Estimated laryngeal airway resistance: Calculated children tend to speak at a higher SPL than adults. di¤erent average airflow values as a function of age Measures made using the Smitheran and Hixon and sex. (Lofqvist. children’s airways are smaller and less compliant mated laryngeal airflow. and I ¼ current. The ing voice production. 1978. Measures of flow and pressure were for contributing to changes in fundamental frequency— used to reflect laryngeal and respiratory function. Assuming that pressure is the same across all (1981) technique include the following: speakers. Beckett. the time it takes for the vocal folds to close. vocal cords) is divided by the period of the glottal (2) prevocalic compared to postvocalic consonants. Subglottal air pressure is of primary im- duction in children (Subtelny. Hillman. 1977). geal airflow. with glottal resistance glottal opening during the closed part of the cycle. and supraglottal areas substantially counteract the po. 1986). von uration. way resistance (Rlaw) through noninvasive procedures A small number of classic studies used average air. duce higher intraoral air pressures than adults. 1967. and Kitzing. R ¼ P=V. Other intraoral air pressure distinctions in chil. and Moore (1958). and (4) stops waveform are taken at a point equal to 20% of alter- compared to fricatives. Intraoral air pressure: Measured peak pressure dur- because they tend to speak at higher sound pressure ing the voiceless [p] to obtain an estimate of sub- levels (SPLs). especially 2. A simplified version of derivation of the glottal airflow waveform. First. Speed quotient: The speed quotient is determined as techniques relative to voice production were developed the time it takes for the vocal folds to open divided by that stimulated new ways of analyzing children’s aero. The open time of the vocal dren are similar to the overall trends described for adult folds (defined as the interval of time between the pressures. 3. Opening and closing instants on the airflow stressed compared to unstressed syllables. Smitheran and flow and intraoral air pressure to investigate voice pro. Stathopoulos and is also important for controlling sound pressure level and Weismer. all factors essential for normal voice production. the original open quotient defined by Timcke. that is. and Sakuda.68 Part I: Voice airflow can be an excellent indicator of the degree of dynamic vocal function. quantifiable analysis of vocal fold constant (K). filtering of the easily accessible oral airflow signal Subglottal air pressure directly reflects changes in the (Rothenberg. Subglottal pressure 1972. K ¼ PV. waveform important to vocal fold physiology include the Children were found to be capable of maintaining the following (Holmberg. nating airflow (OQ-20%). 1967. two important aerodynamic 2. R ¼ laryngeal airway resistance. and boys tend to produce higher of laryngeal dynamics and can be used as a screening average airflow than girls of the same age. Like adults. on analogy with Olm’s law. Worth. portance. V ¼ of oral airflow. Hixon. The findings related to vowel /A/ at midpoint to obtain an estimate of laryn- intraoral air pressure have indicated that children pro. the closed time of size of the lungs is made larger. 1988): same linguistic contrasts as adults through manipula- tion of physiological events such as lung cavity size and 1. and the degree of controlling the size of the rib cage. the overall pressure are mainly regulated through muscular forces shape of the vibratory waveform. This calculation is based than adults’ (Stathopoulos and Weismer. (3) cycle. Opening . it would appear that the greater peak intraoral air resistance. tentially large flows resulting from their high intraoral Measures made using the derived glottal airflow air pressures. and by dividing the estimated subglottal pressure by esti- second. Carlborg. Subglottal air pressure physiology. Diggs. 1981). The derived Boyle’s law predicts the relationship in that a particular volume velocity waveform provides airflow values. In the 1970s and 1980s. It is likely that children’s smaller glottal subglottal pressure (P). Bernthal and Beukelman. Theolke and Cowan. pressure that drives the vocal folds). Airflow open quotient: This measure is comparable to driving pressure. ume velocity waveform can be related to the speed of conversely. Intu. because it is responsible for generating the Arkebauer. Hixon. 1966. R ¼ V=I. versus adults reflect two physiological events. The measures made from the derived vol- will increase when the size of the lungs is decreased. and I ¼ laryngeal airflow (V). Average oral air flow: Measured during the open restricted or lower flow of air. The first technique was inverse opening between the vocal folds. In the pressure in children should lead to a greater magnitude speech system. Dur. Thus. Van Hattum and pressure di¤erential causing vocal fold vibration (the Worth. Supraglottal measure to quantify values outside normal ranges of and glottal airway opening most likely account for the vocal function. or glottal flow used to help increase or decrease the The second aerodynamic technique developed was for pressures (the glottis can be viewed as a valve that helps the estimation of subglottal pressure and laryngeal air- regulate pulmonary flows and pressures). 1971. where R ¼ itively. and Hardy. children produce higher pressures instant of opening and the instant of closing of the during (1) voiceless compared to voiced consonants. The higher pressures produced by children glottal pressure. Changes in subglottal air the vocal folds. a smaller supraglottal or glottal opening yields a higher resistance at the constriction and therefore a 1.

After that age. One of the striking features younger children and women during vowel production that emerge from the aerodynamic data is the change in for the high SPLs (Fig. Di¤erentiating the airflow waveform and then identi- fying the greatest negative peak on di¤erentiated waveform locates the fastest declination. Their MFDRs range from about 250 cc/s/s for com- cussed the data relative to developmental anatomical fortable levels of SPL to about 1200 cc/s/s for quite high data (Stathopoulos. Anatomical di¤erences in the upper and part of the cycle. Sound pressure level: This measure is obtained at the vocal intensity increases. Because the ana. 1988). From these cross-sectional SPLs. This measure reflects the amplitude of vibra- tion and can reflect the glottal area during vibratory Figure 1. Fundamental frequency: This measure is obtained Airflow open quotient (OQ-20%): Open quotient has from the inverse-filtered waveform by means of a traditionally been very closely correlated with SPL. It is notable that the younger children and women produce higher OQ-20%. 4). The increased airway resistance in children Additional measures important to vocal fold physiol. MFDR increases as SPL data as a function of children’s ages. could substantially increase tracheal pressures (Muller ogy include the following: and Brown. As seen in Figures 2A and 2B. 2000). 3). the quency of the vocal folds and corresponds perceptu. sound pressure level. lower airway will a¤ect the aerodynamic output of the vocal tract. Alternating glottal airflow: This measure is calculated by taking the glottal airflow maximum minus mini- mum. 4. Many of the measures listed above Maximum flow declination rate (MFDR): Children have been used to derive vocal physiology. Stathopoulos and adults regulate their airflow shut-o¤ through a and Sapienza (1997) empirically explored applying ob. closed for a longer proportion of the vibratory cycle as 7. adults. It is the lowest vibrating fre. open quotient decreases. quotients for higher SPLs. We can interpret the flow function at 14 years of age for boys. and all speakers vibrating vocal folds. make their voices sound ‘‘normal. it is widely believed that as SPL increases. It is indicative of airflow leak due to glottal opening during the closed SPLs (Fig. The data are discussed in relation to men and boys increase their amplitude of vibration dur- their physiological implications. hence the higher alternating glottal produce higher pressures when they produce higher airflows for adults. 3. corresponds physically to vocal intensity and percep. physiological. jective voice measures to children’s productions and dis. midpoint of the vowel from a microphone signal and which show data from a wide age span and both sexes. regardless of vocal components and from the complex coordination of these intensity. and neurological the cycle than in men and older boys. a¤ects the acoustic waveform by emphasizing the high- tomical structure in children is constantly growing and frequency components of the acoustic source spectra changing. biological systems. children continually alter their movements to (Titze. 5. a clearer picture of increases (Fig. only adults and older teenagers produce lower open tually to loudness. In peak-picking program. Maximum flow declination rate: The measure is obtained during the closing portion of the vocal fold cycle and reflects the fastest rate of airflow shut-o¤. That is. Voice Disorders in Children 69 and closing instants on the waveform are taken at a point equal to 20% of alternating air flow. The mea- sure reflects how fast the vocal folds are opening and closing and the asymmetry of the opening and closing phases. Increasing MFDR as SPL increases child vocal physiology has emerged. Estimated subglottal pressure: Children produce Greater SPLs result in greater lateral excursion of the higher subglottal pressures than adults. 1). Estimated subglottal pressure as a function of age and cycle. The flow measure corresponds to how fast the vocal folds are closing. and physiologically. while women and alternating glottal airflows because of their larger laryn- children seem to have more in common aerodynamically geal structures and greater glottal areas. Additionally. the vocal folds remain ally to pitch.’’ Figures 1 through 7 Alternating glottal airflow: Fourteen-year-old boys show cross-sectional vocal aerodynamic data obtained in and men produce higher alternating glottal airflows than children ages 4–14 years. 1980). Younger children also increase their . 6. ing the high SPLs more than women and children do. combination of laryngeal and respiratory strategies. Minimum flow: This measure is calculated by sub- tracting minimum flow from zero. In children and adults. indicating Voice production arises from a multidimensional that the vocal folds are open for a longer proportion of system of anatomical. boys data to indicate that older boys and men produce higher and men functionally group together.

The interpretation is somewhat complicated by the fact that younger children and women have a shorter vocal fold length and smaller area (Flanagan. acterized by a smaller e¤ective vibrating mass. An interesting result pre- dicted by Titze’s (1988) modeling data is that the 4. Laryngeal airway resistance: Children produce voice with higher Rlaw than 14-year-olds and adults. B. thereby limiting airflow through the glottis. B. Changes in fundamental frequency are more easily e¤ected by Figure 3. as in young children ages 4–6 years. A. increasing tracheal pressure when the vocal fold is char- tion of age.and 6-year-olds produce unusually high f0 values when they increase their SPL to high levels (Fig. Maximum flow declination rate (MFDR) as a func. 1958). Airflow open quotient as a function of age and sound pres- sure level. amplitude of vibration when they increase their SPL. Figure 4. and we would assume an increase in the alternating flow values. sex. Fundamental frequency: As expected. A. Since Rlaw is calculated by dividing subglottal .70 Part I: Voice Figure 2. older boys and men produce lower fundamental frequencies than women and younger children. Alternating glottal airflow as a function of age and sound pressure level. Alternating glottal airflow as a function of age and sex. 6). and sound pressure level. Airflow open quotient as a function of age and sex. and all speakers increase their Rlaw when increasing their SPL (Fig. 5).

. 7). C. See also instrumental assessment of children’s voice. 10. J. 21. L. 84.and sex-appropriate aerodynamic. J. 511– primary factor a¤ecting children’s vocal physiology is 529. (1958). acoustic. whereas larynges in teenage girls plateau and approximate the size of adult female larynges (Fig. 1. L.. since the average glottal airflow is the same across Beckett.. and Kitzing. Lafayette. and Cowan.. (1967). and Perkell. children and adults alike source. crease clearly indicates that Rlaw must be increasing. make a compelling argument that the Journal of the Acoustical Society of America. C. 196–208. 13–17. The fact that subglottal youths. A general scan of Lofqvist. J. male larynges continue to in- crease in size to approximate the size of adult male larynges. and Hardy. A. Stathopoulos Figure 6. R. (1971). P. (1972). Indiana. Glot- important variables of subglottal pressure and SPL. H. Peak pressure by laryngeal airflow. that glottal airflow will increase when Bernthal. the shape and configuration of the consonants: A normative study of children. Hearing Research.. D. Journal of Speech and Hearing Disorders. M. In sum. the constant airflow in the setting of increasing sub. Intraoral air pressure for selected English Physiologically. (1982). 361–371. Initial vali- the cross-sectional data discussed here shows a change in dation of an indirect measure of subglottal pressure . Intraoral air subglottal air pressure increases if laryngeal configura. sure. the size of their laryngeal structure. ular the flow data. B. Diggs. tion/resistance is held constant. British Journal of Disorders in Communication. It is not merely coinci- dental that at 14 years.. Unpublished laryngeal airway must be decreasing in size to maintain master’s thesis. Carlborg.. and adults. C. Figure 7. and sound pressure level. A basic assumption needs to be discussed Normative study of airflow in children. age groups. E. sex. (1978). vocal function at age 14 in boys. and in partic. Regardless of whether it is size or other anatomical fac- tors a¤ecting vocal function. Fundamental frequency as a function of age. the high Rlaw for high intraoral air pressure during speech. 6. W. J. Length of vocal fold as a function of age and sex. Flanagan. here. —Elaine T. Voice Disorders in Children 71 Figure 5. Journal of Speech and SPL is largely due to higher values of subglottal pres. Purdue University. R. R. Some properties of the glottal sound glottal pressures. tal airflow and transglottal air pressure measurements for The cross-sectional aerodynamic data. E. B. pressure during the production of /p/ and /b/ by children. Hixon. and physiological models of normal voice need to be referred to for the diagnosis and remediation of voice disorders. Age. Journal of Speech and Hearing Research. References Arkebauer. J. Hillman. and Beukelman. male and female speakers in soft. A. and that is. Theolke. (1988). 99– continually modify their glottal airway to control the 116. and loud voice. normal.. pressure increases for high SPLs but flow does not in. Holmberg. B.. L. it is clear that use of an adult male model for depicting normal vocal function is inappropriate for children. Laryngeal airway resistance as a function of age and sound pressure level. T. J.

air pressure and rate of flow during speech. and essential functions (pp. and epithelial thickening is a normal accompaniment of A number of pathological conditions that a¤ect voice aging in some individuals. Regulation of vocal power and e‰ciency by fatigue and improve speech phrasing.. M. E. Woo et al. Alzheimer’s disease. and diplophonia. D. 2001). 1992). peripheral paralysis. International Symposium. since prescription Stathopoulos. 4. H. In addition. 1–19. Elderly patients often exhibit neurological voice dis- holm. Gen- Language. tongue. AMA increasing vocal fold adductory force to facilitate closure Archives of Otolaryngology. M. which occurs infrequently (Morri- 152–159. Variations in the and endocrine disorders (Morrison and Gore-Hickman. 1992). Airflow rates in orders involves attention to specific deficits in vocal fold normal speakers. H. although more search and Practice. including Reineke’s edema. 40. and Hearing Research. elderly persons are at increased risk for laryngeal side search. (Leon et al. Indeed. (2000). 2001). and Weismer. 155–176. Speech and Language Advance in Basic Re- neck occasionally occurs late in life. However. (1958). advanced age. 46.. Although the etiology of (Hagen. diaphragm. Estimates Stathopoulos. augmentative communication elderly persons can result from normal age-related strategies might be used. instability of vibra- tion. prevalent in the elderly. A clinical method tors related to a voice disorder are more common in for estimating laryngeal airway resistance during vowel elderly patients than in younger adults. speech prosody. In O. strobo. particularly in later stages of old age. a thorough med. Zeitels et al. supraglottal air pressure waveform and their articulatory 1986. New York: Raven Press. Oral airflow associated with disease processes associated with aging and air pressure during speech production: A comparative (such as lung neoplasm). T. Therefore. Some degree of edema et al. In P. abdo- men. 1992). Symp- Subtelny. Voice Speech and Hearing Research. and vocal abuse/misuse detect abnormalities of mucosal wave and amplitude of have been mentioned as possible causal factors (Kouf- vocal fold vibration that a¤ect voice production (Woo man. production. Journal of Speech. youths. The specific site of the edema is the superficial pathological processes a¤ecting voice in elderly patients layer of the lamina propria. Treatment may focus on vocal fold movement patterns. a number of investigators have concluded that polypoid degeneration. Journal of reduced loudness.. tral neurological disorders such as stroke. Sweden: KTH Voice Research Centre. function such as positioning deficits. Measurement of airflow in speech. Rothenberg. benign lesions. 1992). von Leden. Language.. In some cases. Cleft Palate Journal. Stock. H. Journal of Acoustical Society of America. 37. Intraoral toms of peripheral paralysis include glottic insu‰ciency. 138–146. Voice disorders a¿ict up to 12% of the elderly pop. J. 20. and Hearing Re. White (Ed. and Brown. trauma. cigarette smoking.. J. T. Reineke’s edema and polypoid degeneration is uncer- scopic examination of the vocal folds is recommended to tain. elderly dysphonic patients range from 7% to 21%. 227–238). (1997). Colton. (1986). commonly it is diagnosed between the ages of 50 and 70 Journal of Speech and Hearing Research. or speech intel- ulation (Shindo and Hanson. Journal of Speech. The reason why women are at are prevalent in the elderly population simply because of greater risk than men for developing pathological epi- .). After age 60. and Parkinson’s disease. R. 9. jaw. Child voice. and Sapienza. Devel- opmental changes in laryngeal and respiratory function of the incidence of peripheral laryngeal nerve damage in with variations in sound pressure level. cen- subglottal pressure and glottal width. Casper. Vocal fold physiology: Voice production. commonly in women and are characterized by chronic.. E. 1997).. J. Worth. E. di¤use edema extending along the entire length of the ical examination and history are required to rule out vocal fold. son and Gore-Hickman. Carcinoma of the head and interpretation. E. and Hixon. P. Woo et al. S. and rib cage may also be compromised and may Voice Disorders of Aging require treatment. and incoordination of movements. J. G. 72. Woo et al. R. R. In addition. and Worth. Lyons. focal dystonia. e¤ects from pharmacological agents.. 1986. 1996). Interestingly. (1967). 137–147. orders. Folia Phoniatrica. Woo. (1966). (1981).72 Part I: Voice during vowels. and adults. M. Muller. multiple etiologic fac- Smitheran. Such conditions include neurological dis- 633–635. 1992). T. A review of the development of the and nonprescription drugs are used disproportionately child voice: An anatomical and functional perspective. T. W. R. J. postural changes. Functioning of the velopharynx. (1988). lips.. Voice disorders in ligibility. orders. 1998). J. and Moore.. by the elderly (Linville. Laryn- geal vibrations: Measurements of the glottic wave. reflux. tremor also occur frequently. and Brewer.... A variety of benign vocal lesions are particularly thology and normal age-related changes can be di‰cult. as opposed to idiopathic study of children. Treatment for central dis- Van Hattum. and Nuss.. inflammatory processes. coordination of respiratory and phonatory systems. mechanisms. or medical treatment may be changes in the voice production mechanism or from combined with speech or voice therapy to improve out- pathological conditions separate from normal aging comes (Ramig and Scherer. (Linville. 498–515. breathiness.. C. I. Fujimura (Ed. 1986. 1986. (1977). unilateral sessile polyp. therapy for peripheral paralysis frequently involves Timcke. and Sakuda. erally. 4. 1992). 68. (1980). of the glottis and improving breath support to minimize Titze.). peripheral paralysis in the elderly tends to be Stathopoulos. M. 595–614. 318–389. distinguishing between pa. and be- the vast majority of elderly patients with voice disorders nign epithelial lesions with variable dysplastic changes su¤er from a disease process associated with aging rather (Morrison and Gore-Hickman. respiratory support. 1995. velopharyngeal closure. 1990). than from a disorder involving physiological aging alone Reineke’s edema and polypoid degeneration occur more (Morrison and Gore-Hickman.

Vocal impact of normal age-related changes in both the pul- fold scarring may be present as a consequence of previ. However. or age-related pitch lowering that accompanies vocal fold from neuropathic disturbances resulting from diabetes thickening and edema (Linville. 1998. The incidence of functional hypertensive dysphonia Lifestyle factors and variability among elderly among elderly speakers is disputed. and Schneider.. by a lifestyle that includes exercise. 2001). that elderly e¤ects of aging on the voice. Physical conditioning programs that include aerobic ex- ent for a longer time in the elderly in comparison with ercise often are recommended for aging professional younger adults. or from other traumatic vocal fold injuries. Satalo¤. enhanced These conditions might arise as a consequence of smok. and Nuss. elderly speakers is reduced by controlling for a speaker’s tion that is reported to occur with greater frequency in physiological condition (Ramig and Ringel. Francis and Wartofsky. 2001). al. nerve conduction velocity. Lifestyle factors can either postpone or exacerbate the 1992). high laryngeal position. 2001). Voice Disorders of Aging 73 thelial changes as they age is unknown. Trauma might manifest as granuloma or scar tissue from The e¤ects of smoking coexist with changes related to previous surgical procedures requiring general anesthe.g. 1992. varies both within and across elderly individuals (Finch Inflammatory conditions such as pachydermia. increased risk for traumatic injury to the vocal folds. on the larynx and alters laryngeal function. physiological. although di¤er.. even if the procedure is uncomplicated (e. Kahane and 1993. Secretion disorders of the thyroid (both speaker’s voice (Linville. nerve. the elderly (Richter. Pulmonary disease and hypertensive cardiac disease roidectomy. and cigarette smoking. however. and/or of decline in motor and sensory performance with aging anteroposterior laryngeal compression. 1992). tomical. and nonspecific laryngitis also are diagnosed are directly related to muscle use and can be minimized with some regularity in the elderly (see infectious dis. Lee et al. Although a potentially patients need to be evaluated for evidence of hyper. burns. 1985). Elderly dysphonic patients often are in poor general sult of increased pressure on the recurrent laryngeal health and have a high incidence of systemic illness. articulatory commonly associated with hyperfunction (vocal nodules. functional dysphonia without tissue changes (Woo et al. 1985. Clinicians Age-related changes in the endocrine system also af. De Vito et coexist with vocal fold lesions that may be either be. intubation. These factors result in consider- 1986). Elderly smokers demon- ous vocal fold surgery.. Declines in motor performance gitis sicca. Others report a low incidence of vocal fold lesions able variation in phonatory characteristics. or poor hydration and often (Spirduso. reflux. In addition. precision habits. (Maceri. inflammatory strate accelerated declines in pulmonary function. normal aging in elderly smokers. also di¤er in lifestyle. 2001). and Rosen. elderly patients may be at later life (Satalo¤. The elderly population is ex- vical muscles.. and increased blood flow ing. Debruyne et al. 2000). Since GERD has been pres. Richter. accuracy. 1983). either status of older patients presenting with voice disorders. laryn. or radiation therapy for glottic carcinoma if no pulmonary disease is detected (Hill and Fisher.. Woo et al. and respiratory function capabilities pedunculated polyps).. 1982. 1991). and Hoover. voice changes are possible with thy. monary and laryngeal systems. medications. The benefits of daily eases and inflammatory conditions of the larynx). 1996. That is. Gastroesophageal that variability on measures of phonatory function in reflux disease (GERD) is another inflammatory condi. is also important in nonsingers to prevent dysphonia in Because of advanced age. Linville. exercise include facilitated muscle contraction. a tremely variable in fitness levels. 2000). a report of increased phonatory e¤ort. as well as relatively few cases of among elderly speakers (Linville. 1997). Spiegel. 1987). as mucous gland degeneration might be a factor in although a direct link has yet to be established (Ringel development of laryngitis sicca (Morrison and Gore. Some investigators speakers often blur the distinction between normal and report significant evidence of phonatory behaviors con. as well as to improve but have more severe erosive damage to the esophagus endurance. The rate and extent pattern of glottal attack. They Lyons. 1986). ences in vocal use patterns could be a factor. and neurological changes. 1997. perhaps the most controllable and po- more relaxed phonatory adjustments when evidence of tentially significant lifestyle factors are physical fitness hypertension is found. Emerich. A healthy lifestyle that includes regular exer- nign or malignant. Smoking amplifies the sia. 1986. 1997. and Chodzko-Zajko. Age-related laryngeal changes such cise may also positively influence laryngeal performance. Morrison and Gore-Hickman. Often elderly patients report less severe heartburn ditioning and to avoid tremolo. 1997). 1999). such as hyperactivity of the extent to which they exhibit normal age-related ana- ventricular vocal folds in the elderly population (Hagen. hyperthyroidism and hypothyroidism) occur commonly Clinicians also must be mindful of the overall health in the elderly and often produce voice symptoms. el. 1986. and agility. Physical conditioning (Katz. it is a more complicated disease in this singers to improve respiratory and abdominal con- group. have been cited as particularly prevalent in elderly voice . limitless combination of environmental factors combine tensive phonation and provided with therapy to promote to a¤ect aging. Finch and Schneider. (Morrison and Gore-Hickman. Elderly persons derly women may be more likely to develop hypertensive also may experience vocal symptoms as a consequence phonatory patterns in an e¤ort to compensate for the of hypoparathyroidism or hyperparathyroidism. Clinicians are in agreement. even processes. Elderly persons di¤er in the rate and sistent with hypertension. disordered voice. as a consequence of altered hormone levels or as a re. there is evidence Hickman. Smoking also has a definite e¤ect Beckford. such as visible tension in the cer. must consider smoking history in assessing an elderly fect the voice.

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. and thus L and sp tend to oscillation produces cycles of airflow that create the counter each other. The closeness of the membranous vocal folds partly and optimizing pharmacotherapy. Evalua. glottis determines the ‘‘constant’’ opening there through Rhinology. and Woodson. Drugs and Aging. natory threshold pressure (Titze. 505–512.. New York: tissue. the vocal folds must be within Ramig. S. C. R. Higgins. Glottal adduction has three parts. Distinguishing between the fit and frail elderly. Hirano. Gray. treat. Voice Production: Physics and aTA is the activity level of the TA muscle.. velocity. R. di¤erentiate disease from normal changes. J. the voice. (1990).. and Throat Journal. Muza. (1995). S.. This subglottal pressure increases the lateral amplitude of article discusses some of the mechanistic aspects of pho. and C. 4. and Liss.). (1991). 47– determines whether vocal fold oscillation can take place. (2001).. H. H.. Kacker. Geriatrics. (1997). 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A. x 0 is the velocity of the An interdisciplinary perspective (pp. Slavit. thereby increasing . Silva.. 252–265. and Hall. 78. G. Phonosurgery in the elderly: A review. and dis- ration associated with fundamental frequency and vocal placement of the tissue. b is a vis- Luborsky. Willey. the phonatory adductory range (not too far apart. This equation emphasizes the understanding that tion and management of voice disorders in the elderly. pffiffiffiffiffiffiffiffiffiffiffiffi Tolep. 53.). 677–682. C. (1) evaluation of thyroplasty type I in the treatment of non.. Glottal configu. S. K. Voice Production: Physics and Physiology 75 Liss. 108. E. viz. Ear. Annals of Otology. 103. anced by the external air pressure forces acting on the Omori. 12.. K. 514–518. Geri- atric otorhinolaryngology. and Nichol. and the left-hand side represents the external Morrison. G. where L is the vibrating length of the vocal folds. Slavit. (1998). M. Cavanaugh and S. Vocal fold atrophy: Quantitative folds. 481–485. and Rosenbek. K. 118. viscosity.. S. and r is the Physiology density of the tissue in motion. D. Buder. Kojima. Ishizaka and Flanagan. and will tend to fall if the length.. To permit oscillation.. and sti¤ness each play a role in the mo- Goldstein. are associated with the acceleration. m is the mass of the tissue in motion. D. and Laryngology. Fretwell. 357–362. American Journal of Respira. Each term on the right-hand side characterizes forces in Otolaryngology–Head and Neck Surgery. (1998). Influence of size and etiology of glottal gap in glottic in. k is a spring constant coe‰cient. 44–49. respectively. Annals of Otology. Weismer.. Philadelphia: B. cous coe‰cient. This increases their passive tension. Ripich (Ed. L. 65–90). 1994) and da . sam is the maximum active stress that the TA muscle can produce. Cause of hoarseness in elderly patients. Tanaka. 1972). R. and Luschei. vocal folds. (2) The space created by the intercartilaginous glottic measurement and vocal function. and for pitch control has been o¤ered by Titze (1994). Journal of Voice. G. and Xue. L. 45.C. Decker. C. Lu. Increasing source.. Casiano. 1992) for the prevailing Sinard. N. Vocal F (x) ¼ mx 00 þ bx 0 þ kx. x is the In J.. D. S. K. Laryngoscope.. will tend to rise if the tension of the tissue in Nose. H. Owens. tion (normal or abnormal) of the vocal folds.. F. In multi- Oxford University Press. Journal of Gerontology Psychological Sciences. 1995). N. D. Speech motor control and aging. Titze. (1998).. Handbook of geriatric communi. tissues. mass models of phonation (e. 544–551. (1998). and McMullen.. related to the pitch of 76–79. is P35–P45... F0 ¼ (0:5=L) (sp =r)  (1 þ (da =d )  (sam =sp )  aTA ) 0:5 ... J.. (1) How close the competence dysphonia. sp is tory and Critical Care Medicine. 152. Comparison of diaphragm strength between healthy (2) adult elderly and young men. the passive tension of the tissue in motion. E. Folia Pho. D. (1999).. da =d is the Weismer. G. Kacker... TX: Pro-Ed. 547–553. and x 00 is the acceleration of the tissue. passive stretch.. the voicing sound generally rises with vocal fold elongation). D. the voice signal. Selected The most general expression of forces in the larynx acoustic characteristics of speech production in very old dealing with motion of the vocal folds during phonation males. Gerontology: position of the tissue from rest. J. and Chijiwa. Casiano. F. forces. Baker. Laryngology. J. T. Lu. (1994). and they are bal- register. transglottal pressure must be at or greater than the pho- niatrica et Logopedica. 103. 106. vibration to the total depth in vibration (the other tissue in motion is the more medial mucosal tissue).g. or more generally... S. and Xue. Rhinology.. Whitbourne (Eds. mass. Rhinol- ogy. ratio of the depth of the thyroarytenoid (TA) muscle in cation disorders. which some or all of the dc (baseline) air will flow.. In D. Koopermann (Eds.. Lundy. A. Rammage.. Scherer. D. the passive stretching of the vocal folds transglottal pressure will set them into oscillation. J. Kashima.. Lundy.).. The aging voice: A review. S. J... Slavit. this equation is used for each mass proposed. In J. where F (x) is the air pressure forces on the vocal fold paralytic glottic incompetence. 53. The most general expression to date of vocal fold bowing. S.

1994). the maximum rate that the flow shuts o¤ as the glottis is closing). and corner sharpness respectively Figure 2. Liljencrants. changes. and the sharpness of the baseline corner when the flow is near zero (or near its minimum value in the cycle). The curvature at the glottal exit of the convergent glottis pre- tensity values of the glottal flow source in the region of vents the pressures from being positive throughout (Scherer. 2). and Kucinschi. Ohala. is a combination and coordination of res- piratory. and vocal tract aspects. The length of the glottal duct was 0. typically and the pressures on the walls of the glottis are positive located on the right-hand side of the flow pulse. Increasing the contraction of the TA muscle (aTA ) tive throughout the glottis when there also is rarefaction would tend to sti¤en the muscle and shorten the vocal (negative pressure) of the supraglottal region. and corner positive pressure separates the folds during glottal open- sharpness are all important for the spectral aspects of the flow ing. 1995). partials (Fant. Thus. The flow sponding to the vibrating vocal folds is convergent peak is the maximum flow in the cycle. the shape of the glottis corre- of the waveform. This corner ‘‘shut-o¤ ’’ is. and the pressures on the walls of the lower glot- tis are negative because of this shape (Fig. The radiation away from the lips will increase the spectrum slope (by about 6 dB per octave). Uac is the varying portion During glottal opening. (wider in the lower glottis. the shape of the glottis is di- pulse (see text). mum flow declination rate (derivative of the flow). MFDR. and Lin. large changes in F0 are associated with increased con. the intensity of the first for. including the di¤erentiated contraction of the complex TA muscle. increasing the maximum flow declination rate (MFDR. DeWitt. same time decrease the passive tension (sp ) and the depth along with the alternation of the internal forces of the of vibration (da ). vergent (narrower in the lower glottis. The upper trace increase the intensity of F0. however. 2001). 1983). 1) by increasing its flow peak. . Pressure profiles within the glottis. Intensity increases with an increase in subglottal pressure. 1969. The glottis shows negative pressures throughout most of the glottis. MFDR is the maxi. and will decrease their inten. the source spectrum or quality of the voice. vocal folds. An increase in the subglottal pressure during phonation can a¤ect the cyclic glottal flow wave- form (Fig. Gau‰n and both having a minimal glottal diameter of 0. vocal tract filter function will augment the spectral in. corresponds to the data for a glottis with a 10 convergence mant region (at least). Glottal adduction level greatly a¤ects Plexiglas model of the larynx.3 cm. Titze. The exact glottal shape and intraglottal pressure traction of both the CT and TA muscles (Hirano. The intensity of voiced sounds. F0 control. laryngeal. 2). need to be established in the human and Vennard. and Udc is the o¤set or bias flow. production from highly compressed voice (a relatively Supraglottal pressure was taken to be atmospheric (zero). and subglottal pressure. maintains the oscillation of the vocal folds. the primary larynx for the wide range of possible phonatory and vo- control for F0 is through the coordinative contraction of cal tract acoustic conditions. and the associations with adduction and vocal quality all need much study. both of which would raise F0 but at the alternation in glottal shape and intraglottal pressures. 1985. Figure 1. 2000). the negative slope of the spectrum as one changes voice Glottal entrance is at the minimum diameter position for the divergent glottis. MFDR. as well as the changing shape of the glottis and the changing intraglottal air pressures during each cycle. One cycle of glottal airflow. and von Euler. 1989). which itself depends on both lung volume reduction (an in- crease in air pressure in the lungs) and adduction of the vocal folds (which o¤ers resistance to the flow of air from the lungs). Maintenance of vocal fold oscillation during phona- tion depends on the tissue characteristics mentioned above. Scherer and Shinwari. and the intensity of the higher and the lower trace to data for a glottis with a 10 divergence. anterior pull by the hyoid bone (Honda. the formants (resonances). which would decrease F0. 1989). Greater peak flow. related to the loudness of the voice. wider in the upper glottis). and nega- F0. narrower in the upper glottis). This fold length (L). Leanderson. Typically. and the corner due to this shape and to the (always) positive subglottal curvature at the end of the flow pulse describes how sharp the pressure (for normal egressive phonation) (Fig.76 Part I: Voice sity values in the valleys of the resonant structure (Titze. cricoid tilt via tracheal pull (Sundberg. the TA and CT muscles. The flow peak. The flat spectrum) to normal adduction to highly breathy convergent glottis shows positive pressures and the divergent voice (a relatively steep spectrum) (Scherer.04 cm (using a Sundberg. During glottal closing. 1994). increasing The transglottal pressure was 10 cm H2 O in this illustration.

and phonation. from more resistance (decreasing the flow if the false folds are quite close) to less resistance (increasing the glottal flow when the false folds are in an intermediate position) (Agarwal and Scherer. Bell the glottal jet and create a secondary sound source System Technology Journal. Stockholm: Royal Institute of Technology. J. A finite- et al. R.. M. I. glottal airflow and Fant. 2001). Computer modeling needs to be practical. Voice Production: Physics and Physiology 77 (Zhang et al. The most complete approach so far is to combine finite element modeling of the tissue with computational fluid dynamics of the flow (to solve the Navier-Stokes equations. Q. C. (in press). 1983). With the vocal tract included.. K. the geomet- ric asymmetry creates di¤erent pressures on the two sides —Ron Scherer (i. Acoustical Society of America. 2001. and Hollien. if the two vocal References folds themselves do not have equal values of tension Agarwal. J. Journal of Voice. San Diego.. and Vennard. glottal flow resistance (transglottal pressure divided by Gau‰n. 17–29). R. and Scherer. and Flanagan. The turbulence and vorticities of the glottal flow may also contribute sound sources (Zhang et al. and the fundamental frequency (and pitch) glottal voice source waveform characteristics. Abbs (Eds. 4. The function spectra (quality) and intensity (loudness) result from the of the laryngeal muscles in regulating fundamental fre- combination of the glottal flow. R. I. 2000). G. M. D. and glottal shape (via vocal fold plexity and chaos (pp. Fletcher (Eds.. adduction Alipour. 2000.. Journal of the the air of the vocal tract (to skew the glottal flow wave. ror images of each other across the midline. helpful in describing and predicting subtle aspects of duction. cyclic groupings (Isshiki and Ishizaka. Quarterly Progress and Status Report. quality. tension (via CT. 1972). 3003–3012. Liljencrants. Ohala. San Diego. 2001). of vocal fold length (via CT and TA action). 1991. G.. C. Vocal fold physiology: Controlling com- TA. Relationship between pitch control and Many basic issues of glottal aerodynamics. Source characteristics of diplophonia. Hearing Research. S66. The glottal flow (the volume issues. subharmonics. volume reduction is then employed. Scherer. 1–13. (1969). A four-parameter subglottal pressure are created.. Journal of of the voice. and Sundberg. creating roughness. Spectral correlates of the airflow). Baken. Journal of the 1993. phonation styles and types. The (sti¤ness) and mass. Berry. B. (1996). airflow and vocal fold vibrations.. and Lin. (2000). H. and the output Hirano. S. 1996).. and approaches for phonosurgery. W. flow is a¤ected by the resonances of the vocal tract Gerratt. Synthesis of voiced the presence of the false vocal folds may interfere with sounds from a two-mass model of the vocal cords. 1233–1268. Rothenberg. Also. as in two- mass modeling (Ishizaka and Flanagan. Acoustical Society of America. 470–483. 108. Davis and N. 616–628. (pressures acting at the glottis level) and the inertance of (1988). in press). F. R. 2002) and therefore di¤erent driving forces on the two sides. Precoda. However. acoustics. Vocal fold bulging: Figure 3 summarizes some basic aspects of phona- E¤ects on phonation using a biophysical computer model. Bless and J. 83. A. Steinecke and Herzel. laryngeal function necessary for di¤erentiating vocal pathologies. as well as for providing rehabilitation and training feedback for clients. Berry. posterior cricoarytenoid. 12. The false vocal folds themselves may contribute significant control of the flow resistance through the larynx. and Titze. Factors leading to pitch. resonance.. and interarytenoid muscle contraction). lateral cricoarytenoid. we still need models of phonation that are Figure 3. and modeling remain unclear for both normal Vocal fold physiology: Contemporary research and clinical and abnormal phonation.). one vocal fold may not vibrate like false vocal folds: Shape and size in coronal view during the other one. Combined simulation of (via TA. L... CA: Singular length. and TA rounding e¤ect). The upper left suggests muscle contraction e¤ects Journal of Voice. resulting in motion of the model of glottal flow. (1983). Gerratt Alipour. and Titze.. See text. F. When the two medial vocal fold surfaces are not mir.). 1988. When lung Publishing Group.. Scherer et al. Wong et al. D. and Berke. if there is tissue asymmetry.e. (1985). In D. Titze. Alipour and Titze. (1989). 1995). H. as in finite element mod- eling (Alipour. 1976.. 51. and adduction). 32. K. element model of vocal-fold vibration.. See also voice acoustics. and loudness pro. the glottal Speech and Hearing Research.. adduction. CA: College-Hill Press. (2000). and Herzel. J. and Ishizaka. Speech Transmission Laboratory vocal folds (if the adduction and pressure are su‰cient). 14. . M. quency and intensity of phonation. R. F. 556–565. K. but also closer to physiological reality. velocity flow) is considered a primary sound source. Alipour and Scherer. Honda. Hanson. Alipour. Journal of Speech and tion from the lips. J.. tion.. and radia... In P. (1972). J. that is. aero- vowel articulation. and Titze. pressure asymmetries. form to the right.

(1992). K. Shinwari. Perceptual Evaluation of tions. Patients e¤ect of exit radii on intraglottal pressure distributions in usually seek clinical care because of their own perception the convergent glottis. A. W. I.. (1991)... Frankel. De Witt. The ancient Greeks asso. and most often they judge America. immoral character. and Titze. S.). listeners evalu- of the vocal folds with application to some pathological ate voices on the scales Grade (or extent of pathology). R. B. S. and Kucinschi. for review). (2001). pitch. A. R. Steinecke. Shinwari. loudness. K. brassiness. Journal of the Acoustical Society of America. J. tial cross-disciplinary importance of voice quality. R. Journal of the Acoustical Society. K.78 Part I: Voice Isshiki. Satalo¤. Ito. 1193–1198. speaker. Titze (Ed. preserve voice quality. 2905 (A). In D. breathiness. Journal of the Acoustical Society of America. Intraglottal pressure profiles concerned with how their voices sound after treatment. Computer simulation of ciated certain kinds of voices with specific character pathological vocal cord vibration. Hammarberg and Gau‰n (1995) includes scales for ments of phonation that characterize an individual assessing aphonia (lack of voice). For example. in measuring vocal quality. resonance. (1995). C. and Herzel. or shrillness (see Laver. 91. G. pitch instability.. Zhang. 60. linguists are 109. for cultivating power.. D. pitch breaks. Zhao. both clinically muscles. 1977) includes 7-point scales for laryngeal tone. D. Abbs (Eds.. rate.). Titze. or protocols employing an acous- ciety of America. Bifurcations in an asym. diplophonia. 86– 1981. Thus. J. (1989). with each scale rang- Zhang. (2001). San aspects of voice quality. Laryngeal function during phonation. patients are more schi. Phonation threshold pressure: A missing quality fall into one of two general categories: perceptual link in glottal aerodynamics. 1253–1256. C.. The the diagnosis and treatment of voice disorders. and Afjeh. assessment protocols. In I. Leanderson. C. brilliance. J. (2001). New York: Igaku-Shoin. creakiness.. diplophonia (perception of two pitches in the voice). R. for a symmetric and oblique glottis with a divergence angle Researchers from other disciplines are also interested of 10 degrees. tension. H. R. Gould istics like roughness. N. and overall vocal e‰ciency.. R. Journal of the Acoustical Society of America. America. and law enforcement o‰cials metric vocal-fold model. (1976). the Wilson Voice Profile System (Wilson. B. Journal of the Acoustical Society of America. Observation of perturbations in a lumped-element model In the GRBAS protocol (Hirano. R. (2002). revision to this protocol (Dejonckere et al. of power in the voice). 143–188). For example. 2267–2269. roughness.. 110. B. DeWitt. falsetto. B. ity. emotions appropriately. and Shinwari. I. 97. Asthenicity (weakness or lack 394. Most techniques for assessing voice Titze. San Diego. K. and von Euler. and Ishizaka. Evidence of voice on a numerical scale or a set of scales representing chaos in vocal fold vibration. N. 3. gratings. Korovin.. C. CA: Singular Publishing Group. 1874–1884. Journal of the Acoustical So.. Vocal fold the extent to which the voice is characterized by critical physiology: Frontiers in basic science (pp.. H. R.). (Eds. Evaluation of vocal quality is an important part of Scherer. 17 parameters) and Laver (approximately . R.. NJ: Prentice Hall. Many other similar protocols have been proposed. Journal of the Acoustical Society of need to assess the accuracy of speaker identifications. a listener (or listeners) rates a Cli¤s. Journal of the Acoustical traits. interested in how changes in voice quality can signal Scherer. Voice quality has been of interest to scholars for as long Even more elaborate protocols have been proposed by as people have studied speech. Cox. 155–165). R. Journal of the Acoustical Society of of a voice quality deviation. L. 89. the success of treatment for the voice problem by im- Scherer. 1981). M.. Journal of Voice. DeWitt. In and sweetness. I.. 2412 expanded it to GIRBAS by adding a scale for Instabil- (A).. Vocal fold speech and described methods for conveying a range of physiology: Contemporary research and clinical issues (pp. Principles of voice production. (1983). R. C. 2926–2935. vocal abuse. speech signal and a listener’s perception of that signal. (1994). (1993). and loudness. pitch.. Bless and J. Glottal pressure pro- provement in their voice quality. D. Rubin. M. anatomy or physiology. Fairbanks (1960) Diego. 225–232. R... glottal oscillation frequency. judge success by documenting changes in laryngeal Scherer.. A recent Computational aeroacoustics of phonation: E¤ect of sub- glottal pressure. A 13-scale protocol proposed by Voice quality is the auditory perception of acoustic ele. T. An interactive model for the voice sized voice quality as an essential component of polished source. Scherer. voice breaks. for the qualities harshness. In Titze. CA: College-Hill Press. and breathiness. it is an interaction between the acoustic laxness. changes in meaning. J. Baken. laryn- geal tension. I. and Herzel. and Strain. R. for example. 104). rithms for signal compression and transmission that 112(4). tic or physiologic measurement as an index of quality.. mea- Activity relationship between diaphragm and cricothyroid surement of voice quality is problematic. recommended that voices be assessed on 5-point scales Wong. Intraglottal the perception of emotion and other personal informa- pressure profiles for a symmetric and oblique glottis with a tion encoded in voice. M. H. a nasal voice indicated a spiteful and Society of America. Despite this long intellectual history and the substan- Sundberg.. R. psychologists are concerned with Kucinschi. and experimentally.. R. Ancient writers on oratory empha- Rothenberg. Gelfer (1988. C. (2000). I. H. R. A. 1998) has tricular folds. Englewood perceptual assessments. Breathiness. and for avoiding undesirable character- J. nasal emission. but in general. 1616–1630. Kucin. For example. engineers seek to develop algo- uniform duct. 109.. C. C.. D. 383– Roughness. S. hoarseness. vocal inflec- Voice Quality. and Afjeh. C. cases. and ven. and W. and Mongeau. A clinician may also files for a diameter of 0. ing from 0 (normal) to 4 (severely disordered). (1995). Diagnosis and treatment of voice disorders (pp. Zhang. 107.04 cm.

and contribute to lis. Perceptual Evaluation of 79 50 parameters. reducing the percep- as well as within a given listener. Thus. internal standards for the various rating scales. Much more research is certainly needed measure of acoustic frequency perturbation as a de facto to determine a meaningful. their perceptual assessments of pathological voice qual- In response to these substantial di‰culties. parsimonious set of acoustic measure of perceived roughness (see acoustic assess. This process helps listeners focus attention is made. listeners are apparently unable to useful insight into the perceptual process. (See Kreiman agree in their ratings of voices. because voice quality is by definition the perceptual response to a par. and may vary substantially across listeners on individual acoustic dimensions. Even if an The usefulness of such protocols for perceptual as. listeners vary speech sions within a complex acoustic stimulus. di‰culty isolating individual dimen. and whose levels objectively. across samples of listeners and voices. speech synthesizer. con- ing any number—as opposed to one of a finite number sistent correlations have never been found between per- of scale values—to indicate the amount of a quality ceptual and instrumental measures of voice. or with reference to a listener’s own internal variable to a perceptual one does not necessarily illumi- standards for the di¤erent levels of a quality. and factors like method demonstrated near-perfect agreement among lapses in attention can also influence perceptual mea. listeners can manipulate acous- teners’ previous experience with voices (Verdonck de tic parameters and hear the result of their manipulations Leeuw.g. —Bruce Gerratt and Jody Kreiman . the overall correlation in perceptual strategies are so large that standardization between acoustic and perceptual variables. Ratings may be made with reference to perceived quality. Theo. For example. These they need not refer to internal standards for particular idiosyncratic. acoustic variable were important to a listener’s judg- sessment is limited by di‰culties in establishing the cor. However. In this method. e. for an extended review of these average. acoustic measures that Methods like visual-analog scaling (making a mark on purport to quantify vocal quality can only derive their an undi¤erentiated line to indicate the amount of a validity as measures of voice quality from their causal quality present) or direct magnitude estimation (assign. When a listener (Kreiman and Gerratt. voice qualities. Voice Quality. nate its contribution to perceived quality. suggesting present) have also been applied in e¤orts to quantify that such instrumental measures are not stable indices of voice quality. severity tual complexity of the assessment task and the associated of vocal deviation. using a demonstrated. we cannot know the perceptual importance perception. Theoretical researchers and clinicians to replace quality labels with and practical di‰culties also beset this approach. and and habits that individual listeners demonstrate in their some evidence suggests that di¤erences between listeners use of traditional rating scales. given the great variability in perceptual strategies standardized set of scales for assessing voice quality. more than 60% of the variance in ratings of issues. the synthesis traditional perceptual scaling methods are e¤ectively settings parametrically represent the listener’s perception matching tasks. 2000. ment of vocal quality. solution to this dilemma. for example. These factors (and pos. Further. association with auditory perception. presum- sures of voice (de Krom. averaged e¤orts are doomed to failure (Kreiman and Gerratt. listeners in their assessments of voice quality. Because listeners directly compare each compared to stored mental representations that serve as synthetic token they create with the target natural voice. Greene and Mathieson. ably because this analysis-synthesis method controls the sibly others) presumably all add uncontrolled variability major sources of variance in quality judgments while to scalar ratings of vocal quality. or the acoustic signal for clinical (rather than research) applications remains to be these flawed perceptual measures. di‰culty isolating single perceptual dimen. acoustic parameters that are causally linked to auditory retically. Preliminary evaluation of this sions in complex perceptual contexts. 2001. and that tools can be devised to measure perception researchers suggest substituting objective measures of reliably. measures of that perceptual response. 1998) and with the context in which a judgment immediately. some ity. the nature of that contribution rect and adequate set of scales needed to document the would not be revealed by a correlation coe‰cient. In addition.. allowing perception of such complex auditory stimuli. completely. where external stimuli (the voices) are of voice quality. They measured vocal quality scale ratings may vary depending on variable listener by asking listeners to copy natural voice samples with a attention. fails to provide 1996). parameters that successfully characterizes all possible ment of voice). Researchers have never agreed on a ther. Evidence suggests that on and Gerratt. 1989). Finally. Practically. Fur- sound of a voice. In addition. 1998). response variability. airflow. Evidence suggests that chooses the best match to a test stimulus. internal standards appear to vary with lis. and of particular aspects of the acoustic signal without valid validly specify the voice quality of interest. for These results indicate that listeners do in fact agree in review).) voice quality is due to factors other than di¤erences Gerratt and Kreiman (2001) proposed an alternative between voices in the quality being rated. Such a set could view that listeners are inherently unable to agree in their obviate the need for voice quality labels. and di¤erences synthesis parameters to create an acceptable auditory in listeners’ previous experience with a class of voices match to a natural voice stimulus. avoiding the use of dubiously valid scales for quality. how such protocols will function in physiologic function. ticular acoustic stimulus. This approach reflects the prevailing normal and pathological voice qualities. correlation does not imply ‘‘anchor’’ stimuli that exemplify the di¤erent scale causality: simply knowing the relationship of an acoustic values. 1994). tener disagreement (see Gerratt and Kreiman.

compensation may facilitate the communicative process. In O. E. This may then call Journal of Speech and Hearing Research. Similarly. R. as well as secondary physi- of America. V. and Gau‰n. Doyle. Hirano (Eds. A. ance and resistance to airflow o¤ered by the recon- structed valve.. G. tional valving capacity of the laryngeal mechanism. Hirano. and Hanson. 1598–1608. Erman. Doyle et al. 110. volitional. J. L. 1994). F. (1960). CA: Singular Pub- lishing Group. vation of some degree of vocal function and safe Gelfer. Schecter. (pp. Journal of the Acoustical Society but may also create abnormalities in voice quality due of America.80 Part I: Voice References Voice Rehabilitation After de Krom. (1993). J. Hammarberg. J. 1984. 79–99). From the standpoint of voice production. Measuring vocal qual. San Diego. Keith. 2560–2566.). and Kreiman. ity. 1996. The perceptual struc. Rizer. (1981). CA: Singular Publishing geal structure result in aerodynamic. Crevier. and Cole- Kreiman.. (1977). ment. J. and a framework for future research. Woisard. and Reynolds.. Perceptual and 1981). 21–40. Hoasjoe et al. judgments of the voice by listeners. Two factors in particular. G. R... de Krom (Ed. and Doyle. Reliability and Partial or conservation laryngectomy procedures are clinical relevance of perceptual evaluation of pathological performed not only to surgically remove a malignant voices. Kent. any acoustic characteristics of quality di¤erences in pathological degree of laryngeal tissue ablation has direct and poten- voices as related to physiological aspects. R. Linguistics. and Ball.. Clinical examination of voice. Hen. G. Voice quality but in other instances such compensations may be detri- measurement (pp. lesion from the larynx. Gerratt.. and Gerratt. Perceptual analysis of voice reconstructed laryngeal sphincter. the primary goal of conservation ment and use of rating scales. S. to active (volitional) hyperclosure (Leeper.. 1983.. Perceptual evaluation of voice quality: airflow may negatively influence auditory-perceptual Review. Perceptual observations following a vari- sical period to the 20th century. vibratory. and Reynolds. mental to the speaker’s communicative e¤ectiveness Laver. Sources of listener disagreement in voice quality assessment. London: Whurr. R. and Gerratt. Journal of the Acoustical Society surgical laryngeal sphincter.. Asher and E. 12–15). Remacle. safety. C. this level of Kreiman.). 985–1000. in voice quality. Measuring vocal qual- ity with speech synthesis. gectomy are a consequence of anatomical influences Kreiman.. Voice and articulation drillbook. The voice and its always necessitate tissue ablation... Heeneman. Dejonckere. San Diego. 1984. 1997). P. (1996). ity with speech synthesis. Proceedings of Voicedata98 Symposium grund et al. and Millet. Conservation Laryngectomy ity ratings for di¤erent types of speech fragments. Ball (Eds. In R. 110. Leeper. (1981). However. and Mathieson. J. on Databases in Voice Quality Research and Education 1990. Kempster. Excessive closure of the laryngeal mechanism at either glottic or Gerratt. but also to preserve some func- 247–248. B. Journal of Speech and Hearing Research. Voice disorders. Journal of the compensatory adjustments in respiratory volume in an Acoustical Society of America. 320– laryngectomy procedures is cancer control and oncologic 326. (1998). (1994). In some instances. 37. L. Journal of Voice. B. Revue de Laryngologie Otologie Rhinologie. 1990. supraglottic (or both) levels might decrease air escape. (2000). Heeneman. J. J. The analysis of vocal quality: From the clas. ological compensation. I. 1997). appear to play a significant role in compensatory behaviors influencing auditory-perceptual Further Readings assessments of voice quality (Doyle. e¤ort to drive a noncompliant voicing source charac- Kreiman.. Austin. ety of conservation laryngectomy procedures have been derson (Eds. L.. J. B. with varied degrees of social pen- . Consistency and reliability of voice qual. and ulti- Group. the degree of air leakage through the Verdonck de Leeuw. Validity of rating scale and the resultant physiological function of the post- measures of voice quality. 1995. but data clearly indicate perceived changes Edinburgh: Edinburgh University Press.. 104. New Retention of adequate valvular function allows conser- York: Harper. (2000). Kreiman. Fujimura tially highly negative implications for the functional and M. tutorial. and other features (Blau- G. 283–303). and Gerratt. CA: Singular Publishing Group.). with a secondary goal of maintaining upper air- Gerratt. B. New York: mately acoustic changes in the voice signal (Berke. D. M.. (1995). and Doyle. Vocal fold physiology: Voice quality capacity of the postoperative larynx. 2. the appearance of quality: Trained and naive raters. B. 119. M. Toward a history of phonetics (pp. with disruption of the disorders. diverse. Utrecht. (2001). J. (Doyle. vibratory integrity of at least one vocal fold (Bailey. man. and self-ratings. and Kreiman. (1989). 1997). G. B. Measuring vocal qual. (2000). Fairbanks. ture of pathologic voice quality. P. In compensatory hypervalving. As such. 100. M. B.). B. 1787–1795. H. (1988). 1992.. R. Leeper. Voice quality measure. Doyle et al. Fresnel-Elbaz.. Wilson. J. D. (2001). TX: Learning glottic insu‰ciency and the relative degree of compli- Concepts. B. 36. attention to the voice. 1995. 1996). swallowing. Journal of the Acoustical Vocal characteristics following conservation laryn- Society of America. M. 73–102). Keith. J. San Diego. 1867–1879. 108. conservation laryngectomy will Greene.. B. R. surgery. R. 2560–2566. the Netherlands: Utrecht Institute of Leeper. Gerratt. (1998). and Gerratt.. Kent and M. Springer-Verlag.. Doyle. M. (1998). M. Journal of the Acoustical Society way sphincteric function and phonatory capacity post- of America. In R. and terized by postsurgical increases in its resistance to Berke. Perceptual attributes of voice: Develop. Changes in laryn- control (pp. R.

Increased noted in those who have undergone conservative laryn- e¤ort may be compensatory in an attempt to alter pitch gectomy. (2) a slow. aerodynamic. J. Haji.. the patient during initial attempts at voicing might peutic intervention. tial to negatively alter voice quality. D. and (4) control of Boone. and have undergone conservative laryngectomy may demon- (2) e¤orts to reduce or eliminate compensatory behav. Colton Berke. Clinical goals that focus on in unique limitations for men and women. 1990. Clinical assessment should determine whether commonly used. 502–508.g. 1742–1771. Doyle ological function. Partial laryngectomy and laryngoplasty. (1984). and auditory. This is of particular importance tional (physiological) changes to the sphincter that may when evaluating goals and potential voice outcomes rel- have a direct influence on voice quality. and Baer. D. ablated larynx: A preliminary report. and McFarland. A ton and Casper. Those auditory. comprehensive data on vocal characteristics of those and may result in perceptible limitations in verbal com- undergoing conservation laryngectomy have been avail.. perceptual features that most negatively a¤ect overall The physical and psychological demands placed on voice quality should form the initial targets for thera. Although a ‘‘rough’’ or conservation laryngectomy is available (Doyle. the disrupted sphincter. 1997). Boone on identifying behaviors that hold the greatest poten. 1994. 1977). the speaker’s attempt increase levels of tension that ultimately may reduce to increase vocal loudness may create a level of hyper. Thus. Voice analysis of the partially generation at the initiation of voice and speech produc.). phonation. particularly early during treatment. Careful.. Voice Rehabilitation After Conservation Laryngectomy 81 alty.’’ The intent is to improve vocal Englewood Cli¤s. ative to the speaker’s sex.or overcompensation for See also laryngectomy. and respiration training (Boone. 1990). Col- goals and methods of monitoring potential progress.. ‘‘e¤ortful’’ voice may be judged as abnormal. Boone and McFarland. In such cases of hypofunctional behavior.. B. 81. the speaker must understand the may be experiencing problems that result from post- relative levels of penalty it creates in a communicative operative physiological overcompensation because they context. clinical tasks that focus on reducing over- or loudness. productive transition to voice C. Excessive vocal Maladaptive compensations following conservation e¤ort and a harsh. strategics used in traditional voice therapy (e. 91. R. S. Common facilitation methods The clinical evaluation of individuals who have may involve the use of visual or auditory feedback. G. (1981). Gould. For example.. are appropriate targets.. tion. exces- Although the rationale for such ‘‘abnormal’’ behavior sively aperiodic voices. comfort in the early postsurgical period. A weak voice requires the clini- comprehensive framework for the evaluation and treat.e. munication. Bloch. NJ: Prentice Hall. and Hanson. Rhinology. 311–317. 93. who exhibit increased fundamental frequency. breathy voice quality. Doyle. Bailey. speech rate via phrasing. the contributions of volitional com- pensation. Annals of Otology. gone conservation laryngectomy have evolved from Laryngoscope. G. strained voice quality are commonly laryngectomy often tend to be hyperfunctional behav- observed (Doyle et al. the clinician should be able to discern func. laryngectomy should focus on ‘‘(1) smooth and easy Blaugrund. voice production. 1997). J.. W. . primary treatment targets will frequently address Because active glottic hypofunction is infrequently changes in voice quality and/or vocal e¤ort. 1977. the individual’s phonatory capability. (3) increasing the length of utterance in conjunc. Voice therapy strategics for those who have under. M. or intermittent voice stoppages is easily understood. a subgroup of individuals may present may include videoendoscopy (via both rigid and flexible with weak and inaudible voices because of pain or dis- endoscopy) and acoustic. The voice and voice therapy (2nd ed. Standard evaluation iors. (1977). S. Otolaryngology–Head and Neck Surgery. 1977. —Philip C. the ultimate postsurgical e¤ects of e‰ciency and generate the best voice quality without conservation laryngectomy on voice quality may result excessive physical e¤ort. ear undergone conservation laryngectomy initially focuses training. systematic perceptual assessment has voice therapy is usually directed toward facilitating direct clinical implications in that information from such increased approximation of the laryngeal valve by means an assessment will lead to the definition of treatment of traditional voice therapy methods (Boone. and Laryngology. and as such ‘‘easy’’ voice production without excessive speech rate require clinical consideration. Those individuals closure that is detrimental to judgments of voice quality. cian to orient therapy tasks toward systematically ment of voice alterations in those who have undergone increasing glottal resistance. hyperfunctional closure) are more voice. Further treatment goals should focus on (1) are struggling to produce voice. Metzler. Doyle An acoustic analysis of the e¤ects of surgical therapy on (1997) has suggested that therapy following conservation voice quality. Gerratt. Such compen- perceptual assessment. or simply to initiate the generation of compensation (i. B. it may Depending on the auditory-perceptual character of be preferable for some speakers when compared to a the voice. strate considerable e¤ort during attempts at postsurgical iors that negatively alter the voice signal (Doyle. However. strategies for voice therapy must address changes in anatomical and physi. 1994). Until recently. In this regard. and Casper.. 1995). Many individuals who enhancing residual vocal functions and capacities. voice change is due to under. able. (1983). tion with consistently easy phonation. J. and whether changes in voice quality may be References the result of multiple factors. R. T. only limited sations may remain when the discomfort has resolved.. T. Therefore.

Otolaryngology–Head and Neck Surgery. it is important to know what normal function . Journal of Otolaryngology. Boone and McFarlane. Vocal function following vertical hemilaryngectomy: A pre- liminary investigation. C. C. J. Hawkins.. Micro- acoustical measures of voice following near-total laryn- gectomy. what kind of breathing behavior might contribute to (1998). 66. then. San Diego. D. H. M. Pathways and pitfalls in partial laryn- voice therapy (5th ed. 109.. Rhinology. Transactions of the American Academy of Journal of Otolaryngology. Crevier-Buchman. and Martin... and Gerdeman. Mon. O. A. 6. O. 389–393. (1989). 356–360. F.. and Smith.. A. Understanding voice 93. Breathing—the mechanical process of moving air in and Rizer. tation following laryngeal cancer. H. Supracricoid partial laryngectomies: Oncologic and voice disorders. P. 2–7. reading in ten women with vocal fold nodules. and Wong. H. L. 27–35. D. out of the lungs—plays an important role in both speech Voice quality and intelligibility characteristics of the recon. Glaze. there is a paucity of data on the re- Utility of near-total laryngectomy for supraglottic. base-of-tongue.. in response to ine‰cient valving at the larynx and did Hanamitsu. ior observed in the women with nodules was most likely 105.. Minni. (1989). 92. and voice production. J. lationship of breathing to voice disorders. Archives hemilaryngectomized and near-total laryngectomized male of Otolaryngology. A comparative acoustic analysis of voice production onstration of the development of laryngeal connective tissue by near-total laryngectomy and normal laryngeal speakers. Heeneman. functional results. 1920–1924. Ophthalmology and Otolaryngology. 98. J. Houghton-Jones. Pearson. 1320–1323. Acta Otolaryn- were useful in ameliorating voice disorders. (1997). the breathing behav- gectomy. Leeper. do exist generally describe the breathing patterns that Rhinology.. B.. C.... J. Tucker. 118. Colton. A. (1984). and other cancers. lung volume per phrase. Head and Neck. B. (1995). At present. gectomy. (1998). A. Otolaryngology–Head breathing exercises relative to voice disorders in the and Neck Surgery. Kataoka. 661–667. Hans. K. L. A. and Laryngology. L. gologica. M. CA: Singular Lefebvre. Some books Biacabe. T. Prim. Baltimore: Williams and Wilkins. not closed. and Brown (1997) studied breathing kinematics during Fung. 308–318.. C. F. Voice refinement following conserva. J. either directly Comparison and evolution of perceptual and acoustic or indirectly. L.. Tucker. published literature is mixed.. Pillot. and McFarlane.. G. the larynx.. G. Annals of Otology. R.. (1998). A. R.. F. P. Laryngoscope. Rhinology. R. Cooper. Doyle.. R.. Laryngoscope. (1990). M.. Colton and Casper.. F. L. tion surgery for cancer of the larynx: A conceptual model Pressman. C. and Michaels. S... Hoasjoe. Keith. Englewood Cli¤s.. Laccourreye. G. H. Feasibility of subtotal H. A. Wuyts. and DiNardo. Otolaryngology–Head and Neck Surgery. (1999). C. and Laryngology. R. NJ: Prentice Hall. 39–43. 301–305. A. H.. and Casper... J. breathing exercises are advocated by some. (1996). (2001). What have whole organ sections con- treatment. known about the role played by breathing. For example. H. 98. 65.82 Part I: Voice Boone. K. compartments. Laryngoscope. M. 504–509. and Laryngology. Gallo. and Laryngology. F. C. 131–143. others do (e.. Speech results and complications of near-total laryn. tributed to the treatment of laryngeal cancer? Annals of Doyle.. Growth and spread of laryngeal can- cer as related to partial laryngectomy.. Voice Therapy: Breathing Exercises Leeper. 113. American Journal of Speech. speakers. 2000. pharyn.g. H. Annals of Otology. Heeneman. (1994). Laryngoscope. (1990). Takeuchi. 1984. Herranz. F. A histological dem- (1992). 698–694. D. Stemple. I. Doyle. 21. and Doyle. Yoo. 62–67. in disorders of the voice. found that the women used more air per syllable. A. little is frais-Pfauwadel. and initiated breath groups at Gavilan. 728–748. C.. Sapienza. (1994). C. 698–704. 85. E. and Laryngology. serial laryngeal sections. on voice and voice disorders have no discussion of and Brasnu. accompany voice disorders.. P. 594–599. Rhinology. but there are no data on De Vincentiis. They Doyle. Leeper. J. S. and Olsen. 20.. (1982). Vocal function following radia. the emphasis placed on structed larynx and pseudolarynx. and Reynolds.. problems: A physiological perspective for diagnosis and Kirchner. 111. 1973. the lack of empirical evidence that breathing exercises gectomy with cricohyoidoepiglottopexy. flap: Durational and frequency measures.. G. W. and Kitajima.. (1956). P. Journal of Medical Speech-Language Pathology. (1996).). 118. H. et al.. A review of voice therapy techniques by Casper and Murray (2000) did not suggest Further Readings any breathing exercises for voice disorders. The voice and Kirchner.. F. G. Some clinical inferences from the study of 3. 111. and Coleman.. Larynx preservation: The discussion is Publishing Group. not cause the nodules. Stathopoulos. 1996). L. DeSanto. 19. Rhinology. Heeneman. However. Normal Breathing Kirchner. P. Annals of Otology. 729–733. J. Comparative study of vocal function after near-total laryngectomy. 1980. L. The data that geal. 1995). P. K. A. Schecter. the voice. Annals of Otology. (1984). H. Reed (1980) noted characteristics of voice after supracricoid partial laryn. as the authors point out. Aronson. (1985). Martin. R. Vocal function after vertical partial changing breathing behavior relative to voice disorders laryngectomy with glottic reconstruction by false vocal fold (Case. Foundations of voice and speech rehabili. Language Pathology. 766–773. Leeper... (1999). 109. J. and Brasnu. C. Submucosal compartmentalization of for therapeutic intervention. Robbins. (1975). K. D. K. S. higher lung volumes than women without vocal nodules. J. 73. 635–638. When assessing and planning therapy for disorders of 1516–1521. Perceptual characteristics of laryngectomy based on whole-organ examination. more tion for non-laryngeal versus laryngeal tumors of the head and neck. Laccourreye. D. (1964). and Rabanal. Otology. W. Although Crevier-Buchman. however. P. Doyle. Laryngoscope. S.

observed as the client breathes at rest. Mead. 1974). and Goldman. Saltzman. 1996). ical and e‰cient mechanical advantage to the breathing supine position would generalize to an upright body po- apparatus. 1976). The abdomen not only produces lung volume sition.. and the mechanics of the breathing muscles and requires a it is well endowed with spindle organs for purposes of di¤erent motor control strategy for speech production. 1973. flect the di¤erent e¤ects of gravity (see Hoit. 1995. Stegen. this Valck. As Mead.7 kPa (Isshiki. Pressure for conversational speech is whereas in the upright body position the abdominal typically around 4–7 cm H2 O. what else might be done with the breathing to the rib cage during the expiratory phase of speech apparatus to ameliorate voice disorders? Perhaps mod- breathing. nematic measurement techniques. Hixon and Putnam . Relaxation techniques have been advo- phragm and the rib cage (Goldman. Han. 2000. it consists of muscle fiber types that are abdominal volume increases. In light of the mechanical and generated by both muscular and inherent recoil forces. Hoit (1995) points out. pressure. It does so in two behavior but is e¤ective in relaxing individuals with ways. the pressure generated by the rib voice problem. Second. inward abdominal position as it is maintained provides a Other Approaches platform against which the diaphragm and rib cage can push in order to produce the necessary pressures and If learning breathing techniques in the supine position is flows for speech. speaker’s desire to maintain the flow of speech in his or Hixon (1982) showed kinematic data from a patient with her favor. 1976. it also optimizes the It may be that this technique does not change breathing function of the diaphragm and rib cage. This volume range is e‰cient and The changes that occur in speech breathing with a economical. audible inspiratory turbulence and would not assist in developing as rapid and as large was evident during her broadcasts. Kelso. In the upright body position. Mead. Using breathing ki- an alveolar pressure change (Hixon and Weismer. flow.. or woman (a local television broadcaster) with a functional wasted motion. This action cated to reduce systemic muscular tension in individ- positions the expiratory muscle fibers of the rib cage and uals with voice disorders (Boone and McFarlane. With regard to Reference to flow is in the macro sense and denotes breathing at rest. Hoit et al. Mead. 1966). sensory feedback. body configura. Hixon. or 0. and Goldman. Friedreich’s ataxia whose abdominal wall was assumed tion refers to the size of the abdomen relative to the size to be paralyzed because it showed no inward displace- of rib cage. Thus. muscle fibers of the diaphragm on a more favorable Greene and Mathieson. and Goldman. it should be noted that this task is not shorter inspiratory durations relative to longer expira. For speech production in the upright body ment and no movement during speech. The rib cage is e‰cient in dis. it seems unwar- and the interworking of these forces depends on the level ranted to position an individual supine to teach ‘‘natu- of lung volume (Hixon. neural control issues discussed earlier. Proctor. and Tuller (1986) tory durations. Hixon (1975) provides a useful parameterization of E¤ects of Posture breathing for speech that includes volume. muscles are quite active (Hixon.4–0. Hoit et al. Pressure (translaryngeal pressure) is For example. This modification changes able to generate fast and accurate pressure changes. his abdominal wall was displaced larger relative to relaxation (Hixon. Stathopoulos and Sapienza. specific to speech. the abdomen is smaller and the rib cage is this patient laughed. for a Most lung volume exchange for speech is brought about comprehensive tutorial). expiration while using less neural energy. Hixon and Putnam in a paradoxical manner during expiration. As a result. speaking or vocalizing. Pressure is 1976. muscular activity of the abdomen during speaking. and Mead. First. in that extra e¤ort is not required to over. voice disorders. If the abdomen did not o¤er resistance not useful. This di¤erence in timing reflects the hypothesize that the control of speech is task-specific. 1989). 1989). The change of abdomen (Hixon. switch from the upright position are numerous and re- come recoil forces (Hixon. 1993). and breathing exercises portion of their length-tension curve. and inward and displayed a great amount of movement. for changing breathing behavior learned in a resting. and Goldman. For conversa. Lung volume is the amount of air available for literature and been applied to voice therapy. It seems curious why this technique is advocated. Goldman. Although she had a normal voice and no cage would alter the shape of the breathing apparatus positive laryngeal signs. In supine speech breathing by rib cage displacement and not by displacement of the involves approximately 20% less of VC. change in the expiratory direction. 1964. and body configuration or shape. body configuration from the upright position to the su- placing lung volume because it covers a greater surface pine position means that rib cage volume decreases and area of the lungs. 1973). beginning at 60% VC and ending at around 40% and increased outward movement of the abdomen is VC (Hixon. little tional speech in the upright body position. the following of this information has found its way into the clinical apply. This allows quicker are known to be beneficial in reducing heart rate and and more forceful contractions for both inspiration and blood pressure (Grossman et al. it seems unlikely that techniques The upright body configuration provides an econom. 1995). ral’’ breathing for speech and voice. in the supine position there is little or no related to the intensity of the voice (Bouhuys. Paradoxical (1983) described breathing behavior in a 30-year-old motion results in reduced economy of movement. when position. inward abdominal placement lifts the dia. 1976). Voice Therapy: Breathing Exercises 83 is. However. 1973). Mead. 2001. The volumes used for speech are only one breathing technique to improve voice pro- usually within the midvolume range of vital capacity duction is usually described: The client is placed supine (VC). Although much is known about speech breathing. it would be forced outward and would move ifying lung volume would be useful. Clement.. 1988). and Woestijne.

Grillner. D. Schein. individuals matics of the chest wall during speech production: Volume can produce consistently higher lung volumes during displacements of the rib cage. J. D.). Mechanical coupling of the diaphragm vocal nodules. ary approach. tion. Madison. T. and language. C. Englewood Cli¤s.. the Hixon. (1990). C. and creased resistance in the lower airways that occurs at low Gavish.. B. J. Reed (Eds. 7. and abdomen. Speech Disorders. More research thorax. Plassman and Hixon. rib cage. L. Thomas. Breathing-control lowers blood pressure. J. (1996). Research e¤orts should Speech and Hearing Research. Goldman. 42–60. A. J. lung volume. Brown. Saltzman. in men. The therapy (6th ed. Lansing. diaphragm. Even after the call by Reed (1980) more than 20 years Hixon. dynamic perspective on speech production: Data and Bouhuys. UK: Pergamon Press.C.. Journal of attempts to modify lung volume. (1973). 195–201.. Understanding voice prob. 65.. using video-endoscopic and breathing ki. T. Pengally. and laryngeal contributions to maximum phonation dura- stone. and Hixon. 263–269. (1973). hearing. and F. S. (1988). 32. Solomon. Proctor. (1982). 14. and Goldman. Regulatory mechanisms of voice intensity Aronson. C. in lung volume during voice and speech production in normal Case. (1995). Altman. Speech breathing during reading in women with Goldman.). 45. and Putnam. Clinical management of voice disorders. W.. (1999). J. Rebuk. J. 19. Boston: Allyn and Bacon. The voice and voice Kelso. K.). (1996). Influence of breathing therapy on if she were to produce speech at higher (more normal) complaints. Mil. 1123–1130. G.. N. Zimlichman. Unpublished dissertation. Cooper. T. (2000). 78–115. little has been done. Hixon. (1973). N. J. M. 14. Dynamics ago for more empirical data on breathing exercises to of the chest wall during speech production: Function of the treat voice disorders. ing phonation at lower lung volumes. Journal of Human Hypertension. 14. Normal lung volumes compared with low lung volumes. J. and Mathieson. Hoit. L. 16.. Colton. Then researchers implications for the evaluation and treatment of voice dis- orders. 17–29. and Lansing. between 45% and 10%. M. (2001). M. MD: Aspen.. 21. (1983). T. and Murray.. (1966). WI. E. 481–493. D. anxiety and breathing pattern in patients with lung volumes. Mead. Voice therapy methods in Plassman. Laryngeal function associated with changes 483–496.. A. London: Whurr. Otolaryngologic Clinics of North America. New York: B.. (1964). Casper. Kinetic theory. Lubker. 157–169. M. S. said that when she spoke at lower lung volumes. F. 297–356. The voice and its dis- VC. Journal of Speech and Hearing Research.. 29–59. burgh study of speech breathing. Speech motor control (pp. Boone. S. J. Solomon.). When a person inspires to higher lung volumes. and Morgan. inspirations were due to the turbulence created by in. aspects of singing. Stegen. Springfield: Charles C. Williams (Eds. 341–347.. and Milbrath. her voice Hixon. Journal of Voice. J. D. Influence of body position on breathing and its havior contributes to voice disorders. Valck. Respiratory Loaded breathing (pp. R.. and this pulling is believed to generate passive Hixon. In L. Respiratory-laryngeal evaluation. 9. Isshiki.. T. Garlitz. stein (1999). found that at high lung volumes. it is possible the telecaster’s Han. Therefore. 69. B. In S. T. R. However. Journal of Speech and research is of great importance because of the reluctance Hearing Research. R. Garlitz. W.. Journal of Applied 983–1002. Persson (Eds. the woman Psychosomatic Research. Abdominal muscle activity during speech —Peter Watson production. B. Journal of Applied Physiology. Tucson. T. Hoit. Hixon. this abnormal breathing behavior—if it exists. and Milbrath (2000) found that Hearing Research. Journal of Voice. should examine what techniques are viable for changing Hoit. D. and W. Perceptual cues used to dysphonia. Arizona. In F. J.. J. Journal of Phonetics. J..). 217–231. J.84 Part I: Voice found that this person spoke in the lower range of her Greene. . Oxford. D. Physiology. tance to be reduced during syllable production at high Minifie. Kine- Lansing (1990) showed that with training. (2000). the Hixon. Journal of Speech and 1960). 5. 41. L. Grossman. of Speech and Hearing Research. J. R. A. (1986). T. and A.. (1976). (1980).. Modern techniques of vocal rehabilitation. 2656– References 2664. They believed the noisy orders (5th ed. Of note. aspects of speech. A. Clement. T. focus first on how and whether abnormal breathing be. and lung. M. 353–365. Clinical voice disorders: An interdisciplin. was in a lower vertical position in the neck than dur. Journal inspiration. S. J.). R. T. Respiratory function in speech. E. and van de noisy inspirations could have been eliminated or reduced Woestijne. (1989). B. M. of third-party insurers to cover voice disorders. J.. 50–63). J. Rock. A. the authors did not report any hyperventilation syndrome and anxiety disorders. 11. (1975). C. Speech and Hearing Disorders. Decker. (1995). Paper pre- sounded more authoritative. and that her voice seemed sented at the Veterans Administration Workshop on Motor to be much lighter when she spoke at higher lung volumes. Hixon. Journal of in this area is decisively needed. K. and Casper. Seminars in Speech and Language. J. Milstein. M. Perspectives on the Edin- adductory forces on the vocal folds (Zenker and Zenker. Voice therapy: A need for research. there was a tendency for laryngeal airway resis. and C. Voice abnormalities in re- downward movement of the diaphragm pulls on the lation to respiratory kinematics. Speech breathing kinematics and mecha- laryngeal area appeared more dilated and the larynx nism inferences therefrom. D. Stathopoulos. Plassman. London: Churchill Living. variation. and Mead. T. trachea. Speech breathing in women. (1984). abdomen. M. (1997). and rib cage. (1974).. NJ: Prentice-Hall. E. and Tuller. Journal of Voice. T. B. and Weismer.. and Mead. Journal of lems (2nd ed.. J. nematic analysis. 38. reproduce an inspired lung volume. 75–93). J.. 331–340. J.. (2000).. E‰cacy (1989). speaking women. Reed. Sapienza... and McFarlane.. (1980). Baltimore: Williams and Wilkins. Lindblom. Grossman. 33. D. E. A.. Journal of Applied Physiology. University of ville..

Journal of Speech and Hearing assumption that has not been proved empirically. pathology: Theory and management (2nd ed. E. (1986). A. Raphael (Eds. Hixon. and Gerdeman. J. L. 10. L. Mead (Eds. 49–56. and Sapienza. J. F... 1–36. J. MD: American Physiological Society. R. M. 1995. Sabol. E. (1990). supplied by the respiratory sys- cel Dekker. 411–427). this is considered Porter. and Loring. Respiratory Watson. Hoit. 387–409). Lansing. 24–31. Hogue. one management approach is direct modification Physiological Society. Cognitive- exercise and manipulation. Whenever a voice disorder is present. 32... 269–272. a change in the Konno. singers. and Griscom. 4. (1960). Guz (Eds. Folia Phoniatricia. speech intensity. 51. T. Respiratory kinematics in classical (opera) singers. Disturbances may occur in of diaphragmatic length on lung volume and thoraco- respiratory volume. T. J. 3.. Finally. T. and flow. J. In include Vocal Function Exercises (Stemple. W. and Adams. P. and F. Lee. and Bruce. 2000). E. P. J. Journal of Applied Physiology. Stemple. The Vocal Function Exercise program is based on an Watson. J. (1985). Washington. 93–104. 2000). 3.. Surface recordings and approximation. (1986). Ellis. B. S. and Davis. E. N.). San Diego. S. as well as sev- speech breathing kinematics in world-class Shakespearean eral e‰cacy studies (Stemple. vol. T. and Banzett. In The overall causes of vocal disturbances may be me- P. and Tobey. 3. H. power. nasal Handbook of physiology (vol. and Agostoni. 39. W. (1994). N. production: A Festschrift for Katherine Sa¤ord Harris 2000). Über die Regelung der verbal decision behavior upon respiration during speech Stimmlippenspannung durch von aussen eingreifende production. Mead. MD: American cause. 64–75.. manifest in vocal fold tone. 1552–1561. . 1994). balance. Druz. T. D. 40. J. and Zenker. Resonant Voice Therapy (Verdolini. Psychophysical events are measurable and may be modified by voice methods in the study of respiratory sensation. In Psycholinguistics: Experiments in spontaneous speech (pp. Clinical voice (1989). These physiological Journal of Applied Physiology.. oral cavity. (1986). In a double-blind. and actors. T. the Accent Method of voice therapy (Kotby. J. Voice Therapy: Holistic Techniques Goldman-Eisler. Glaze. tone may cause or be implicated in a voice disorder 657–667. strengthen and balance the vocal mechanism. Language. Nonetheless. S. pp.. and Sharp. Respiratory kinematics in female classical tensity variation. and the Lee Silverman Voice Smith. R. 104–122. Journal of Speech and Hearing Research. P. Respiratory sensation. J. voice are addressed in one exercise. J. tem. E.. Examples of holistic voice therapy namic analysis of speech and non-speech respiration. Studies in speech Klaben. and Hixon. 36. P. (pp. and Environment. Hoit. M. Handbook of physiology (vol. and Hixon.. (1985). pp. Research. Passive mechanical Treatment (Ramig. 159–169. (1967).. Mead (Eds. and Maher. the coupling of the supra- of respiratory muscle activity during speech: Some prelimi. and linguistic American Physiological Society. A.). T. 415–428). Journal of Voice... Bethesda. Webb. and laryngeal function of women and men during vocal in. J. 407–422. voice production may be assumed. Stemple. 100–106). (1993). 59. Activity of respiratory 535–556.. New York: Academic Press.. Watson. and Minifie. (1987). Journal of Voice.. 1. L. pressure.).. balance of these vocal subsystems may lead to or be Loring. T. W. Variability and consistency in speech breathing dur- tory system (3rd ed. glottic resonators and the placement of the laryngeal nary findings. R.. J. J. and Smith. Mechansimen. H. In P. MD: ing reading: Lung volumes. P. In P.. H. (Titze.. T. Speech breathing Further Readings and the lombard e¤ect. and Watson. Journal of Applied Physiolgy. Journal of Speech and Hearing Research. C. 1961–1970. factors. Adams therapy. Harris. Loring. Stathopoulos. sti¤ness.. When all three subsystems of linguistic demands and speech breathing.. supraglottic resonators (pharynx. A. S.. Roy et al. and Mead. Betheseda. D. R. Agostoni. Macklem and J. R. In L. (1968). Whatever the (3rd ed.). Betheseda.). (1989). Macklem and J.). J. B. (1994). H. E¤ects of Zenker. C. Bethesda. 120–128. Journal of Speech and Hearing Research.. 2000). mass. J. DC: American Institute of Physics. flexibility. Journal of Speech. R. The significance of breathing in speech. D. D. Statics of the respiratory Winkworth. A.. system.. Mead considers the use of Vocal Function Exercises to (Eds. Abdominal muscle activity during classical singing. E. The respiratory system chanical. 1–25). Normal voice production depends on a relative and A. or psychological. (1967). CA: Singular Publishing Group. D. Bell-Berti and L. McFarland. this assumption and the clinical logic that Watson. and may abdominal configuration.. holistic voice therapy. pp. Williams. To breathe or follows have been supported through many years of not to breathe—that is the question: An investigation of clinical experience and observation. 28. J. In P. 1995. W. J. Hixon. Winkworth. (1996). coordination. The respira. Mead.. Glaze. T. (1995). balance among airflow. cavity). E. Journal of Speech and Hearing Research.. 2001). Respiration. Any disturbance in the relative physiological MD: American Physiological Society. and Sullivan. Mead (Eds. T.. Macklem and J. Macklem and J. laryngeal muscle strength. A. 1994. 12. J. Methods for study of and stamina. R. 3. 22. Journal of Voice. 3. 429–442).).. (1996). 37. Journal of Speech and Hearing Research.. F. vol. of the inappropriate physiological activity through direct Mitchell. New York: Mar. pp. (1981). 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Significant improvements in the physiologic tion Exercises. The goal is to achieve no voice breaks. The patient’s lips are to be patient to normal voice production. the goal is based on reaching 80–100 mL/s voice. Jacobson and evening. cluding increased airflow volume. The patient may requires the use of all laryngeal muscles.and post-testing of all three home. the intrinsic range. forward focus. Briess suggested the current range and the patient typically has more that for the voice to be most e¤ective. appropriately. The patient language pathologists trained by the experimenters in is then taught a series of four exercises to be practiced at the two approaches. if the flow volume is 4000 mL.) Voice breaks will typically occur in the regain the balance among airflow. the patient is encouraged to continue the glide A series of laryngeal muscle exercises was first de. 1995).86 Part I: Voice placebo-controlled study. patient’s own stroboscopic evaluation video. rounded. lem to the patient. The program begins by describing the prob- weeks the experimental groups followed their respec. during randomly assigned to three groups: Vocal Function which they may plot the progress of their return to vocal Exercises. and connective tissue. injured. Indeed. These exercises were modi- regimen of singers. and his therapy methods were not in maximum phonation times. in. preferably morning groups using the Voice Handicap Index (VHI. and control groups. this group of superior voice users. 1997) revealed significant improvement in the Vocal Function Exercise group. Briess’s strated that Vocal Function Exercises were e¤ective in exercises concentrated on restoring the balance in the enhancing voice production in young women without laryngeal musculature and decreasing tension of the vocal pathology. It stretches the then begin conservative voice use and follow through vocal folds and encourages a systematic. decreased airflow whether the disorder is one of vocal hyperfunction or rates. All exercises and then the primary rehabilitation begins. The glide mit healing of the mucosa to occur. Unfortunately. Barnes (1977) Sabol. or the word whoop may step was neglected—the systematic exercise program to also be used. These exercises include the following: et al. to sustain. When the knee is 40–45 s.. almost but not quite nasal. the glide may be continued without voice as the . parison of knee rehabilitation with rehabilitation of the In our clinic. 1959). and a sympathetic vibration should be felt on patients are not fully rehabilitated because an important the lips. Placement of the tone should be in an extreme The immobilization is followed by assisted ambulation. similar in concept to physical therapy. (1994) demon. So. seem reasonable to patients. of airflow. when presented Roy et al. and the encourages a forward placement of the tone as well as an therapy program often is successful in returning the expanded open pharynx. decreased airflow rates. and supraglottic placement of the tone. Rehabilitation of the voice may also involve a short period of voice rest after acute injury or surgery to per. the word knoll. even in hypofunction. the goal is equal to the longest /s/ that the patient is able mobilization to reduce the e¤ects of the acute injury. two times each. direction. F rated themselves worse. laryngeal muscle transitions between low and high registers. tongue trill. When breaks activity. using illustrations as needed or the tive therapy programs and were monitored by speech. many patients are enthusiastic to have a concrete pro- Teachers who reported experiencing voice disorders were gram. Subjects in the control group sical note: F above middle C for females and boys. Pre. without hesitation. (A lip trill. This is considered a warm-up strengthen and balance all of the supportive knee mus. The exercise program strives to balance measurements of voice production were achieved. used graduate students of opera as fied and expanded by Stemple (1984) into Vocal Func- subjects. Sustain the /i/ vowel for as long as possible on a mu- the vocal hygiene group. twice a day. experimenting with described a modification of Briess’s work that she the value of Vocal Function Exercises in the practice termed Briess Exercises. below middle C for males. cles for the purpose of returning the knee as close to its 2. Frequency ranges were widely followed. Lee. The primary physiological e¤ects were hyperfunctioning muscles. and Stemple (1995). For 6 e‰ciency. (Pitches may be modified The laryngeal mechanism is similar to other muscle up or down to fit the needs of the patient. the goal is cartilage. The exercises are simple to teach and. however. slow engage- with all of the management approaches that seem nec. muscles of the larynx must be in equilibrium. Full voice use is then resumed quickly. Glide from your lowest note to your highest note on normal functioning as possible. exercise. but not breathy. The goal of the exercise is based on airflow volume. This exercise is designed to voice must be engaged. and strengthen the subsystems of voice production. and no improvement in 1. strengthen voice production persisted. tion Exercises in a population with voice pathology. ment of the cricothyroid muscles. When the voice breaks at the top of scribed by Bertram Briess (1957. and a subsequent increase tion were incorrect.) the analogy that we often draw with patients is a com. The concept of direct exercise to extended significantly in the downward direction. in the form are produced as softly as possible. vocal hygiene. many as- reflected in increased phonation volumes at all pitch sumptions Briess made regarding laryngeal muscle func- levels. Seldom are systems and may become strained and imbalanced for a they modified by more than two scale steps in either variety of reasons (Saxon and Schneider. Indeed. When airflow measurements are not available. and increased maximum phonation time. occur. Stemple et al. The word knoll essary. (2001) studied the e‰cacy of Vocal Func. Often. Both the knee and the larynx consist of muscle. rehabilitation includes a short period of im. The of systematic exercise.

). thus giving the sense of more air. This is considered a low-impact Each taper should last 1 week. 1 time per day (morning) ability. The shape of the pharynx in  Full program. Sustain the musical notes C-D-E-F-G for as long as therapy goal. This  Full program. many of our patients desire to taper the exercise pro- The goal is the same as for exercise 1. 2 times each. Rather. (1957). exercise. and Orliko¤. Times do not increase with improved lung capacity. and supraglottic placement. Assessment of laryngeal function. 2 times each. then a tapering maintenance should be around middle C for females and boys. The patient is to compare today with tomorrow. Finally. 2 times each. Voice Therapy: Holistic Techniques 87 folds will continue to stretch. Briess exercises. posturing the vowel momentarily. Although the basic range of middle C (an octave  Exercise 4. Cincinnati. . breathing. D.) Behrman. 1 time each. 1 time each.  Exercise 4. 6(4). the exer. Archives who think they are ‘‘tone deaf’’ can often be taught to of Otolaryngology. New York: the exercises may be given to the patient for home use. which is lacks tension. or the word boom may also be used. The range symptoms have improved. or a tape recording of live voice doing and D. The quality of the tone is also monitored for voice Vocal Function Exercises provide a holistic voice breaks. In C. The following systematic taper is recommended: duced with an open pharynx and constricted.) This is continue the program through the discomfort should it considered a contracting exercise. In fact. When the patient has reached the predetermined 4. Some ing the sympathetic vibration at the lips. because of the word knoll. 1 time each. 9–16. 61–69. Raven Press. In addition. the downward patients experience minor laryngeal aching for the first glide encourages a slow. latory system. Phonosurgery (pp. and breathiness. by an inexpensive pitch pipe that the patient purchases Bless. Identification of spe- match than the pitch pipe. Extreme care concept of physical therapy for the vocal folds is under- is taken to teach the production of a forward tone that standable. with attention paid to training abdominal muscle activity. but sented at the Southwestern Ohio Speech and Hearing As- rather the e‰ciency of oxygen exchange with the circu. As this focused growl. Workshop pre- aerobic exercise does not improve lung capacity. wavering. (1997). laryngeal deeply. Seldom. October). Glides improve muscular approximate the correct notes well with practice and control and flexibility. Glide from your highest note to your lowest note on ress. R. and so on. 85% of their peak time. OH. Voice therapy: Part 1. occur. voice users choose to remain in peak vocal condition. The estimated time this exercise. no growl is permitted. discomfort will soon subside. 2 times per day respect to the lips is like an inverted megaphone. Bless (Eds. We have found that patients cific laryngeal muscle dysfunction by voice testing. which is a means of plotting prog- 3. that might occur with any new muscular exercise. they are encouraged to tongue trill. Tone quality treatment program that attends to the three major sub- improves as times increase and pathologic conditions systems of voice production. B. 1 time per day (morning) cises may be customized up or down to fit the current  Exercise 4. is the exercise shifted more than two scale steps in either direction. J. 66. Many patients find the tape-recorded voice easier to Briess. and the voice quality and other vocal possible on the word knoll minus the kn. 1 time per day (morning) lower for men) is appropriate for most voices. This is considered a stretching guidance from the voice pathologist. A. By keeping the pharynx open and focus. The -oll is pro- gram. Although some professional octave below middle C for men. normal daily variability. an program is recommended. progress may be easily plotted. 1 time each. of completion for the program is 6–8 weeks.  Exercise 4. It is explained to the patient that maximum phonation times increase as References the e‰ciency of the vocal fold vibration improves. and it appears to balance and tal onset of the tone. It is much more di‰cult to produce soft tones. sympa- thetically vibrating lips. instructed to feel a half-yawn in the throat throughout weekly comparisons are encouraged. and then initiating the exercise gesture without a forceful glottal —Joseph Stemple attack or an aspirated breathy attack. (1977. It is therefore. systematic engagement of the day or two of the program.. patients are encouraged not The goal is to achieve no voice breaks. Instrumentation in voice The musical notes are matched to the notes produced assessment and treatment: What’s the use? American Jour- nal of Speech-Language Pathology. patients are given a chart on which to mark their sustained times. cause it is reasonable in regard to time and e¤ort. (Even Barnes. 1 time per week (morning) however. similar to the muscle aching thyroarytenoid muscles without the presence of a back. The patient is asked to breathe in strengthen the relationships among airflow. (1991). (A lip trill. sociation. Progress is monitored over time and. The program appears to begin to resolve. Ford for use at home. 91–122). Patients should maintain adductory power exercise. 1 time per day (morning) exercise may be tailored to the patient’s present vocal  Full program. otherwise they should move up one step in the taper until the 85% criterion is met. attention is paid to the glot- inherently motivating. 3 times per week (morning) vocal condition or a particular voice type. All exercises are done as softly as pos- benefit patients with a wide range of voice disorders be- sible. the vocal subsystems will receive a better similar to other recognizable exercise programs: the workout than if louder tones are produced.

for further clinical studies to rule out neurological causes. 1994). Stemple traceable to hyperadduction resulting from vocal fold (Ed. to several di¤erent voice therapy options. In turn. K. The accent method of voice therapy. amplitude oscillations during voice production. to several di¤erent classification schemes. each therapy option maps to multiple and Stemple. Many of J. Bethesda. Resonant voice therapy. Treatment that National Institute of Deafness and Other Communicative increases vocal fold closure is indicated in such cases.). (1994). 1995). 42–49). (2000).. (1995)..88 Part I: Voice Briess. Columbus. and non- orders. Pho- Stemple. impact stress (Jiang and Titze. and by the Roy. L. 44.. Dove. and non- agement (1st ed. and Schneider. Johnson. paresis. Here we review voice therapy in relation treatment approaches for teachers with voice disorders: A to (1) vocal biomechanics and (2) a specific therapy prospective randomized clinical trial. (1984). A. In J. Kotby. Journal of Speech and approach—roughly the ‘‘what’’ and ‘‘how’’ of voice Hearing Research. J. Lack of voice restoration suggests the need 66–70.. However.. Principles of voice production. breathy disruptions in occupational. specific inflammation consequent on voice use are Stemple. and Pickup. L. or emotional domains. same token. The accent method of voice therapy. cases. San Diego. D’Amico. B. Vocal exercise physiology. vocal fold paralysis. health-related. Voice therapy: Clinical studies (2nd ed. voice therapy is e¤ective in reducing such dis- phases of laryngeal muscle dysfunction. should be reduced by it. matory. 69. CA: Singular Publishing Group. J. Hicks. the conditions listed in the various classifications map pp.. or diagnostic considerations. Essential treatment tions. Vocal function exercises. There is evidence that the quiet. Stemple (Ed. This general approach is sensible for the reduction of hyperadduction and thus Voice Therapy for Adults phonotraumatic changes. The ditions. L. which results viduals with neurological disorders: Parkinson disease. Examples include Titze. in that vocal fold impact stress.. Health-related concerns are less common laryngology. the use of widely separated vocal folds and small- San Diego. K. 271–278. communicative. ruptions. precancerous. 34–46). voice therapy may be indicated in cases of cative Disorders.. (1959). Lee. indi- voice problems often experience significant functional viduals may also restrict their use of a quiet. In cal disease such as cancerous. Functional voice assessment: What to mea. (1995). C. The restoration of a normal or near-normal Voice Handicap Index (VHI): Development and validation. N. and Stemple. see Hillman et al. In Assessment of speech and voice production: Re.. and phonotrauma. M. and Klaben. 46–62). and Newman. (1997). L. (2000). Voice therapy: Clinical studies (2nd ed. pp. therapy. N. H. 1993). Journal of Voice. Sabol. 6(3).). J. Adults with clinic (Verdolini-Marston et al. Verdolini. useful adjunct to medical or surgical treatment in these MD: National Institute of Deafness and Other Communi. voice extraclinically because it is functionally limiting physical. breathy voice approach is Voice therapy for adults may be motivated by func.. 8.. problems that are amenable to voice therapy involve San Diego. (2001).. San Diego. I. B.). social..). CA: Singular Publishing Group. Corbin-Lewis. Casper. Benninger. S.. J. 61–69. MD: discussion. In in a certain amount of nosological confusion. J. Adduction causes monotonic increases in San Diego. physi- Harris. (2000).. The preponderance of voice Saxon. Vocal Biomechanics. 9. B. inflam- J. G. S. (Titze. Voice therapy may be a Research and clinical applications (pp. exacerbated by behavioral factors such as smoking. (1991).. K.). Clinical voice stress appears to be a primary cause of phonotrauma pathology: Theory and management (3rd ed.. impact stress. e¤ective in reducing signs and symptoms of phono- tional. The value of vocal function exercises in the practice regimen of singers. (1994). Simon.. San Diego. CA: Singular Publishing Group. diet. bowing. adduction is indicated in cases of hyperadduction. or neurogenic disease may exist and may be pp. 1994). (2000). diagnostic uncertainty. (1991). 1995). Grywalski. atrophy. B. polyps. Lee Silverman voice treatment for indi. Journal of Voice. J.. the problem. 286–296. 62–75). or phonotrauma. C. exam- ples are use of a ‘‘quiet.. D. Lee. voice with therapy may suggest a functional origin of American Journal of Speech-Language Pathology. pp. 204–209). (2000). Gray. 1989). CA: Singular Publishing Group. Finally. (Verdolini-Marston et al. J. CA: Singular Publishing Group. Voice therapy: Part II. An evaluation of the e¤ects of two classifications. impact Stemple. NJ: Prentice-Hall. Voice therapy: Clinical studies (2nd ed. Englewood variety of biomechanical solutions. The traditional ap- Cli¤s. 76–81). An- cacy of vocal function exercises as a method of improving other large group of diagnostic conditions involves voice production.. sure and why.). precipitants of voice therapy in adults. traumatic lesions for individuals who use it outside the Functional issues are the usual indication. Stemple (Ed. Measurements for assessment of voice dis. A classic situation is the need Jacobson. Bethesda. E‰. In J. Clinical voice pathology: Theory and man. A. Silbergleit.. However. Glaze. . some form of abnormality in vocal fold adduction. CA: Singular Publishing Group.. C. Archives of Oto.. for a search and clinical applications (pp. breathy voice’’ (Casper et al. CA: Singular Publishing Group. San Diego. Voice therapy can be characterized with reference Ramig. B. adducted hyperfunction (muscle tension dysphonia. In Assessment of speech and voice production: hydration.. I. M. 1993) or quiet ‘‘yawn-sigh’’ phonation (Boone and McFarlane. OH: Merrill. Voice therapy: Clinical studies (2nd ed. notraumatic lesions such as nodules.. 27–36. (1995). Stemple proach to hyperadduction and its sequelae has targeted (Ed. and in selected popula. Disorders. Voice therapy addresses adductory deviations using a Titze. hypoadduction of the vocal folds. therapy targeting a reduction in Stemple.. to distinguish between functional and neurogenic con- Jacobson. 1989. Thus.

1988. There is increasing support was developed for individuals with either hyper. hypophonia. paragraphs. resis may also be implicated. Solomon and DiMattia. Programmatic approaches to resonant the basic biomechanical changes described in preceding voice training have shown reductions in phonatory ef.. 1996. and others. Hamdan et al. such as altering conditions known or presumed to be related to hyper. and thus reduces the potential for phonotraumatic injury Specific Therapy Approach. as in mutational falsetto... Facili- that individuals use this type of voicing outside the clinic tating techniques are used by many clinicians and are more than the traditional ‘‘quiet. and sleeping position.. 1994. 1998). Brief eling has indicated that nonlinear source (vocal fold)– courses of aggressive laryngeal massage by skilled prac- filter (vocal tract) interactions are critical in maximizing titioners have dramatically improved voice in individuals voice output germane to resonant voice and other voice with this condition (Roy et al. voice problems and dehydration (Verdolini-Marston. Often. Resonant voice training may also be useful in ception is digital manipulation. 2000).. a wide range of laryngeal diseases. 1995). the medical condition in. Moreover.. An example is the Lee The clinical consensus is that voice therapy generally is Silverman Voice Treatment (LSVT). Sapir. cal hygiene programs alone in voice therapy apparently volves barely separated vocal folds. LSVT uti- aspects of biomechanics that influence the vocal fold lizes a predetermined hierarchy of speech tasks in 16 mucosa.g. the Lessac-Madsen Resonant Voice Therapy (LMRVT). as long as 2 years following therapy termination ioral control of laryngopharyngeal reflux. Titze. The configuration in. Sapir. some of which have been sub- abnormalities are functional. In comparison grams (see voice hygiene). Fox et al. Thus. as well as other maneuvers. may temporarily improve symptoms of adduc- vocal fold elongation abnormalities as the salient feature tory spasmodic dysphonia and increase the duration of of the vocal condition. Some data are consistent with the 1993).. 1994). Verdolini. such as falsetto and breathy A relatively small number of clinical cases involve voicing. 2002). hydration regimens are appropriate for individuals with Another programmatic approach to voice therapy. used for with hypoadducted dysphonia. eclectic and entails implementing a series of facilitating Marston et al. Titze. including inflamma- volved ‘‘pushing’’ and ‘‘pulling’’ exercises.. Ramig. and Titze. therapy can play a supportive role to the medical or 1994). and laryngeal appearance (Verdolini.or for the view that laryngopharyngeal reflux plays a role in hypoadducted voice problems associated with nodules. such as nodules. although thyroarytenoid pa. However. Dehydration (Ramig. Voice Therapy for Adults 89 The traditional approach to hypoadduction has in. Recent theoretical mod. voice therapy usually also addresses nonphonatory cies in individuals with Parkinson’s disease. and using digital manipulation. data are lacking for most of the techniques. mitted to formal clinical studies. Indeed. changing the loudness of the voice. However. 2001). contexts. Critical aspects of LSVT that may whereas hydration decreases it and also decreases laryn. The traditional approach is fort. but also prosodic and articulatory deficien- ics. breathy voice’’ because generally considered e¤ective. has increased vocal loudness and voice inflection for The primary issues targeted are hydration and behav. formal e‰cacy it is functionally tractable (Verdolini-Marston et al. in addition to addressing laryngeal kinemat..’’ perceptually corresponding to anterior oral related to voice training and therapy models. surgical treatment of laryngopharyngeal reflux by edu- sions that this approach can increase voice intensity in cating patients regarding behavioral issues such as diet individuals with glottal incompetence (Yamaguchi et al. ‘‘loud’’ voice to treat not only hypoadduction and Finally. Speech- vibratory sensations during ‘‘easy’’ voicing (Verdolini language pathologists may train individuals to acquire et al. some data corroborate clinicians’ impres. as well as reductions in functional techniques such as the ‘‘yawn-sigh’’ and ‘‘push-pull’’ disruptions due to voice problems in individuals with techniques. titions of the target ‘‘loud voice’’ in a variety of physical and Fennell. emerged in cognitive mechanisms involved in skill ac- ate laryngeal configuration has been called ‘‘resonant quisition and factors a¤ecting patient compliance as voice. An ex- 1995).. view that control of laryngopharyngeal reflux can im- A more recent approach to treating adductory prove both laryngeal appearance and voice symptoms in abnormalities has focused on the use of a single ‘‘ideal’’ individuals with a diagnosis of laryngopharyngeal reflux vocal fold configuration as the target for both hyper. and Woodson. 2001). strength (relatively strong) and vocal fold impact stress. the e¤ectiveness of botulinum toxin injections (Murry volves cricothyroid paresis. Such issues are addressed in voice hygiene pro. (Shaw et al. Coun- increases the pulmonary e¤ort required for phonation. Voice therapy has been less Several programmatic approaches to voice therapy successful in treating such conditions. vo- adduction and hypoadduction. which is ‘‘ideal’’ produce little benefit if they are not coupled with voice because it optimizes the trade-o¤ between voice output production work. tryman et al. Voice produced with this intermedi.g. ‘‘yawn-sigh’’ phonation. Voice reduce the glottal gap (e. contribute to its success include a large number of repe- geal phonotrauma (e. 2001. Also. This treatment uses useful in treating mutational falsetto. LSVT mucosal vulnerability to trauma are the key concerns.. interest has (Berry et al. 1997). which should tory and even neurogenic and malignant disease. 1995). Recently. the tongue position. therapy sessions delivered over 4 weeks. 2001). adduction. voice quality. there is evidence using chant talk. Other elongation have been developed. presumably hyperfunctional dysphonia.. specifically manual improving vocal and functional status in individuals circumlaryngeal therapy (laryngeal massage). Mucosal performance and with control and alternative treatment groups. . variants of types (Titze. idiopathic. Sandage. Boone and McFarlane.

K. some clinicians have found that sensory matched controls. Koufman.. Accent Therapy. Verdolini. P.. in adult monkeys. W.. Data on preliminary versions of LMRVT Boone. and sulcus vocalis. 1994). M. and Panetti. 279–282. K.. Rele- hypoadducted conditions (Smith and Thyme. S. Changes in vocal loudness following intensive voice treat- tions have been reported relative to ventricular phona. Journal of Speech- quent to overuse. Journal of Voice.. reflux.. Boone. S. (1987).. N.. R. typically are delivered over 8 weeks. 75–80. Journal of Voice. laryngeal appearance. ing for sorority women with phonotrauma or the use Byl. 98–103. H.. and Fuleihan. Carryover exer. Searl.. R. and Jenkins. et al. J. 47. Neurosurgery. In J. B. Measurement of vocal fold ideal laryngeal configuration—barely touching or barely intraglottal stress and impact stress. a configuration considered to disorder patients. visual feed. 10. addresses the Jiang. be ideal because it maximizes the ratio of voice output Chan. A quantitative output- intensity to vocal fold impact intensity (Berry et al.. (1993). The voice and indicate that it is as useful as quiet.. M. N... S. S. Laryngeal image biofeedback for voice vocal folds for phonation. L.g. H. M. and Titze. C. 286–296. 868–872. R. Dove. 44. 79–83. Y. bowing. that is. numerous voice conditions.. An evaluation of the e¤ects of cupational injuries. Amin. A 6. A of amplification for teachers with voice problems in primate genesis model of focal dystonia and repetitive strain injury: I. D. S. Movement Disorders. voice therapy (5th ed. M. (2001). Neurology. W. P.. Colton. Montequin. A critical view of sizes sensory processing and the extension of ‘‘resonant the yawn-sigh as a voice therapy technique. (2001). R. J. Hess. 493–498. and McFarlane. 121.. L. L. (2001). breathy voice train. 44. 28. Berry. LMRVT targets the use of barely touching or barely separated Bastian... 373– 2001). K. Countryman. D. R. M. J. Young. Learning-induced dedi¤erentiation of the repre- reducing various combinations of phonatory e¤ort. Sapir. Younes.. S. 16.. A.. Voice therapy: Clinical both hyper. and Woodson. 32. Gray. N. separated vocal folds—in individuals with hyper. for phonation. D.. J. 410–418. Also.. S. ment (LSVT) in individuals with Parkinson’s disease: tion (Bastian. repetitive strain injury—one of the fastest growing oc. Objective assessment of vocal greater phonatory ease. G. 6. C. Otolaryngology–Head and Neck Sur- cally stressed vocal repetitions. Another program. Investigation of selected voice therapy techniques.. treatment of adductor spasmodic dysphonia with botulinum rope and Asia than in the United States.. (1995). Electromyographic biofeedback has been reported to Ramig.. . toxin and voice therapy. —Katherine Verdolini Folia Phoniatrica. R.. Journal of voice’’ to a variety of communicative and emotional Voice. B. paralysis. I. vance of reflux in 113 consecutive patients with laryngeal Training entails the use of specified rhythmic. D. Byl. 508–520. 1. prosodi.. Journal of Voice.. I. Corbin-Lewis.. L. (1996). O.. and better voice clarity than that hyperfunction: An experimental framework and initial achieved with vocal hygiene treatment alone (Roy et al. M.). omeprazole. 1987).. 1976). Journal of Voice. week program of VFE in teachers with voice problems Hillman. Acta Otolaryngologica. 7. Care of the Professional Voice. J. W. 29–37.90 Part I: Voice polyps. 385–388. Simon. Hoehn. be e¤ective in reducing laryngeal hyperfunction and la. O’Brien. back using videoendoscopy may be useful in treating Ramig. Subjective. A comparison with untreated patients and normal age- Finally. laryngoscopic. (1976). Training consists of dation. and functional sta. vocal folds that are barely touching or Paper presented at the 18th Symposium of the Voice Foun- barely separated.. Sapir. consonants and progressing to phrases and extended Murry. (1994). R. Stemple et al. J. G. The Accent Method is more widely used in Eu. and Thyme. results. atrophy..).. 1996). Intensive voice treat- ryngeal appearance in individuals with voice problems ment (LSVT) for patients with Parkinson’s disease: A 2 linked to hyperadduction (nodules). cost ratio in voice production. (2001). A. year follow up. In LMRVT. the treatment of repetitive strain injury is motivated by (1996). Walsh. beginning with sustained gery. J. 271–276. K. E.. resulted in greater self-perceived voice improvement. K. E. A. R. environments. A. (1993). C. and Psychiatry. (2000). I. Combined-modality speech. C.. D. M.and hypoadducted conditions is called Vocal methods (pp. Stemple (Ed. Brewer. tus (Verdolini-Marston et al.. P. Pawlas. repeating maximally sustained vowels and pitch glides Hamdan. S. Fox. 1995). Merzenich. NJ: Prentice Hall. Casper. and acoustic measure- reports of fused representation for groups of movements ments of laryngeal reflux before and after treatment with in sensory cortex following extensive digit use (e. N. 39–45).. E¤ect of aggressive therapy on laryngeal symptoms twice daily over a period of 4–6 weeks.. eight structured therapy sessions Hearing Research. Merzenich.. Sharara. Objective methods for the evaluation of Another programmatic approach to voice therapy for vocal function. and voice characteristics in patients with gastroesophageal cises to conversational speech may also be used. and Vaughan.. Shaw. M. References paresis. St. R. specific clinical observa. Statistic research on changes in speech due to pedagogic treatment (the accent method). (2001). 123. and Jenkins. Repetitive strain injury involves two treatment approaches for teachers with voice disorders: decreased use of manual digits or voice and pain subse. M. 8. approach targets similar vocal fold biomechanics as (1989).. J. Smith.. D. Attention to sensory di¤erentiation in Language-Hearing Research.. Journal of Neurology. 71. C. Journal of Speech-Language- 2001). Function Exercises (VFE. di¤erentiation exercises may help in the treatment of Roy. Holmberg. and Miner. Journal of Speech and Hearing Research. and Woo.and 132–144. A. Englewood Cli¤s. A prospective randomized clinical trial. and voice disorders. O. W. M. Perkell. A. and McFarlane. This Casper. J. A. (1994). and Titze. sentation of the hand in the primary somatosensory cortex voice quality. and Countryman. S. (1989). W. LMRVT. Louis: Mosby–Year Book. T. and Stemple. nonspecific phonotraumatic changes. Training empha. New York. 392. C.

Dependence 1983). (1994). neurological aging-related voice disorders and their Hirose. K. 1989. Preliminary study of two methods A thorough laryngological examination coupled with a of treatment for laryngeal nodules. voice disorders associated with aging. changes from voice disorders. Journal of Voice. 9. CA: Singular Publishing Group. Stemple (Ed. CA: Singular/Thompson Learning.. In 1983. Central nervous system changes include nerve cell losses Verdolini. Druker. is associated with decreased Diego. 1001–1007. Sandage. and Di Mattia. The upper respiratory system. larynx and respiratory sys- San Diego. Ringel suggested that age-related changes of the voice Verdolini.. B. D’Amico. Some considerations structure and function do exist as a result of aging. the layers of the lamina propria. ever. This results in the slowing of motor move- ments (Scheibel and Scheibel. S. D. This article focuses on neurologically based voice disorders associated with general aging. and speed of articulation (Leonard et al. Glaze. San Diego.. N.. R. Case study: Resonant voice therapy. M. Voice therapy: Clinical studies (2nd ed... Voice therapy: Clinical studies (2nd ed. (2001). D..). I. Journal of Speech remodeling account for changes in laryngeal function and Hearing Research.). M. S. (1998). R. (1994).. 1997). and Bless. (1994). although changes in therapy (5th ed. N. E. (2000). complete voice assessment will likely reveal obvious 74–85. Related Voice Disorders Stemple. Ramig and pp. L. Pushing treatment options. strength. Mechanical stress in phonation. Yotsukura. McFarlane. Watanabe.. Verdolini. I... (1994). R. (1993). Voice Therapy for Neurological Aging-Related Voice Disorders 91 Solomon. S. parietal. must be viewed as part of the normal process of physio- (1998). C. San Diego. E‰- cacy of vocal function exercises as a method of improving voice production. Neurological. 37. Regulating glottal airflow in phonation: The neurobiological changes that a person undergoes Application of the maximum power transfer theorem to a with advancing age produce structural and functional low dimensional phonation model. Titze.... Anatomical (Hirano. and Ramig. 341–362. IA: National Center for Voice and Speech. NJ: Prentice Hall. (2000). San Diego. Verdolini. Journal of paralysis is described in another entry. (2000). 367–376. 7. D.. 26. D. Colton. Y. (2002). endurance. and vocal output in older adults. a . I. Journal of Introduction Voice. P. 1965) clearly demonstrate that di¤erences in Verdolini. Traumatic or idiopathic vocal fold exercise program to correct glottal incompetence. K. of the brain. (1999). CA: Singular Publishing vocal folds lose collaginous fibers. Nervous system changes are also associated with tremor. and Caldwell. gan system interaction (i. and Krebs. Principles of voice production. 8. E. (1994). The studio (pp. and Gerdeman. It still remains Verdolini-Marston. 271–278. or- Stemple.. Kurita. and chemical degradation at synaptic junctions.). (1996). G. L. This entry describes Yamaguchi. Englewood Cli¤s. DeVore. Review: Occupational in the cortex of the frontal. L. CA: Singular Publishing Group. tems). Hirosaku. 315–327. Englewood Cli¤s. 8. K. and temporal lobes risks for voice problems. K. Journal of Voice. Palmer. J. Nerve conduction velocity also contributes to speed of voluntary move- ments such as pitch changes.. K. 99–105. (1994). H. do not necessarily result in abnormal voice quality. J. vocal Verdolini. and Fennell.). disease... 12. In vocal fold epithelium. P. 1975). and Titze. Arnold.. Burke. logical aging of the entire body (Ramig and Ringel. and Vocology.. J. coordination. sti¤ness. mal changes that result from aging. In tract. H. The Accent Method of voice therapy. Titze. R.e. J. G. A. Phoniatrics. Voice Therapy for Neurological Aging- cally fatiguing task and systemic hydration on phonation threshold pressure.. R. Baltimore: Williams and Wilkins. C. and McCoy. K. E¤ects of a vo. 46–62).. Lee. the larynx. Titze. K.. Voice tradition and technology: A state-of-the-art and the muscles of the larynx change with aging. 1987) and histological studies (Luchsinger and Titze. and Samawi.. 1987). S. NJ: Prentice Hall. K. M. and oral cavity all reflect both normal and abnor- J. San like other organ systems.. speed. (1995). Stemple. Clinical voice pathology: Theory and management (2nd ed. J. C. (1995). and Pickup. Laryngeal adduction in resonant voice. and Casper. 227–239). Journal of the Acoustical changes in all of the organs and organ systems in the Society of America. 250–256. Glaze.. N. Journal of Voice. R. similar across organ systems. C. A. These changes. musculoskeletal. M. nerve conduction velocity. Aging of the vocal organs.. (1995). K. leading to increased Group. as is Parkinson’s Voice.. The voice and voice (Chodzko-Zajko and Ringel. K. M. Nair. circulatory function.. L. Understand voice prob- specific organs may derive from various causes and lems: A physiological perspective for diagnosis and treatment mechanisms. The on the science of special challenges in voice training. 8. Iowa City. H. Kobayashi. and circulatory of phonatory e¤ort on hydration level. 30–47. and Yukizane. I. Kotby. Ostrem.). K. Journal of Voice. 14. increased loudness. R. I.. CA: Singular Publishing Group.. Lessac. The e¤ects of normal aging are somewhat (2nd ed. accuracy. Y. how- Verdolini-Marston. Journal of Logopedics. Kahane. body. The neurological impact to the aging larynx includes National Center for Voice and Speech’s guide to vocology. central and peripheral motor nervous system changes. Further Readings Voice production in the elderly is associated with other bodily changes that occur with advancing age Boone. 111. for the clinicians along with the help of the patient E¤ect of hydration treatments on laryngeal nodules and to identify and distinguish normal age-related voice polyps and related voice measures. K. R. 37–46. Journal of Voice.

Indeed. presence of tremor. but due to muscular weakness of the Other neurological disorders 16 8 upper body (Ramig and Ringel. atrophy. tion may reveal evidence of tremor. extended conversations. 1994). resulting in decreased current and previously diagnosed diseases. selective denervation of type complaint about his or her voice consists of an extensive II fast twitch muscle fibers (Lexell. Diagnoses of Subjects Age 65 and Older Seen at the function which result in patient perceived and listener University of Pittsburgh Voice Center perceived vocal dysfunction. Murry and Rosen reported on 205 ment of choice for most elderly patients with neurologi- patients 65 years of age and older.. increased breathy quality during condition seen more in the elderly than in young indi. the speaking and singing voice is not likely to be perceived Vocal fold atrophy 46 23 as ‘‘old’’ nor function as ‘‘old’’ (McGlone and Hollien. and as . if the neuromotor Diagnosis N % systems are intact and the elderly patient is healthy. Vocal fold paralysis 39 19 Laryngopharyngeal reflux 32 16 1963). The most common symptoms reported by this group Treatments for Neurological Aging-Related of patients are shown in Table 2. and pitch viduals. or decreased hearing acuity Muscular tension dysphonia—secondary 38 19 resulting in excessive vocal force (Chodzko-Zajko and Edema 14 6 Ringel. Excluding vocal fold paralysis. tremor (of the neurological aging may result in a number of voice dis. vocal fatigue. 1999). previous surgeries. and Durson (1996).92 Part I: Voice Table 1. 1990). Table 1 shows the cal aging-related dysphonias. The total number of diagnoses is larger since some tion that are characteristically associated with age- patients had more than one diagnosis. dopaminergic changes which decline breaks (especially breaks into falsetto and hoarse voice with aging may also a¤ect the speed of motor processing quality). direct vocal exercises. A review of surgical treatments can be found in Ford (1986). Prior to voice therapy. inaccuracies. Postma (1998). cardiovascular Muscular tension dysphonia—primary 15 7 changes (Orliko¤. thought to be broadly related to environmental e¤ects of A careful examination of the elderly patient with a trauma (Woo et al. Voice Disorders Neurological changes to the voice accompanying aging are related to decreased neurological structure and Treatments for elderly patients with mobile vocal folds presenting with dysphonia include behavioral. the voice may be perceived as ‘‘old’’ Parkinson’s disease 26 13 not solely due to neurological changes in the larynx and Essential tremor 8 4 upper airway. Tremor 7 to reduce hoarseness or breathy voice qualities. Hirano. 1987). increased breathiness. voice therapy is the treat- all vocal output. and in distal and motor neurons. certain aspects of voice produc- N ¼ 205. Spasmodic dysphonia 7 3 There are. contractile strength and an increase in muscle fatigue perceptual. and management of one complaint. and surgical approaches. diagnosis of this group (Murry and Rosen. The clinical examination of elderly individuals who complain of voice disorders should spe- cifically address and test for loss of vocal range and volume. scarring. vocal volume defi- ciencies. and physiological assessment of vocal func- (Doherty and Brown. and Chijina. and/or vocal fatigue. and changes in vi- The peripheral changes that occur in the elderly are brato (Tanaka. 1983). The use of Patients 65 Years of Age and Older medications and their relationship to vocal production Symptom % of Patients and vocal aging can be found in the work of Satalo¤ and colleagues (1997) and Vogel (1995). and vocal use requirements. Acoustic. the vocal environment. due to lack of glottic closure. 1993). or lesions. and to Intermittent voice loss 6 maintain a broad pitch range for singing. pharma- cological. 1988). Conversely. 1992). larynx or other structures). Elderly singers should be evaluated for pitch (Morgan and Finch. The Most Common Voice Symptoms Reported by (2000). however. In the orders. depending on the patient’s complaints. These needs Articulation-related problems 5 are met with vocal education including awareness of Total exceeds 100% as some individuals reported more than vocal hygiene. Examination of the larynx Voice Changes Related to Neurological Aging and vocal folds via flexible endoscopy as well as strobo- The central and peripheral degeneration and con. 1997) and decrease history including medications. asymmetrical vibration. related neuropathy. Finally. these neurological absence of suspected malignancies or frank aspiration changes account for disorders of voice quality and over. Koufman Table 2. Di‰culty breathing during speech 18 diagnosis. The most com- Talking in noisy environments 15 mon needs of patients with neurological age-related Loss of clarity 16 voice disorders are to increase loudness and endurance. videolaryngoscopy is essential to reveal vocal use pat- comitant regenerative neural changes that occur with terns. Loss of volume 28 Raspy or hoarse voice 24 Voice therapy for neurological aging-related voice Vocal fatigue 22 disorders varies.

or loudness that was present in earlier treatment of vocal fold lesions. senior citizen resi. 1997). to counteract the physical e¤ects of The confidential voice technique is appropriately reduced amplitude of motor acts including voice and used to treat benign lesions. and Gerdeman. and Lessass. and vocal fatigue in the in respiratory e¤ort. Rather. variety of other techniques (Verdolini-Marston. typically use to describe or discuss confidential matters.. Glaze. conditions with in- wears a hearing aid or aids. functional voice prob- years. One focus of the circumlaryngeal mas- its disorders. The goal is to create treatment method of voice therapy may be the most healthier vocal folds and a neutral state from which promising of all for neurological aging-related voice healthy voice use can be taught and developed through a disorders. and Heisey. This use and the vocal environment. endurance. laryngeal area. of continued pounding. Since then. and (5) force a heightened awareness of voice other forms of progressive neurological disease. it is necessary to push the entire . (2) specifically for patients with idiopathic Parkinson’s dis- allow lesions such as vocal nodules to heal in the absence ease (Ramig. (1990) and later elaborated by Morrison and Rammage dences. Voice therapy is one treatment modality for almost General body massage in which muscles are kneaded all types of neurological aging-related voice disorders. hands-on final vocal output. he or she should wear them complete glottal closure. Burke. 1997). 1995. 1995). The technique was first proposed by Aronson cal voice disorders. This program is observing changes in voice quality as the patient pho- an excellent guide for all aging patients with neurologi- nates. If the patient treatment of vocal fold paralysis. Therapy focuses on the production of Vocal education coupled with vocal hygiene provides the this voice primarily through feeling and hearing. Vocal maximum vocal function. (4) reset the internal volume extended to include aging patients and patients with meter. and Lemke. of four sessions per week for 4 weeks eliminate hyperfunctional and traumatic behaviors. Resonant voice. Ramig and colleagues developed a structured inten- Theoretically. Murry and Rosen pub- approach in which the clinician massages and manipu- lished a vocal education and hygiene program for lates the laryngeal area in a particular manner while patients (Murry and Rosen. and Poburka. bradykinesia. usually refers to an easy voice associated with vibratory sensa- Vocal Education tions in facial bones (Verdolini-Marston. Increased use of la. Recently. odyno- pathophysiology. and reduction hyperfunctional dysphonia. and their treatment. or those who demonstrate rigid postures. speech production. Bonitati. An understanding of how all body coupled with humming help the patient identify to opti- organ systems are a¤ected by normal aging helps to ex. desired goals should be e¤ective vocal communication and building muscle power. Res- plain why the voice may not have the same quality. Bless. it is produced with minimal vocal fold sive therapy program. e¤ort and control. for the therapy sessions. While treatment is designed to restore phonia. tenderness in the neck muscles. They reported almost normal voice Direct Voice Therapy following a single session in 93% of 17 subjects with hyperfunctional dysphonia. used with patients who report neck or upper body ten- creasingly focused on the specific nature of the observed sion or sti¤ness. function exercises are designed to pinpoint and exercise muscle wasting. or a scarred vocal fold. 1995). Roy and colleagues reported on their use of this outline as the first step in patient education when the massage technique in controlled studies (Roy. a thorough audiological early postoperative period. all of the systems that contribute Manual circumlaryngeal massage (manual laryngeal to the aging of these organs are responsible for the musculoskeletal tension reduction) is a direct. Burke. The softness of the pro- and forestalling continued vocal deterioration (Satalo¤ ductions is said to increase muscular and respiratory et al. rigidity. the up of the muscles. mum pitch/placement for maximum voice quality. stretching and contracting of muscles. and manipulated is known to reduce muscle tensions. 1997). the aging process of weakness. sage is to relieve the contraction of those muscles and ryngeal imaging and knowledge of laryngeal physiology allow the larynx to lower. to im- from our understanding of the aging neuromuscular prove vocal fold flexibility and movement. Confidential voice is the voice that one might balance airflow (Stemple. or voice with forward focus. 1994). vocal tract functions. muscle tension dysphonia. patients complain of voice disorders. This technique is most often have provided a base for behavioral therapy that is in. on the principle that. and system endurance may not restore specific laryngeal muscles. The confidential voice technique is used to (1) ment program. Nursing homes. The recent explosion of knowledge about the larynx is This concept is adapted to massage the muscles in the matched by an equal growth of interest in its physiology. 2000). Voice Therapy for Neurological Aging-Related Voice Disorders 93 part of the diagnostic process. mild vocal atrophy. and to re- process. The exercises are hypothesized to Specific techniques for the aging voice have evolved restrengthen and balance laryngeal musculature. and geriatric specialists should consider o¤ering (1993). the Lee Silverman voice treat- contact. It is not appropriate for assessment of the patient should be done. Exer- patient with an understanding of the aging process as it cises to place the vocal mechanism in a specific manner relates to voice use. and paralysis. The four steps address warm- the voice to its youthful characteristics. Since the voice is the product of respiratory and lems. Leddy. pitch onant voice therapy is described as being useful in the range. Samlan. (3) eliminate excessive muscular the e‰cacy of the treatment for this population has been tension and vocal fatigue. The Lee Silverman voice treatment program is based and Lessass.

18. Annals of Otology. A. Speaking fundamental fre- quency and chronological age in males. change is vocal tremor. challenge to the speech-language pathologist. Brody. P. and Ringel. system must provide more driving power. Journal of Nutrition. sound loudness. which is available in published mobile vocal folds and a neurological disorder may form. Diagnosis.. 1. Easy voice production with an open. Doherty. the treatment of aging-related dysphonias during voluntary movements of older individuals. the respiratory loss of clear voice quality. Vocal Tremor Hollien. B. of the patient in ways that may be novel and unusual. endurance problems. T. They are primarily interested in rapid 1248–1257. Rhinology. (1972). W. 40–44. Speech-Language Pathologists and Audiologists. M. E¤ective be helpful in reducing the perception of tremor especially treatments for hyperfunctional voice disorders. absorption materials such as rugs and cushions are used The program is highly structured and involves five in large meeting rooms. R. G. C. Voice use is maximized in latory mechanisms all benefit from the e¤ort to increase environments where background noise is minimal. Evidence for nervous system degeneration ditioning.. Otolaryngology–Head when vocal fold atrophy is also diagnosed. Advances for those that focus on increasing vocal fold closure (i. Postma. Voice clinicians work with individuals Ford. accentuated and rhythmic movements of the body and then of voicing. 52A. Clinical voice disorders. 135–140. T. a task that cannot always be Hirano. Connective tissue changes in the larynx voice disorders having a neurological component. and actors (Satalo¤ et al. and Yukizane. restoration of normal voice. which and relative sizes of the nar motor units as selected by mul- requires only that a pill be taken or an injection received. (2) a high degree to help with visual components of communication. Physiological methods used. which identifies the vocal use has been used to treat all types of dysphonias (Smith and habits of the patient is critical to identify strategies and Thyme. J.. and Poburka. Journal of Voice. H. lock. (1989). (4) the patient’s self-perception must be calibrated. 1011S– cises... of e¤ort is required. Leonard. Samlan. and the The vocal environment should not be ignored as a vocal folds must adduct more completely. and the ability to monitor voice change help to 1013S. Muscle and Nerve. Summary ductions and outcomes are quantified.. (2000). (1990). the laryngeal. (1997). and Speigel. The scope of this Progressive neurological aging-related disorders o¤er a article does not permit inclusion of the extensive litera. it factor in communication for patients with neurological seems that the respiratory. and ing on loudness. Lexell. munication.94 Part I: Voice phonatory mechanism to exert greater e¤ort by focus. originally developed by Smith. Indeed. 98. —Thomas Murry throat feeling is stressed. and the articu. tremor has been treated in the past with medications. maintain voice or retard vocal weakness.. 537–541. S. Laryngoscope. or overall volume Thieme-Stratton. voice disorder. This References method is useful for treating those individuals with Aronson. therapeutic techniques presented in this article may also Leddy. Journal of Voice.. (1986).. R. the patient with of the therapy protocol. voice therapy demands the cooperation aspects of aging. General physical con. particular behavior or set of behaviors. The aging brain.e. 155–159. It di¤ers from the surgical approach. fatigue. Cummins. Tremor often accompanies many Kahane. Durson. M. N. G. 18–26. K. J. T. To increase loudness. It has been adopted more widely abroad the specific exercises needed to maintain and/or improve than in the United States and focuses on breathing as the voice production. warmup. Regardless of the Chodzko-Zajko. Satalo¤. 96. J. 16. and (5) pro. 355–366. W. 122.. T.. 1976). It di¤ers from the work of voice and laryngeal nerve paresis and paralysis. H. 127. underlying control mechanism of vocal output and uses See also voice disorders of aging. M. Journal of Speech One neurological aging-related disorder that often resists and Hearing Research. (1993). (1997).. Kurita. Koufman. Diedrich. and Brown. E. (1987). (1992). benefit from specific exercises to maintain vocal com- The accent method. J. Histologic studies on the fate of soluble who never thought about the voice until they acquired a collagen injected into canine vocal folds. Journal of should include techniques used in training singers Gerontology. C. New York: vocal fatigue.. and Bla- and in some cases with laryngeal framework surgery.. Vocal and their e¤ects on voice. Lee Silverman voice treatment and the Accent Method). weakness. and Laryn- gology. A. wherein the sur. The specific and Neck Surgery. N. C. increased respiratory function exer. . Matsumoto. R. and proper lighting is available essential concepts: (1) voice is the focus. M. (3) treatment is intensive. D. normal voice. Vocal fold paresis. Journal of Voice. (1987). Asymmetry accomplished. 14. The estimated numbers Voice therapy di¤ers from the medical approach. and McMillan. 10. P. with advancing age. Superior geon does the work. Acta Neurologica Scanda- All voice therapy is a directed way of changing a navica (Supplement). 1997). of the laryngeal framework: A morphologic study of ca- daver larynges. Changes in neural modulation and motor control Finally.. In the ab- ture available on this method or an extensive description sence of surgery for vocal fold paralysis. Medical Sciences. tiple point stimulation in young and older adults. 137. acting coaches. 15. R. aging-related voice disorders. 27–30.. L. and attention is paid primarily to an abdominal/diaphragmatic breathing pattern. J. (1997). (1996).. M320–M325. J. who work to enhance and strengthen a 206–211. and Shipp.

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The e¤ects of drugs on com- guage: Clinical communicology—Its physiology and pathol. and Lessas. and Carter. and Heisey. Typically. R. 6. and Spiegel. R. D. Otolaryngologic Clinics of North America. 9. Emerich. either phonotrauma or functional problems. San Diego. McGlone. Other occupations at risk for voice laryngeal therapy for functional dysphonia: An evaluation problems are lawyers. (1998). R. firefighters. A. T. and Ringel. Rosen. D. Morgan.. recognition software. Journal of Speech and Hearing Re. Age. 98–103. scope.. J. Statistic research on changes The consequences of voice problems for professionals in speech due to pedagogic treatment (the accent method). R. 2. M. Thus. A professional voice user is a person whose job function Murry. K. between one-fifth and one-half of of Medical Speech-Language Pathology. L. L. Smith. CA: Singular Publishing recently surfaced in the form of repetitive strain injury. (1994). Ramig. G. In 1999. involves weak- J. Journal At any given time. 115. and Hollien. A. Structural changes in the petitive strain injury typically begin in the fingers after aging brain. The full 450–457. Rosen.. C. ness and pain from somatic overuse. L. and Woo. phonia in the aging: Physiology versus disease. C. and Thyme. This condition. (1997). and Gerdeman. loss of work. Vocal aging: Treatment critically depends on use of the voice. H. ment of an approach and preliminary e‰cacy data. Laryngo- search. Belmont. Hawkshaw. The aging adult voice.. Woo. Professional A new occupational hazard for voice problems has voice (pp. range of non-use-related vocal pathologies may occur in Postma. J. A. Symptoms of re- 156–160. C. K. Roy. where rele- geal nodules. Rosen and auctioneers are among those who use their voices sig- T. injuries in the United States in general. R.. Not only singers options (abstr. C... 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con- plicated by pathology. especially if these are unmiked. motor learning literature also clearly indicates the need ease. tually linked to heavy performance schedules without tioners feel that a specialty focus on vocology is impor. e. The motor learning literature indicates that groups that use the voice quantitatively (e. 2001). stages include aromatic diisocyanates. 2001). and Prinz. 1997). The literature describes a clergy. the performers may be right. contributes to greater including Lessac-Madsen resonant voice therapy (Ver. however. the completion of performance. palatal position.. Therapy for per. Research conducted thus far has corroborated more emotionally variable. measurable goals. 1999. than many indi- some aspects of the approach (e. and lifestyle issues. part of training. Performers are threatened with loss of income. teachers (Roy et al. Smith and Thyme. Spe- problems due to voice in at least one class of professional cific noxious substances that have been measured on voice users.. loss of Voice therapy for performers often replicates voice health care benefits.. Höß. cited in Schmidt 1994). that are independently varied to It is probably safe to say that individuals who are create ‘‘recipes’’ for a variety of sung and spoken voice drawn to vocal performance are more extroverted. and performers are subject to a injury. practices that are at odds with performers’ best interest. 1970. The vocal practitioner system recently has gained currency in voice therapy as should be comfortable dealing with performers’ individ- well as vocal pedagogy. Also. 2002). the Accent Method (S. 316–317). performers. quentans and formaldehyde in cork granulate. Penicillium fre- Therapy for individuals with qualitative both quali. attorneys). A variety of training cautions exist. systematic fading of and flow mode therapy (see. In this approach. suite of special personality. tumes weighing 80–90 lb or more and unusual. Voice training for acting tends ual personal styles. and to prevent new ones. or voice therapy. lenges in the physical and political environments of per- tervention alone and more e¤ective than intensive res. Vocal hygiene. with specific. An intermediate untrained stimuli in untrained environments if less spe- vocal fold configuration. formers. and qualities. general body work (alignment. and alveolar-size the voice is required occupationally. biofeedback support appears critical for transfer. theatre and increas- reflux control.. that is. Heavy cos- formers have exacting voice needs. involving slight separation of cific transfer exercises are used. the mainstay In respect to training modalities. Vocal per. 1997. and Lee. and aryepiglottic space. the possibility of rest if they are ill or vocally indisposed. in voice therapy. including hydration and However. tant in working with performing artists. to this goal (Berry et al.. appears relevant useful adjunct to voice therapy and training.96 Part I: Voice in question. Training in this general laryngeal configuration The voice therapist may need to address special chal- appears to be more e¤ective than vocal hygiene in. 1976). for most professional voice users. mental attitude toward to be less technically oriented and more ‘‘meaning performance plays a central role in the performing do- driven’’ than singing training (e. cobalt tative voice needs recognizes that a special sound of and aluminum (pigment components). however. the voice training of singers and torted postures required during vocal performance may actors is not standardized. exceptions exist.g. movement) as a central cal management may be appropriate in selected cases. However. main. and piratory training in reducing self-reported functional compromising to vocal and overall physical health. individuals are dolini. The current emphasis is on training individuals to for special attention to transfer in training. because numerous ‘‘degrees of freedom. for many reasons. and loss of professional reputation if pedagogy methods. meeting commercial goals. over an extended period of critical dependence of motor learning on sensory pro- time or at sustained loudness. career. performers may find themselves contrac- All of these factors make many speech-language practi. see also Wulf. The principles of sports psychology fully apply to . Titze. Gau‰n and Sundberg. pp. Open-air performing formers—singers and actors—with voice problems is environments can present particular vocal challenges to conceptually challenging. has emphasized voice cessing and deemphasizes mechanical instruction (Ver- conservation. learning than on-line feedback. going performance (Armstrong. Skills ac- meet their voice needs while they recover from existing quired in a clinic or studio may transfer poorly to problems. Vocal Function Exercises (Stemple et al.. The system identifies 11 or 12 physical cern for performers’ vocal health. 1998). 2000). teachers. and less experiential than typical performing arts models Traditional therapy for phonotrauma in professional of training. Such goals may dictate vocal The most comprehensive technical framework for pro. The primary di¤erences are an em. 1989). few scientific studies on add further challenges and may even contribute to training e‰cacy exist.. which occurs during on- dolini. political issue has to do with directors’ drive toward tion. Terminal biofeedback. Stage environments can be frankly toxic. false vocalists are available to replace injured ones who are vocal fold position. which may be com. The limited at least as much by the treatment as by the dis. Surgi.’’ such as voice onset type. traditional speech- of intervention for voice problems is behavioral work on language pathology models tend to be more analytical voice production.g. plays a role in most treatment programs ingly singing training and voice therapy incorporate for professional voice users (see vocal hygiene).g. The viduals in the population at large. on average. Linklater. Also. 2002). quartz sand (Richter et al.g. laryngeal height. Politically. Another phasis on injury reduction and a shorter-term interven. Biofeedback may be a the vocal processes during phonation. fessional voice training in general has been proposed by Directors and producers may sometimes show little con- Estill (2000). provided after methods are available for this approach to vocalization. they refuse to perform when they should not. unwilling or unable to perform. Moreover.

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Di¤erent individuals take the lead. radic. Regulating glottal airflow in phonation: some form of fiscal support for treatment. Lee.. M. (2000). Acker (Eds. D’Amico. G. (2001). In M. Hess. 120–125. Schlömicher- Their. S. 169–179. Verdolini. Case study: Resonant voice therapy. K. E. Santa Rosa. (2002).. K. Instructions for motor learning: Di¤erential e¤ects of internal versus ex- —Katherine Verdolini ternal focus of attention. M. (1976). 44. J. 286–296. 65–80). Stemple. Linklater. Exercise and fresh air may be restricted. San Diego. E. Höß. Journal of Speech-Language. chokers tend to show a pre. 94–96. sponsible for medical issues. Journal of Mountain View. (1998). chology literature are applicable to attitude issues in Schmidt. professional voice users should be equipped to provide Titze. and Pickup. Hampton and B. Voice Therapy for Professional Voice Users 97 the performing arts. Smith. New York: Lessac. A. particularly issues that bear on a potential mismatch be. A quantitative output. IL: Vocal performers may have erratic lifestyles that are Human Kinetics. Frequency of voice problems among teachers and routines may be nonexistent. convergent e¤orts are required Verdolini. 16. 12. A. 145–150. T. J... (2000). K. Folia Pho- importance of communication across individuals within niatrica et Logopaedica. Lemke. from persons who perform well under high stress. Motor control and vocal performance. Daily H. 467–479. 43. the direction of the opera stage: Possible negative e¤ects on singers’ respi- attention appears key for distinguishing ‘‘chokers’’ ratory tract. 72–80. Many other findings from the sports psy- Disorders of Communication. (1998). thologist and voice teacher generally work together on Verdolini.. Acker gologist. Voice therapy: Clinical studies (2nd ed. (2000). New coach. tions for voice training. M. (1989). Speech and Hearing Research. B. Hampton and B. C... Löhle. D. 26. DeVore. M. (people who tend to perform poorly under pressure) Roy.. Vocal performers with voice in speech due to pedagogic treatment (the accent method). risks for voice problems. The physician is re- In J. and Prinz. implying verbal analytic thinking and evaluative Language-Hearing Research. K. voice. (2001). Journal of Voice. (1997). An evaluation of the e¤ects of According to some reports. speech-language pathologist.). two treatment approaches for teachers with voice disorders: dominance of left hemisphere activation when under the A prospective randomized clinical trial. Touring groups literally may live on Smith. CA: Singular Publishing Group. and Greenwood. Mountain View. 44. References Further Readings Berry. and Acker. L. and Thyme.. The vocal vision: Views on voice (pp. other occupations.. Verdolini. New York: Applause. (2001). Hearing Research. 83. 46–62). M. tend to of voice. Champaign. W. W.. (1998). 30. training and applications to speech-language pathology. and Verdolini. (1976). (1994). Application of the maximum power transfer theorem to a Practitioners working with vocal performers agree low dimensional phonation model. Pay may be poor and spo. J. Gray. problems often cannot pay for treatment because their Folia Phoniatrica. Journal of Voice. Lessac. Knapp. depending on the issues at hand. therapy and the art anxiety levels. M. and Lee. Theatre Arts Books. Montequin.. Golf. Also. activity consistent with imagery and target awareness Sapir. A. L.. and Titze. 556–565. 6. B. Bio-dynamic approach to vocal life. K.. CA: Machlin. (2001). Chan. Vocology.. A. to minimally include an otolaryn. buses. K.). 367–376. and Ramig. R. High-level performers tend to show more Russell. K. Journal of Voice. R. D. ate person to address career issues with the performer..). J.). Level one primer of basic figures. Benefits often are not provided unless the per. K. Taylor. Voice problems at work: A challenge for tween the individual’s aspirations and capabilities. and. Weikert. Kirchner. ways to establish intermediate arousal states and stay Richter. J. Freeing the natural voice. The use and training of the human voice: A Gau‰n.). E. . voice problems lead to lack of employment and thus lack E‰cacy of vocal function exercises as a method of improv- of income and benefits. Verdolini. learning: A behavioral emphasis (3rd ed. patient. (Eds. A..). A. D. E..

Special considerations relating to Foundations of voice education. Group. Professional voice: The science and art of clinical care (2nd ed. O. T. art studio. and Ramig. Motor control and Verdolini. (2001). (1997). CA: Singular Publishing Miller. L. K. K. (1974). S. R. Schmidt. 37–46.. Metuchen. K. Scientific American. Iowa City. J. National Center for Voice and Speech’s guide to Rodenburg. San Diego. (1998). NJ: distinction (rev. J. Voice tradition and technology: A state-of-the. CA: Singular Publishing Group. Professional voice: The science and art of of F. DeKalb. Nair. Satalo¤ (Ed.. London: Thames and Hudson. San Diego. In pursuit of excellence. San Diego. Verdolini. . Human Kinetics. (1987). Logopedics.). Care Network. E. Speak with how they relate to functional e‰ciency. The acoustics of the singing voice. N. and Mansell. (1997).. and Lee. L. MN: Voice- members of the acting profession. German and Italian tech. (1997). ed. New York: Applause... (2000). L. and McCoy. The actor speaks. DeVore. 203–205). Matthias Alexander. T. Phoniatrics. E. French. 236. IA: National Center for Voice and Drama. D.). T. Scarecrow Press.. T. Champaign. pp. IL: IL: Northern Illinois University Press. The science of the singing voice. 82–91. London: Methuen vocology. Review: Occupational learning: A behavioral emphasis (3rd ed. Sundberg. A. Thurman. (1990). P. clinical care (2nd ed. T. Vocology. 26. The Alexander technique: The essential writings Satalo¤.). (1977. (1977). Collegeville. Speech.98 Part I: Voice Maisel. Champaign. In R. CA: Singular Publishing Group. (1999).. Monich. G. March). R. and Welch. J. (1997). G.).. (1999). B. IL: risks for voice problems. Ostrem. Sundberg. Orlick. Body mind and voice: Raphael.. niques of singing: A study in national tonal preferences and Skinner. Human Kinetics. R. English.

Part II: Speech .

.

AOS may be the phrasal and sentence-level prosodic abnormalities. Du¤y reported that 58% had a vascular study of 12 subjects with AOS also failed to reveal a etiology and 6% presented with a neoplasm. and Although this motor speech disorder has a languor. patient care sites. Its frequent co-occurrence with (segment segregation) durations (overall slowed speech). a first-pass estimate of sons purported to have AOS (e. an AOS/ orders and from phonological paraphasia are (1) length. Prospective studies of the Based on retrospective analysis of the records of AOS-producing lesion have been undertaken by a num- 3417 individuals evaluated at the Mayo Clinic for ber of investigators. McNeil ous and tortuous theoretical and clinical history and is et al. oral-nonspeech apraxia comorbidity of 83%. In 15% of cases the AOS was a phonetic-motoric disorder of speech production caused by traumatically induced (12% neurosurgically and 3% ine‰ciencies in the translation of a well-formed and filled concomitant with closed head injury). Kertesz. Although apraxic speakers may produce proposed it as a neurogenic speech pathology that is a preponderance of sound substitutions. tactile. Doyle. lesion in the frontal lobe and 50% had posterior le- spective analysis of 107 patient records indicating a di. region of the postcentral gyrus in the parietal lobe as a anticipatory. Acoustically well-produced (non. nor to deficits in the processing of auditory. aphasia comorbidity of 81%. they area. and may not be representative of other durations of consonants. Du¤y (1995) reported found that 50% of his AOS subjects (N ¼ 18) had a a 4. 1984. p. Sommers. however. an AOS/limb The kernel perceptual behaviors that di¤erentiate apraxia comorbidity of 67%. and Brown (1975) coarticulation. 4% were associated Apraxia of speech is with dementia. with a tendency to make errors on suggest that the occurrence of AOS in isolation (pure more stressed than unstressed syllables. (McNeil. represented in Broca’s area. these sub. Comorbidity estimates or reflexes. limb apraxia. Marquardt and Sussman’s (1984) prospective agnosis of AOS. and cognitive disorders. theoretically and clinically di¤erent from aphasia and stitutions do not serve as evidence of either AOS or the dysarthrias. Luria (1966) proposed that the frontal lobe mech- are not localizable to one part of the motor control ar. with a result that set the dysarthria. Retrospective studies frequently confused with other motor speech disorders of admittedly poorly defined and poorly described per- and with phonemic paraphasia. an AOS/limb apraxia and apraxia of speech (AOS) from other motor speech dis. aphasia. lables and words. including to conduct a prospective search.g.g. or oral-nonspeech variable in type. One per. syl. and Schmidt.. kinesthetic. 9% were unspecified.. (3) relatively AOS) is extremely rare. vowels and time between sounds. He language. der of motor programming. 1990) have received support. 1997. Its occurrence unaccompanied by relatively consistent in location within the utterance and in. Aronson. 329) Doyle. and in the phonologic frame to previously learned kinematic parameters remaining cases the cause was undetermined or was of assembled for carrying out the intended movement. consistent relationship among lesion location (cortical .. aphasia. sponsible for the disorder. AOS-producing lesions programming-generated mechanisms and are attribut. or language information.or gestures (speech or nonspeech). It is characterized by distortions of seg. other disorders and its frequent diagnostic confusion resulting in (2) abnormal prosody across multisyllable with those disorders that share surface features with it words and phrases. 1984) do not some of its epidemiological characteristics has been pre. show a single site or common cluster of lesion sites re- sented by McNeil. and Wambaugh (2000). 1978) as well as able to the phonological encoding mechanism. and an AOS/dysarthria ened segment (slow movements) and intersegment comorbidity of 31%. influenced by the type of patients typically seen at the ments. Robin. and 3% were associated with primary progressive aphasia). those in the postcentral gyrus (Square. especially in Broca’s absence of an anatomical explanation. and exchange) errors that cross word critical area governing coordinated movement between boundaries are not compatible with motor planning. Sound distortions serve as evi. taken alone. consistent trial-to-trial location of errors and relatively The lesion responsible for AOS has been studied since nonvariable error types. and (4) impaired measures of Darley (1968) and Darley. Errors are most infrequent. the responsible lesion has dence of a motor-level mechanism or influence in the been sought in the motor circuitry. He also proposed the facial distorted) sound-level serial order (e. do not di¤erentiate AOS grams for limb gestures or for speech segments were from the dysarthrias. Without doubt.Apraxia of Speech: Nature and cent presented with a seizure disorder and 16% had a diagnosis of degenerative disease.. subtending Broca’s area (Mohr et al. Deutsch (1984) was perhaps the first acquired neurogenic communication disorders. proprioceptive. averaged across studies and summarized by McNeil. sions. Marquardt and Sussman. It is not attributable to deficits of muscle tone apraxia is extremely rare. including Creutzfeldt- Phenomenology Jakob disease and leukoencephalopathy (of the remaining. 1982. and Wambaugh (2000) indicated an AOS/oral- nonspeech apraxia comorbidity of 68%. resulting in intra. anisms for storing and accessing motor plans or pro- chitecture and. intersegment transitionalization resulting in extended Mayo Clinic. AOS. Darley.and inter-articulator temporal and spatial segmental and mixed etiology. Because Darley defined AOS as a disor- phonemic paraphasia. Based on this same retro. these proportions are prosodic distortions. perseverative. stage for most of the rest of the results to follow.6% prevalence of AOS. dysarthria. These distortions are often perceived as Among all of the acquired speech and language sound substitutions and the misassignment of stress and other pathologies of neurological origin. and other neurogenic speech.

Other theoretical accounts of AOS include the over- Although AOS is predominantly viewed as a disorder specification of phonological representations theory of of motor programming (Wertz. ume. glottal closure. the majority of Motor programs. Dogil. on the other hand. Two of the four AOS subjects had sponsible for AOS. lip round- ing. jects but without the presence of AOS were reported to AOS is therefore proposed to be a deficit of the direct have had a complete sparing of this specific region of the encoding route. ably less examination in the literature and will not be peting theories. and physiological features. It is terns for frequently used syllables (the direct route). jects with AOS and one of the three subjects with con. Motor The study of and clinical approach to AOS operate plans are derived from specific speech sounds and specify under a scientific paradigm generally consistent with the the spatial and temporal goals of the planned unit. When it occurs.g. In this theory. the management of speech production disorders. or classified as a motor speech disorder in the scientific the patterns are calculated anew (presumably from literature. the dysarthrias). that the major able features discussed earlier. it is frequently accompanied . including oral nonspeech (buccofacial). writing perceptual. acoustic. force. with a reliance on the indirect encoding insula. deficit of the direct phonetic encoding route to account AOS is an infrequently occurring pathology that is for AOS. That is. The only common lesion site for these with AOS. specify the move- practitioners view AOS as a disorder of previously ment parameters (e.. In this account. and (4) reduced coarticulation. and Wambaugh. fashion. The diagnosis muscle groups. Dronkers Speech produced by normal speakers for infrequently (1997) reported that 100% of 25 individuals with AOS occurring syllables. and Rosen. model. most definitions ioral features of AOS. The diagnosis requires that ming. Whiteside and Varley (1998) proposed a described here. For Van der Merwe. articulatory integrity. are said to had a discrete left hemispheric cortical lesion in the pre. LaPointe. a combined motor planning and motor programming derlying the movement. (2) syllable segregation. In this to date.. the apraxic speaker involvement of the insula. These accounts have received consider- McNeil. derived from its historical roots based in dynamical systems breakdown theory of Kelso and other apraxias (particularly limb-kinetic apraxia. control group of 19 individuals with left hemispheric (3) inability to increase the speech rate and maintain lesions in the same arterial distribution as the AOS sub. 1984). learned movements that is di¤erent from other speech range. feature-by-feature. Doyle. while two of three subjects with a reduced bu¤er capacity is required to reload or with phonemic paraphasia (diagnosed with conduction reprogram the appropriate (unspecified) bu¤er in a aphasia) had a lesion in the insula. or motor-control-variable-by-motor-control-variable duction aphasia evinced involvement of Broca’s area. motor plans carry information (e. there are com. raising or lowering Theoretical Accounts of the tongue tip. graphic lesion data from four individuals with AOS un. lesion vol. The attributes ascribed to motor plans in this fundamental structural and sensorimotor abilities to model are consistent with the array of cardinal behav- carry out the movement. normal speech production in. Two of the four sub. McNeil et al. Based on experimental evidence that the phonologi- accompanied by other neurogenic speech or language cal similarity e¤ect should not be present in persons pathologies. and Wambaugh (2000) argue that patients display the ability to process the language un. the lesions responsible for AOS remain used to define the entity and consistent with the observ- open to study. mechanisms ascribed to apraxia.. 1999) hypothe- ‘‘pure’’ apraxic speakers was in the facial region of the sized a reduced bu¤er capacity as the mechanism re- left postcentral gyrus.g. smaller verbal motor patterns) by an indirect route. and the presence or absence of AOS. McNeil. These criteria are generally impairment as specified by Van der Merwe (1997) is consistent with those used for the identification of other required to account for the array of well-established apraxias. anterior versus posterior). and Vollmer (1994) and the coalitional/ bek. direction. such central gyrus of the insula. Mayer. clinically recognized by most professionals dedicated to volves the retrieval from storage of verbal motor pat. Critical to this view is the challenged by the AOS/lesion data that are available separation of motor plans from motor programs. and limb apraxia. Doyle.e. One hundred percent of a as (1) articulatory prolongation. (1990) reported computed tomo. muscle tone. disorders of motor can be confidently applied when assurance can be programs result in the dysarthrias and cannot account obtained that the person has the cognitive or linguistic for the di¤erent set of physiological and behavioral signs knowledge underlying the intended movement and the of AOS. anterior/posterior divisions common to aphasiology and Van der Merwe (1997) proposed a model of sensori- traditional neurology as sites responsible for nonfluent/ motor speech disorders in which AOS is defined as a fluent (respectively) disorders of speech production are disorder of motor planning. Rogers and Storkel (1998. 2000). jaw depression. sound-by-sound. however. This requirement would give rise to essentially The unambiguous results of the Dronkers study not. share many of the core features of apraxic speakers. interarticulator phasing/coarticulation) that is articulator-specific. and rate of movement) of specific muscles or movement disorders (i. syllable-by-syllable. It is clear. Tuller (1981). Additionally. not muscle-specific. route.102 Part II: Speech versus subcortical. the same observable features of AOS as those commonly withstanding. using the indirect route. of apraxia suggest an impairment of movements carried Though their view is expanded from the traditional out volitionally but executed successfully when per. view of AOS as simply a disorder of motor program- formed automatically. (agraphic).

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p. Brain and physical manipulations to achieve the desired articu- Language. D.). verbal descriptions and ulation in a patient with apraxia of speech. Acquired apraxia of speech been described in detail by Wertz. Rockville. Robin. (2001). phasing of the articulators at the segmental and syllable MD: Aspen. 1996. (3) integral stimulation and phonetic placement. D. 1978. J. 15. (1986). LaPointe. M. and (4) minimal pairs lation in apraxia of speech: Acoustic evidence. East Sussex. C. Wambaugh. M. Ziegler. In addition. and von Cramon. Level. Several facilitative techniques have been recom- ogy Press. in. such principles facilitate learning and retention of motor Apraxia of speech: An overview and some perspectives. K. 15. nonreplicable treatment protocols. and Whiteside. Contemporary investiga- proposed (Van der Merwe. and ification of intended articulatory movement parameters or word levels. Rosenbek. Rogers. R. man. considerable work has However. word pairs in which one member of the pair di¤ers min- imally with respect to manner. 1983. stimulation. which employ visual models.. (Ed. Darley and apraxia of speech in adults. E.104 Part II: Speech Miller. 2000). the evidence supports a conceptual. 1973. A. 74–77. 1977. 26. P. (Ed. Explana. Disturbed coarticu. and Rosen- in aphasic adults. J. mended to enhance postural shaping and phasing of the Roy. tions have addressed these methodological shortcomings Overwhelmingly. Thomp- that could not be accounted for by disrupted linguistic or son and Young. These techniques include (1) phonetic deri- Varley. and Spencer. and von Cramon. 117–130. 15. phonetic placement. which refers to the shaping of speech sounds impairment in acquired apraxia of speech? Aphasiology. segments. and (2) segmental sequencing of longer speech Miller. W... J. pre-experimental research designs. purposes of specifying the structure of AOS treatment Aphasiology.. What is the underlying vation. tenance e¤ects of targeted sounds at 6 weeks post- posed that seek to enhance (1) postural shaping and treatment. (1985). and minimal pair con- assignment of stress. and other phrasal and sentence-level trasts in 11 well-described subjects with AOS (Wam- prosodic abnormalities. E. 1997). CA: College-Hill Press. R. More recently. 1984. N.). syllable and word durations.. aerodynamic. G.and interarticulator Specifically. M. Aronson (Eds. and Heilman. conclusions regarding the validity and generalizability of tory models consistent with these observations have been the reported treatment e¤ects. (2001). 1–72). (1997). and reported positive In the years since Darley (1968) first described apraxia of treatment responses (Rosenbek et al. (2001). examined the e¤ects of a procedurally explicit treatment tersegmental transitionalization. (1985). S. Anticipatory coartic. A. 3–47. bek (1984). in isolation or in various combinations. L. Robin. San Diego. sessions have been proposed. (2001). for all subjects across all studies. which involves the gradual Ziegler. Ziegler. the e¤ects of these facilitative techniques on speech production. Apraxia of speech is not a lexical disorder. which requires patients to produce syllable or Language. 1989). N. acoustic. (Eds. 15. C. and that characterize AOS (cf. the mis. based on evidence that Rosenbek. L. two subjects showed positive . and A. Brain and contrasts. R. McNeil. based on corresponding nonspeech postures. and support earlier findings regarding the positive e¤ects ization of AOS as a of treatment techniques aimed at enhancing articulatory neurogenic speech disorder caused by ine‰ciencies in the spec. London: Taylor and Francis. and Doyle. (1984). K. ological limitations. kinematic aspects of speech at the sound. which precluded firm 1997. McNeil. (1986). and Schmidt. McNeil. kine. 62–68. (McNeil. and electromyographic features tion criteria. West. or voicing features from the other member of the pair. 1991). 1984). 1999. C. on targeted phonemes in trained and untrained words garding appropriate tactics and targets of intervention. Traditional and contemporary conceptualizations of 2000). and Wambaugh. gressive approximation. motor programs which result in intra. 261–273. These studies revealed positive treatment e¤ects the disorder have resulted in specific assumptions re. In routines involved in skilled limb movements (Schmidt. 1998. of motor learning principles (Schmidt. 1997. Holtzapple speech (AOS) as an articulatory programming disorder and Marshall. W. W. including inadequate subject selec- matic. and movement. and LaPointe. UK: Psychol. J. latory posture. (2) pro- 39–84. acoustics. Wambaugh. articulators at the segmental and syllable levels and have Square-Storer. 29. levels. P. 1998. Rothi. D. Apraxia: Enhancing Articulatory Kinematics at the Segmental The neuropsychology of action. 1988) for the 68–74. agement (pp. Wertz.. Spoken word pro. (2001). units (Square-Storer and Hayden. A. Wambaugh and Cort.. 15. LaPointe. fundamental motor processes. most of these studies su¤ered from method- been done to elucidate the perceptual. shaping of targeted speech segments from other speech Aphasiology.). Deal and Florance. Doyle. Such subject experimental designs Wambaugh and colleagues movement distortions are realized as extended segmental. Dyspraxia and its management. Apraxia of Speech: Treatment Several early studies examined. in a series of investigations using single- temporal and spatial segmental and prosodic distortions. Rosenbek. and positive main- and a number of treatment approaches have been pro. 329) baugh et al. and Schmidt. Amsterdam: North-Holland. L. place. treatment is reviewed here. Neuropsychological studies of apraxia and related disorders. Kent. protocol employing the facilitative techniques of integral and are frequently perceived as sound substitutions. 1998. linguistics. The empirical support for each approach to Apraxia of speech: Physiology. arguments supporting the application duction without assembly: Is it possible? Aphasiology. (1989).. A. syllable..). Dual or duel route? Aphasiology.

respect to whether the intended movement was per- tion of the facilitative technique and the dependent formed accurately or not. 1987). these facilitative techniques are most fre- articulatory movements and highlight rhythmic and quently used as antecedent conditions to enhance target prosodic aspects of speech production may be e‰cacious performance. management of AOS has long espoused intensive drill of geted speech unit. research on motor learning (Rubow et al. Dworkin and Abkarian. Knock et al. sions facilitates greater retention and transfer of targeted tonation therapy (Sparks. treatment. in the behaviors targeted for of feedback are frequently employed in the treatment intervention.. 1996. 1978). only five subjects were studied. KP provides information re- measures reported (Southwood. untrained phrases). That is.. The final principle to be discussed concerns the nature rate control.e. 1985). and one subject showed replicated. generalized stimulation and phonetic placement provide the type e¤ects) were evaluated. (2000) in two adult subjects with AOS in As with studies examining the e¤ects of techniques the only study to date to experimentally manipulate designed to enhance articulatory kinematic aspects of random versus blocked practice to examine acquisition. Both types techniques were applied.. Treatment programs and tac. Indeed. have also been (Schmidt. 1989). their generalizability remains unknown. speech at the segmental level. and in the extent to which important of AOS. 2000. KR provides information only with to be drawn regarding the relationship between applica. Whereas each of these studies reported positive performed. Apraxia of Speech: Treatment 105 generalization of trained sounds to novel stimulus con. and Adams. Wambaugh and Martinez. 1990) and temporal constraints skilled movements. This research Enhancing Segmental Sequencing of Longer Speech has led to the specification of several principles regarding Units. intended action and how the intended action is to be 1999). 1997. movements are practiced. knowledge of results (KR) and knowledge of studied under conditions that permit valid conclusions performance (KP). 1975). garding aspects of the movement that deviate from the 1988. Further. the e¤ects ent skilled actions in random order within training ses- of similarly motivated treatment programs. until these findings can be systematically texts (i. As such.. 1978.. 2001) and surface prompts actions than does blocked practice of skilled movements (Square. transfer. the structure of practice and feedback that were found mended to improve speech production in persons with to enhance retention of skilled limb movements post- AOS. These results provide General Principles of Motor Learning. AOS (McNeil et al. The e¤ects of several such specific targeted speech behaviors (Rosenbek. prolonged little attention has been paid to the structure of drills speech (Southwood. These include 1984). With respect to the first of these principles. the empirical evidence retention. The e¤ects of the nature. and retention of skilled movements sounds. skilled movements. clinical ing the natural rhythm and stress contours of the tar. been studied extensively in limb systems from the per- spective of schema theory (Schmidt. melodic in.. supporting the facilitative e¤ects of rhythmic pacing. 2001). positive generalization to untrained sounds within the same sound class (voiced stops). Wambaugh et al. and context in which the various facilitative motes greater retention of skilled movements. Three such principles production of longer speech units (and other complex are particularly relevant to the treatment of AOS: (1) the motor behaviors) are governed by internal oscillatory need for intensive and repeated practice of the targeted mechanisms (Gracco. Chumpelik. However. Several facilitative techniques have been recom. and greater transfer of treatment e¤ects to ordination of movement parameters required for the novel movements (Schmidt. motor learning) and their controlling variables have expected. However. and (3) the nature and sched- tics grounded in this framework employ techniques ule of feedback. vibrotactile stimulation used in treatment. 1988. Dworkin. based on the premise that the sequencing and co. The contempo- initial experimental evidence that treatment strategies rary explication of AOS as a disorder of motor planning designed to enhance postural shaping and phasing of and programming has given rise to a call for the appli- the articulators are e‰cacious in improving sound cation of motor learning principles in the treatment of production of treated and untreated words. designed to reduce or control speech rate while enhanc. 1987. manipulating the number of treatment trials on the ac- Abkarian. 1991). and transfer of speech movements. the limited available of information that is consistent with the concept of evidence suggests that techniques that reduce the rate of KP. Wertz et al. . and intersystemic facilitation (i. Dworkin and Abkarian. quisition and retention of speech targets in AOS. The there is limited evidence that for some patients and some habituation. Two types of feedback have been That is. in limb systems has shown that practicing several di¤er- finger counting) (Simmons. and stress manipulations on the production and schedule of feedback employed in the training of of longer speech units in adults with AOS is limited.. it is di‰cult to compare them because of di¤er. Schmidt and Lee (1999) argue that KP is results. This finding has been replicated by reported. in the frequency. 1978. (2) the order in which targeted (Kent and Adams. However. In addition. that KR administered at low response frequencies pro- duration. the facilitative techniques of integral aspects of treatment e¤ectiveness (i... facilitative techniques have been studied. most beneficial during the early stages of training but ences in the severity of the disorder. and response-contingent feedback fre- in improving segmental coordination in longer speech quently takes the form of KR.e. units. among the reports cited. 1999). no studies have examined the e¤ects of metronomic pacing (Shane and Darley. generalization to untrained contexts may be (i.e. 1991).e. Dworkin et al. and Johns. and 1996. Ballard. 1982).

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in the absence of depression or other psychiatric sentence types based on prosodic contour (e. has also been found to occur in the linguistic domain. In receptive tasks they have been asked to deter- dic features and somewhat uniform intersyllable pause mine the emotional valence of expressive speech and to time. aphasia. particularly if they su¤er Cancelliere and Kertesz (1990) speculated that the basal from other forms of denial of deficit. and Heilman. behind the message as conveyed through both linguistic Finally. Deficits in prosodic perception and role for the right hemisphere in processing content gen- comprehension are less apparent in clinical presenta. schizo. Even the disturbed prosody of tention (which may reduce sensitivity to prosodic cues). tional content in normal and in filtered-speech para- tal responsivity. brain function. Dravins. 2001). been at least one report sis has varied across studies. 1998. 1991). or aprosodia. subject selection criteria.. Patients with Research findings have varied as a function of task persistent aprosodia may be aware of the problem but type. intrahemispheric site of lesion. sphere (Heilman. cortical structures contribute to normal prosodic pro- Expressive aprosodia is easily recognized in patients cessing. greenhouse versus green house). Bowers. 1991). lesion localization studies have found that cer- and emotional prosody. Even then. level. Be. Patients glect and dysarthria. monotonic.. Treatment has which adds a subjective component. body language. somewhat robotic. Kertesz. In others. aprosodia may last for months and even years of emotion in motor action. It is important to note that receptive and expres. and methods of data feel incapable of correcting it. analysis. patients may have problems both encoding and themselves are lateralized. using stress pression subsequent to RHD. ganglia may be important not only because of their role for example. based on perceptual judgments by one or more listeners. 1992). patients with aprosodia are usually lar.108 Part II: Speech speech disorders. stilted prosodic in reading tasks at the single word. however. conducted to answer questions about the laterality of sequent to RHD (Sweet. research. 1975. Myers. Lovallo. 1990. and in the absence of motor programming intonation pattern for interrogatives versus the flatter deficits typically associated with apraxia of speech. in imitation.g. phrase. they may deny it.. Lorch et al. when other signs of RHD have abated. aprosodia Ko¤. 2001). the basal ganglia in particu- In the acute stage. a Monnot. depression. nouns and noun phrases based on contrastive stress pat- cial expression).. Subjects with unilateral left or right brain Ross et al. 1998. accompanies discriminate between various linguistic forms and emo- flat a¤ect. Price et al. Blonder. Borod. a more general form of reduced environmen. fa. gesture. Bradvik. chronic alcoholism. Nixon. independent of their function decoding the tone of spoken messages and the intention (emotional or linguistic) (Van Lancker and Sidtis. typically refers to the prosodic some combination of conditions. these variables have rarely and to signal mood by explicitly stating their mood to been taken into account in research design... In some studies it has been of successful symptomatic treatment using pitch bio. Linguistic tasks include discriminating between features of communication (gesture. In rare frontal connections which may influence the expression cases. Federo¤. It is not clear the extent sphere damage (RHD) (Du¤y.g. such as schizophrenia. facial expression) the exception of site of lesion. the presence or absence of ne- patients to adopt compensatory techniques. as well as right hemi. Myers. Fichtner et al. Holtas et al. terns (e. 1985. but not always. whether receptive aprosodia is due to perceptual inter- head injury. Primeau. a resource allocation problem. to restricted at- right hemisphere focus. The term pragmatic problem. and flattened. Much of the research in prosodic processing has been areas considered important to prosodic impairment sub. 1994). may be the result or to some as yet unspecified mechanism. and Ross. has been found to correlate with prosodic in motor control. lying mechanisms of aprosodia. Aprosodia can occur in patterns to identify sentence meaning (Joe gave Ella the absence of dysarthria and other motor speech dis. and identifying orders. other illnesses.g. but also because of their limbic and deficits (Starkstein. play a role in prosodic processing (Cancelliere and unaware of the problem until it is pointed out to them. and Watson. The first hypothesis suggests that a¤ective or sive prosodic processing can be di¤erentially a¤ected in emotional prosody is in the domain of the right hemi- aprosodia. and may be taught to attend more carefully to other forms of severity of attentional and other cognitive deficits.. cause it is associated with damage to the right side of The emphasis on laterality of function has helped to the brain. or progressive neurologic disease with a ference in decoding prosodic features. data are . First observed in the emotional domain. 1998). Another hypothesis holds that prosodic cues Thus. erated the central hypotheses guiding prosodic laterality tion. tain subcortical structures. and mania. of alterations in right frontal and extrapyramidal areas. however. The condition often.. There has. Severity of neglect. 1995. flowers versus Joe gave Ella flowers). to which expressive aprosodia is a motor problem. reduced sensitivity to the paralinguistic digms. Similarly. feedback and modeling (Stringer. it usually occurs in the absence of linguistic establish that both hemispheres as well as some sub- impairments (Du¤y. the rising disturbances. With emotional expression (e. Subjects across and within studies may vary in Treatment of aprosodia is often limited to training terms of time post-onset. damage have been asked to produce linguistic and emo- The clinical presentation of expressive aprosodia is a tional prosody in spontaneous speech. and attenuated animation in facial ex. Data analy- the listener. 1996). been somewhat limited by uncertainty about the under- phrenia. it is not clear impairments that can accompany RHD from stroke. and sentence production characterized by reduced variation in proso. pattern for declaratives). Scholes. 1995. The extensive literature supporting a particular with flat a¤ect.

Rosen. The neurological substrates for pro- whether unilateral brain damage produces prosodic def. rather than describing the characteristics of proso. Non-temporal properties such as pitch Brain. the opposite. Prosodic perception or comprehension deficits asso. (1987)... K. E. J. RHD population. Boongird. and Potisuk. D. R.. Cooper. 32. Robin ditory compatabilities in aphasia.and left-hemisphere-damaged Ingvar. F. A. (1990). 1989. and Gra¤-Radford. Aphasi- prominent in aprosodia. (1991). The role of the right hemisphere in the which pitch patterns in individual words serve a seman. as pitch information (Chobor and Brown. and Kertesz. and (1992) found that right.. S. S. and Heilman. X. Ponglorpisit.. 1987. Van Lancker and Sidtis Bradvik. 1989.. Almost all studies of prosodic deficits have focused on Emmory. The ciated with aprosodia tend to follow the pattern found in role of the right hemisphere in emotional communication. B. Production of a¤ective production of emotional prosody appears particularly and linguistic prosody by brain-damaged patients. right hemisphere-damaged population. and may produce emotionally toned sentences —Penelope S. which a¤ords increased sodic deficits can occur in both left as well as right objective control but in some cases may not match lis.. Sidtis Divenyi. M. (1991). (1989). J. about the nature of RHD prosodic deficits consists Duration and timing cues are considered to be in the largely of subjects with and subjects without prosodic domain of the left hemisphere (Robin. St. The main problem is that while sub- lateralized according to individual prosodic cues rather jects in laterality studies are selected for unilateral brain than according to the function prosody serves (emo. K. duration. (1995). 1986. Brain and Language.. Although a study by Pell and Baum (1997) failed patients. E. appear to be more problematic than time-dependent Borod. The body of laterality research has established that pro. from dichotic listening and other studies that have Intonation variability in the speech of right-hemisphere investigated temporal versus time-independent cues such damaged patients. R. I.. 1987. impair. Brain and Language. which may explain why impaired Baum. RHD screening patients are undertaken. Van Lancker and Sidtis. Baum and Pell. Ryalls and Reinvang. W.. less than normal variation in pitch for interrogative sen- tences. 1990. However. the data pool on which we rely for conclusions considered to be in the domain of the right hemisphere. Acta Neurologica Scandi- Patients with RHD tended to base their decisions on navica. J. Aprosodia 109 submitted to acoustic analysis. 11. and Norwegian) in Behrens. 1988. and Pell. and Nicholas. 379–383. However. 1992). et al. 13. abnormally flat pitch pattern in declarative sentences. S. S. For example. and impairment. Disturbances of speech prosody fol- patients used di¤erent cues to identify emotional stimuli. A. Lesion localiza- durational cues rather than on fundamental frequency tion in acquired deficits of emotional expression and com- variability while left-hemisphere-damaged patients did prehension. 1999). Emmory. M. Brain and Language. 345–348. (1997). P. 1997. tional versus linguistic). acoustic analyses of prosodic productions laterality has had some drawbacks for understanding by RHD patients supports the theory that prosody is aprosodia per se. and Robinson. Dechongkit. R. Gandour. Chinese. Brain and Language. and Feldman. 30. Myers with less than normal acoustic variation (Behrens. patients are minimally if at all impaired in the produc. Holtas. Characterizing sentence intonation in a Gandour et al. The characteristics of aprosodia. sodic aspects of speech. L.. Joa. Du¤y. Divenyi and Robinson. the focus on In general. M. hemisphere damage. Cancelliere. right hemisphere lan- tion of emphatic stress. tonal languages (e. the data are supported by data Colsher. Nonlinguistic au- and Volpe.. E. 1986. D. D. Ryding. function (Packard. pitch has been found to be a left hemisphere 104–127. 1989. (1989). 84. S.. pitch cues are Thus. 114–126. Louis: Mosby.. Sidtis. P. 42. production of linguistic stress. P. J. J.. D. Pell. Lexical . L. These issues will remain unclear until factors in the impaired prosodic production of RHD a working definition of aprosodia is established and de- subjects (Colsher.. N. and Brown. See also prosodic deficits. bre monitoring in left and right cerebrovascular accident ment. 1990). M. production. Interestingly. L. 177–198. 1988. 1992. Ko¤. Brain and Cognition. C. C. J.. Baum nisms. These data suggest a perceptual. rather Chobor. K. its mecha- Damasio. E. damage. In particular. and has furthered our understand- tener perception of severity of impairment (Ryalls. tic role.. S..g. (1987). Pell.. ing of the mechanisms and di¤erences in prosodic pro- nette. 37. 1992). in the case of ology. 30. properties such as duration and timing (Divenyi and Channels of emotional expression in patients with unilateral Robinson. right hemisphere language disorder. Bowers. Motor speech disorders. Thai. frequency of occurrence in the general and Pell. 114... 1999a). Brain and Language. 1987). Pitch variation is crucial References to signaling emotions. and Gra¤-Radford. scriptive studies using that definition as a means of Behrens. and the presence/absence of other Research suggests that reduced pitch variation and a RHD deficits that may accompany it have yet to be somewhat restricted pitch range appear to be significant clearly delineated. Cooper. W. to replicate these results... Archives of Neurology. (1992). (1985). dic problems in patients known to have prosodic deficits. they are not screened for prosodic impairment. 33. J. Dravins. Boonklam. Behrens. L. Blonder. 305– icits.. Tranel. (1987). Lorch. cessing across the hemispheres. B. 320. P. 78–284. 1990. Phoneme and tim- than a functional (linguistic versus emotional). 133–147. S. Brain and Language. Khunadorn. 290–396. they may have an guage and communication functions in adults.. Van Lancker and brain damage. 181–200. (1988). 1115–1127. lowing right hemisphere infarcts. 1987. H. 37. 1997). A. Robin et al.

augmentative and 10. The neural bases of fective speech. Journal of Neurology. P. E. (1979). Orbelo.. Cartwright. we can isolate four: (1) communication of wants and aged speakers. I. guage and Speech. Federo¤. without linguistic tones: Acoustic evidence from Norwegian. 57. sclerosis) (American Speech-Language-Hearing Associ- roradiologic correlates of emotional prosody comprehen. Brain bral palsy.110 Part II: Speech tones in Thai after unilateral brain damage. D. (1998). The aprosodias: Fur. K. of a¤ective-prosodic stimuli by left.g. 597–604. 70. Monnot. (1975). symptoms. cere- pitch or speech discrimination after unilateral lesion. S. 1998. Psychiatry Re. 62. Cortex. Neuropsychological and neu. 362–369. High- prosodic deficits in schizophrenia: Profiles of patients with technology AAC systems use electronic devices to sup- brain damage and comparison with relation schizophrenic port digitized or synthesized communication strategies. Mohrad-Krohn.or light-technology systems include items such chiatry. ment. 38. Augmentative and Alternative Altered emotional perception in alcoholics: Deficits in af- fective prosody comprehension. and the acoustic cues to munication of wants and needs. 516–522... D. appropriate AAC system addresses not only basic com- Pell. T. (1999b). as ‘‘those for whom natural gestural. acquired disabilities and Language. includes any existing natural speech or vocalizations. R. M. Brain and Language. 1). formal sign language.. Treatment of motor aprosodia with pitch biofeedback and expression modelling. J. 275–307. 235–245. 38. D. R.. Hansel. and no-technology gard. It Ross. Sweet. Lovallo.. (1994). A. low. conditions (e. M. G. (1987). (e. and as such it incor- 539–555. alternative communication approaches in children). 25. 161–192.and right-hemisphere- Gorelick. S. M. J. 389–398. 81. Brain and Language. (1997). (1987). (1998). 44. and Psy. Lutz. (2) information transfer. amyotrophic lateral and Robinsn. 29.g. San Diego. (2001). and Damasio. Fichtner. H. E.. 301–308. of which guistic and emotional prosody by right hemisphere dam. prosodic comprehension deficits. J. multiple sclerosis. L. A.. ganization of the a¤ective components of language in the gestures.. D. maintenance.g. H. L. Selective loss of complex disabilities. (1990). 10) describes these people blunting in patients with schizophrenia. Journal of Neu- rology. R. D.. communication Ryalls. and aided communica- right hemisphere. including congenital disabilities (e. 405–415. focal left and right cerebral lesions.. J. and Buck. Functional lateralization of body movements.. Competent Pell. Fundamental frequency encoding of lin. D. T. ation [ASHA]. Cortex. J. Y. H.. Myers. 163–182. B. 581–608. S. ASHA (1991.-M. 195–214. C. M. 34. D. R. Brain Injury. AAC is considered multimodal. Van Lancker. Nixon. D. 69–72. Low. 13. needs. (1999a). Bur. Alcoholism: Clinical and Communication Approaches in Adults Experimental Research. 963–970. Au- ditory a¤ective agnosia: Disturbed comprehension of af. J. R. In Right hemisphere damage: Disorders of communication and cognition (pp.... technology. Ryalls. A. enhance their competent communication. An infarcts. J. Lan. and/or search. 73– An augmentative and alternative communication (AAC) 90).. a¤ective language in the right hemisphere. CA: Singular. Archives of Neurology. and Volpe. T. and Sidtis. An acoustic books. in respect to the aids used in implementation. Primeau. Neurosurgery. Adults with severe communication disorders benefit Dissociation of a¤ect recognition and mood state from from AAC.. and Psychiatry. 583–590. stroke). and Mesulam. Scholes. but also the establish- prosody. Prosodic deficits.. and Reinvang. and Pell. Brain and Lan. D. as communication boards (symbols).. Archives of Neurology. Testa. M. written communication is temporarily or permanently . 212–223. C. 1989). Neurosurgery. and Baum. S. gestures. tion. Joanette. E. Tranel. the use of specific aids or devices. Auditory relationships using information transfer. and development of interpersonal Robin. 144–148. M. 561–569. The temporal organization of a¤ective (4) social etiquette (Light. (1992). S. 553–560. Unilateral brain damage.. Dysprosody or altered ‘‘melody of language. ‘‘AAC allows individuals to use every mode possi- Ross. and Feldman. gesturing.. G. M.. (1981). (1986).’’ Brain. 29.. Price. speech. G. These four functions and non-a¤ective speech in patients with right-hemisphere broadly encompass all communicative interactions. B. M. (1947). The identification guage. 35. Aphasiology. R. Individuals at any point across the sion. D. and prosody: Insights from lesion studies and neuroimaging. 36. AAC is used to assist adults with a wide range of Sidtis. damaged subjects: All errors are not created equal. (1999). Further Reading Heilman. Neurosurgery. P. D. and light pointing devices. E. porates the full communication abilities of the adult. (3) social closeness. 35. (1988). social closeness. 685–694. and sign language. AAC systems are typically described as high- Ross. Y.. Psychiatry.or light-technology.. M. W. R. (1996). and Ross. p. J. (1986). M. J. traumatic head injury. S. (2001). p. mental retardation).. Neurology. P. Journal ther functional-anatomical evidence for the organization of of Speech and Hearing Research. J. such as prosody. communication serves a variety of functions. 23. Tone production deficits in nonfluent individuals with severe communication disorders to aphasic Chinese speech. and Watson.. perception of temporal and spectral events in patients with and social etiquette. life span and in any stage of communication ability may Stringer. and degenerative Starkstein. 50. 43. system is an integrated group of components used by Packard.. G. The aprosodias: Functional-anatomic or. Baum. Brain and Language... A no-technology sys- comparison of normal and right-hemisphere-damage speech tem involves the use of strategies and techniques. A¤ective. 1988). 39. Journal of Neurology. D. use AAC (see the companion entry. E. 70. Leiguarda. R. Dominant language functions of the right hemisphere? Prosody and emotional ble to communicate’’ (Light and Binger. and Pell. and Ross.. Brain and Language. E.

middle phase. speech intelligibility disrupts the circulation serving the lower brainstem. AAC intervention makes use of both the disease progression. result is often severe dysarthria or anarthria. 2000). people. In the early phase. locations). In the communication e¤ectiveness varies across social sit. 2000). educational. AAC applications during this phase include textual information through AAC techniques will in.’’ tion should be completed when an individual reaches An important consideration is that ‘‘although some 50% of his or her habitual speaking rate (approximately individuals may be able to produce a limited amount 100 words per minute) on a standard intelligibility as- of speech. multiple sclerosis. Access to a communication communication. the person exhibits no functional speech. In the late adult severe communication disorders are described phase. way to indicate basic needs and giving a response traumatic brain injury. (Ball. and AAC persons who are unable to speak because of severe cog- strategies learn to switch communication modes de. 2001). and numerous motor and treatment process. mately 10 months after diagnosis. AAC intervention may be complicated by co- rapid degeneration involving the motor neurons of the existing cognitive deficits. speech symptoms typically occur early in ational settings. intelligi. and Pattee. Parkinson’s disease. For those whose initial impairments are in ticipate in social. it is here. usually involve nonelectronic. AAC intervention strategies speech impairments benefit from using AAC (Beukel. acoustic speech quality. Guillain. sessment (such as the Sentence Intelligibility Test. functioning is categorized into phases (Blackstone. Natural speech is more time-e‰cient and lin. Generally. Frequent objective be used to support comprehension and cognitive abilities measurement of speaking rate is important to provide by capitalizing on residual skills and thus facilitating timely AAC intervention. the person is minimally re- quality acoustic signals and poor environmental sponsive to external stimuli. brain that involve rapid acceleration and deceleration. In stage timing of an AAC evaluation. mouth. Beukelman. p. demonstrate some ability to communicate using natural Traumatic brain injury (TBI) refers to injuries to the speech. ‘‘Given that choices of real objects to support communication. and Tice. guistically flexible than other modes (involving AAC). because the 1. (Doyle et al. an AAC evalua. it is likely a Beukelman. result of chronic motor control and language impair- The patterns of communication disorders in adults ments. ACC approaches for a few technology interventions to express needs. sages is enhanced (Lindblom. optimizing any available con. and Grossman. 1996). On average. It is in this phase that use natural speech. or CVA) pairment begins in the lower spine. low-technology pictures and communication boards and crease the comprehensibility of the message. 1991. Benton. Brainstem stroke (cerebrovascular accident. AAC goals during this phase address providing a vary from condition to condition. AAC intervention is typically described bility is not a good measure to use in determining the in five stages (Beukelman and Mirenda. Communication the onset of the abrupt drop in speech intelligibility symptoms vary considerably with the extent of damage. likely the result of specific motor or language impair- Amyotrophic lateral sclerosis (ALS) is a disease of ment. Augmentative and Alternative Communication Approaches in Adults 111 inadequate to meet all of their communication needs. and recre- the brainstem. Rather. AAC goals include provid- information result in a deterioration in message com. 1982). and re- agnosis. the person exhibits improved consistency uations and listeners. For those whose im. recovery of cognitive comprehensibility—intelligibility in context—of mes. If they do not pending on the situation and the listener’’ (Hustad and become speakers by the end of this phase. it is important that individuals who of responses to external stimuli. and there is no a variety of settings and to assist the individual to par- known cure. and Gutmann. Beukelman. 1989). if the person continues to be nonspeaking. Some individuals maintain functional speech duced ability to control the muscles of the face. modality that increases participation in the evaluation Barré syndrome. Yorkston. The cause is unknown. provision of functional ways to interact with listeners in erally intact. it is inadequate to meet their varied com. speech-supplementation. p. speech intelligibility low. of AAC in TBI is to provide a series of communication edge to increase the listener’s ability to understand systems and strategies so that individuals can communi- a message. a drop in speaking rate predicts and larynx voluntarily or reflexively. recovery. Clinically. intervention is to provide early communication so that . vocational. The goal of speaking rate declines more gradually. unable to speak. while others may be Because the drop in intelligibility is so sudden. or no- man and Mirenda. poor. which results in compromised neurological and topic supplementation) used in conjunction with function (Levin. nitive confusion become able to speak.and high-technology strategies in this phase of in this (bulbar) group declines precipitously approxi. 1998). 10). low-technology. York- munication needs’’ (ASHA. The declines precipitously approximately 25 months after di. Similarly. When a speaker experiences reduced discriminate one of an array of choices (objects. Intervention goals address brain and spinal cord that leaves cognitive abilities gen. 80% of Some individuals are dysarthric but able to communi- individuals with ALS eventually require use of AAC. whereby the brain is whipped back and forth in a quick Speech supplementation AAC techniques (alphabet motion. cate partial or complete messages. Persons with aphasia. 103). much longer. system is increasingly important as ALS advances Many adults with severe communication disorders (Mathy. As the quality of the acoustic signal and cate at the level at which they are currently functioning the quality of environmental information improve. AAC may also ston. As a group. The goal natural speech can provide extensive contextual knowl. ing support to respond to one-step motor commands and prehensibility. 2000.. 1990). 1998).

. Yorkston (Ed. L. Ball. The staging of AAC DeRuyter. New York: Oxford University Press. Yorkston. and J. (2001). Baltimore: Paul H. by working directly to develop control over the respira. tive and alternative communication (AAC) system is an . D. Hustad. and Culp. A protocol for Yorkston. (2000). cation with the traumatically brain injured population. Aug- AAC device. See what we say: Vocabulary and tips for In summary. and J. Beukelman. —Laura J. Doyle. and Beukelman. medical setting (pp. remitting. Benton. Baltimore: Paul H. adults with severe communication dis. Augmentative and al. H. and J. Speaking up and References spelling it out: Personal essays on augmentative and alterna- tive communication. the goal is to reestablish speech mentative and Alternative Communication. and Bersani. K. San Antonio.. or stable.. and Tice. Reichle (Eds. AAC for Huntington 33(Suppl. Augmentative communication in the med- (2000). adults who use augmentative and alternative communication.. and Kimelman. however. J. initial choice Lindblom. York- tory. and J.. Interaction involving individuals using aug- bidirectional process of interactions between speaker and mentative and alternative communication systems: State of the art and future directions. Neuro- behavioral consequences of closed head injury. R. Beu. E. 2001). 220–230. 233–270). Re. Beukelman.. K. NE: Tice Technologies.. 6. 31. ing services in augmentative communication. In stage 2. In K. 66–82. F. 191. man and K. Brookes. 5). Baltimore: Paul H. Ball TX: Pro-Ed. Yorkston. Garrett. (1988). AAC and traumatic brain injury: Influence of cog. Austin. (pp.. Brookes.. D. D. Beukelman.). K. (1989). Baltimore: Paul H. In K. In stages Beukelman. Further Readings munication breakdowns. Children who are unable to meet their daily Communication. For consumer: Societal rehabilitation. Baltimore: Paul H.. (1998). K. Augmen- identification of early bulbar signs in ALS. and Gutmann. B. 317–365). Augmentative com- interventions is influenced by the individual’s communi.). and introduction of a multipurpose listener interaction and the development of speech. and Pattee. 43–53. and Grossman. In D. Brookes. orders (pp. M. J. the use of AAC may become necessary only to support writing. (2000). D. (1991). R. orders are able to take advantage of increased commu.). Communication disorders whether advancing. A. H. ASHA. and Yorkston. and Strand. M. and Kennedy. Augmentative and alterna- 107–110. language. (1990). Children Levin. AZ: Communication Augmentative Communication News. M. (1982). Early in this stage. ASHA. 183–229). (2000). Augmentative communication in the Blackstone. In D. with alphabet sup- plementation used early. Brookes. Yorkston. In stage 3. Integrating AAC strategies with natural speech in adults. ternative communication: Management of severe communi. the person Yorkston. (2000).. D. Augmentative and alternative of speech and swallowing in degenerative diseases. (2000). AAC and aphasia: Competencies for speech-language pathologists provid.. Ladtkow. M. Jausalaitis. Canada: William Bobek Productions. and Light. Augmentative and Alternative listener. 139–243). pointing. Yorkston. tative and alternative communication for adults with acquired rological Sciences. and J. J. Baltimore: Paul H. 83–106). 2(3). Reichle (Eds. Journal of Neu. E.. G. K.. Sentence exhibits independent use of natural speech.. 5(3). (1989). the person no longer needs to use an AAC acquired neurologic disorders. Skill Builders. In K. Beukelman. On the communication process: Speaker- making. (1997).). Aug- mentative and alternative communication for adults with 4 and 5. Augmentative and Alternative native communication for adults with acquired neurologic Communication Approaches in disorders (pp. and articulatory sub- ston. K. Mathy. Reichle (Eds. Brookes. Baltimore: Paul H. S. Yorkston (Eds.). Beukelman. munication following traumatic brain injury. and motor impairments (pp. phonatory. Brookes. American Speech-Language-Hearing Association. Beukelman.). port: Augmentative and alternative communication. Baltimore: Paul H. D. 339–374). D. Augmentative systems. Light. (1995). K.112 Part II: Speech the person can respond to yes/no questions. Miller. intervention focuses on intelligibility. and Phillips. messages with natural speech.. M. M.). 271–304).. disease and Parkinson’s disease: Planning for change. nition on system design and use. K. D. K. 9–12. In this stage. Reichle (Eds. (1991). needs using their own speech require alternative sys- Light. tems to support their communication interaction e¤orts petence with individuals who use augmentative and alternative (Reichle. Management kelman. Kennedy. In Brookes. tive communication for adults with acquired neurologic dis- American Speech-Language-Hearing Association. Cognitive-linguistic considerations. communication for adults with acquired neurologic disorders AZ: Communication Skill Builders. late in this stage neurologic disorders (pp. Beukelman. Augmentative communi- cation disorders in children and adults. K. (1998). B. B. P.. and Binger. An augmenta- communication. system. Augmentative and alter. neurologic disorders (pp. G.. R. Ontario. The acquisition of communication skills is a dynamic. M. Tucson. Collier. persons are able to convey an increasing percentage of Brookes. (1996). Brookes. following traumatic brain injury: Management of cognitive. Fried-Oken. AAC for individuals with amyotrophic lateral sclerosis. Tucson. D. Yorkston. The AAC Intelligibility Test.. Reichle (Eds.. Building communicative com. D. C. P. (2000). ical setting. Baltimore: Paul H. TX: Psychological Corporation. velopharyngeal. the AAC system will support and alternative communication for adults with acquired the majority of interactions. 1–3.. (1992). (1992). North York. nication through the use of AAC. and Reichle. Beukel- cation abilities and the natural course of the disorder. and Mirenda. Beukelman. In K. but later only to resolve com. Yorkston. Lincoln. Klasner. Yorkston..

problems that impair their control of their speech mech- who are preliterate. A sec- system. For individuals support communication. gestures. Beukelman. In the United States. e¤ectively as they mature. and establishing a foundation for communication. It includes variety of di¤erent listeners. Typically. Examples include ‘‘Hello’’. Calculator and Bedrosian noted (Ball et al. and aided communication. social skills. achieve appropriate participation for any child. self-direction. language. 1985. For children with commu- of vocabulary needs is exhibited by preschool children. vided to these children by a team of interventionists. opera. ventions allow children to develop the linguistic. AAC systems are used by children with a variety of tional. and parents. the pri- Careful analysis of environmental and communication mary team often includes occupational and physical needs is used to develop vocabulary for the child’s AAC therapists. including school talk. Augmentative and Alternative Communication Approaches in Children 113 integrated group of components used by a child to en. 1989). With children. have not yet developed reading and anisms. Large numbers of persons with who are not literate. Generic small talk refers to messages that ‘‘communication is neither any more nor less than . and pediatric ophthalmologists. 1998. basis for AAC interventions. ‘‘I like that!’’. in the form of the Individuals literacy. In resources available to children with disabilities. This vocabulary selection assessment includes ondary support team might include orthotists. and provides a legal and wants. it provides a foundation for language develop. 1998). 2001). This power allows them to express their needs with Disabilities Education Act. Public policy changes have tion. nication impairments. early communication develop. Mathy-Laikko. any existing natural speech or vocalizations. rehabili- examination of the ongoing process of vocabulary and tation engineers. Children and physical growth throughout their formative years. knowledge. 1998. Early inter. Yorkston. and com. ‘‘AAC and ‘‘Leave me alone!’’ allows individuals to use every mode possible to com. school-age children. It must be appealing to children so that propriate and context appropriate serve as critical tools they find the system attractive and will continue using it for academic success (Sturm. teachers. self- from preschool through high school. and participate in social. ‘‘What’s that?’’. home living. Children with disabilities cannot use traditional spelling and reading severe cerebral palsy primarily experience motor control skills to access their AAC systems. self-care. Very young children. aca- meet needs and develop social closeness. AAC support is pro- ment focuses on vocabulary that is needed to communi. AAC support for contained to departmentalized programs. which includes four variables that can be manipulated to Children experience significant cognitive. An example 18 (Luckasson et al. Home talk is used with familiar persons to community use. educational. health and safety. Extensive instructional resources are available to municate’’ (Light and Drager. interactions. when in preschool and at home gated environments. (Light and Drager. while older children with severe cognitive may be so severe that AAC technology is required to impairments may remain nonliterate. The resulting motor speech disorder (dysarthria) writing skills. exchange informa. develop social closeness. addition. been adopted in numerous other countries to address munity activities (Beukelman and Mirenda. ‘‘What are you doing?’’. Intellectual disability. and children with disabilities. 1999). addition to the communication/AAC specialist. A 2001). Timeliness in implementing an AAC prehensive communication through systematic planning system is paramount (Reichle. e¤ective AAC systems that are age ap. participation model (Beukelman and Mirenda. Mirenda and codes. The earlier that graphic and gestural mode framework for integrating children into general educa- supports can be put into place.. in which they speak tioning coexisting with limitations in adaptive skills with relatively unfamiliar adults in order to acquire (communication. it is important to engage in AAC who have been found to use generic small talk for nearly instruction and interactions in natural rather than segre- half of their utterances. formal sign language. transitioning from preschool to elementary school. that can be used without change in interaction with a hance or develop competent communication. 1998). p. 1). and independence. or school to children must address both their current communication post-school (vocational) will attain optimal participation needs as well as predict future communication needs and when consideration is made for integration. or mental retardation. and social competencies necessary to support severe communication disorders. developmental neuromuscular disorder resulting from a Many young children and those with severe multiple nonprogressive abnormality of the brain. and Light. is char- The vocabulary needs of children comprise contextual acterized by significantly subaverage intellectual func- variations. the federal The goal of AAC support is to provide children with government has mandated publicly funded education for access to the power of communication. cerebral palsy successfully use AAC technology (Beu- tems must be represented by one or more symbols or kelman. 1992). as well as to demics. 391). and work) that appear before the age of assist parents in understanding their child. AAC interventionists facilitate transitions from the ment and facilitates literacy development (Light and preschool setting to the school setting by ensuring com- Drager. academic participation. Cerebral palsy is a their participation in academic settings. In cate essential messages and to develop language skills. so that they will be prepared to communicate ticipation. 2001). and Smith. social par- abilities. technologists. leisure. ment. the greater will be the tion programs may be implemented by following the child’s ability to advance in communication develop. p. message maintenance.. messages within their AAC sys. linguistic. Because participation in the An AAC system must be designed to support literacy general classroom requires many kinds of extensive and other academic skill development as well as peer communication.

Dawson and Osterling. Bernthal. He and Alternative Communication. Motor speech disorders in support very intense schedules of interventions. Beukelman. language. and ultimately independence. and significant speech ternative communication: Management of severe communi- production disorder. Caruso and E. the need to provide these children with some means ment of motor speech disorders in children (pp. When orders. Camarata. related speech disorders may result in prolonged periods San Diego. and speech- There is ongoing debate over the best way to manage intelligibility training. thus necessitating considerable collaboration (Simeons. and Mirenda. Augmentative and forts. G. repetitive. Augmentative and al- limit e¤ective social interaction. DAS have a guarded prognosis for the acquisition of Calculator. Culp. 104). Augmentative DAS who were provided with AAC technology. in the various activities of daily living’’ (1988.unl. communication problems that influence Hall. (1993).. (2) impaired communication. J. (1989). Third- cal systems are impaired because of their di‰culties in party payer response to requests for purchase of com- munication augmentation systems: A study of Washington managing the intense motor demands of connected state. Olley. CA: College-Hill Press.).. and Rosenthal. of behaviors.. Articulation and phono- Developmental apraxia of speech (DAS) results in logical disorders (3rd ed. but rather used the technology to resolve commu.. with and without accompanying physical vere DAS that their speech is unintelligible is receiving impairments. Diagnostic and sta- and as a result. Brookes. and communication is References extremely important (Dawson and Osterling. 5. (1985). 15. Cumley (1997) studied children with mentative communication: A case example.. (1999). These children: Definitions. 1994). 5– speech (Strand and McCauley. K. (1996). and Bankson. son. social intervention. background. Baltimore: Paul H. web site (http://aac. ety of perspectives. 333–351).. and stereotypical patterns communication abilities and access to memberships.). Koegel and R. others with motor learning tasks. Koegel (Eds. (1998).. Collier. C. communication through the use of AAC. Ball. and activities (American Psy. work. Children with a pervasive developmental disorder tion about AAC resources for children and adults. Ball emphasis on speech. D. A a spectrum of impairments of di¤erent causes (Wing. D. 1985c). interests. S. (2000). Some children with DAS have been Positive behavioral support: Including people with di‰cult treated with phonologically based interventions and behavior in the community (pp. A. and processing impairments. . and Parnes. and Bedrosian. may have cognitive. 2000). D. E. 1993). 1999). Developmental apraxia of speech and aug- creasingly accepted. D. 1985b. In L. DC: Author. How. suspected DAS. 1989. Membership involves integration. 15.. Cumley and Swanson. AAC technology.). for speech (Caruso and Strand. with professionals whose views di¤er from their own. Cumley. 1. Baltimore: di‰culty performing purposeful voluntary movements Paul H. L. children with severe communication boards and books) options (Light.114 Part II: Speech a tool that facilitates individuals’ abilities to function tion has been documented extensively (Kent.). Communication as- intelligible speech (Bernthal and Bankson. 145–155. The negative e¤ect of reduced opmental apraxia of speech: Three case studies. DAS. 1987. academic performance. 27–34. p. S. Marvin. Augmentative and Alternative Communication. naturalistic language. 1997). disorders benefit from using AAC systems. communication problems that Beukelman. J. Yorkston. Lincoln. Children with suspected DAS have cation disorders in children and adults (2nd ed.. particularly during the early elemen. P. sion of AAC intervention is influenced by the child’s and (3) restricted. social/communicative. using AAC strategies involving high-technology (elec. Their phonologi. (1994). Some interventionists Caruso. American Psychiatric Association. alternative communication options for children with devel- nication breakdowns. G. of unintelligibility. reported that the group of children with lower speech Cumley. and Strand. These disorders occur as academic participation. (1999). In A. Strand (Eds. sessment and intervention for adults with mental retardation. they did not reduce their speech ef. tive and Alternative Communication. 1–28). and a theoretical frame- arguments have changed little in the last 20 years. Freeman. 1996). and Swanson. 110–125.. chiatric Association. (1997). from a vari- 1985a. S. Generic small talk use by preschool children. Augmentative and Alternative Communication. On the importance of integrating tary grades. 1999). 1997). New to communicate so that they can successfully participate York: Thieme. Lasker. Camarata. have demonstrated considerable success increased attention (Culp. AAC interventionists may need to work tistical manual for mental disorders (4th ed. Children with 9. J. NJ: Prentice language delays. social participation. Children with an assortment of clin- Autism and pervasive developmental disorders are ical disorders are able to take advantage of increased described with three main diagnostic features: (1) im. Beukelman.edu) provides current informa- 1996). Clinical manage- ever. Unpublished doctoral dissertation.. 1993. D. 1997. tronic devices) and low-technology (communication In summary.). (1988). Brookes. Augmenta- speech intelligibility on social and educational participa. K. Englewood Cli¤s. The use of AAC strategies to support Children who are unable to speak because of cognitive the communicative interactions of children with such se- limitations. Introduction of augmentative and alternative intelligibility scores used their AAC technology more modality: E¤ects on the quality and quantity of communica- tion interactions of children with severe phonological dis- frequently than children with higher intelligibility. N. and Smith. language. The provi- paired social interaction. socially and in educational activities is becoming in. University of children with DAS with low intelligibility scores used Nebraska. A range of intervention approaches has been suggested. and Rupp. Washington. Early intervention with an —Laura J.

tative and Alternative Communication. but Academic Press. et al. Baltimore: Paul H. D. 171. Augmentative and Alternative Communication. R. (2001. children and their primary caregivers: Part III. Communication tion. (1997). Coulter. However. Brookes.’’ which he observed in 11 boys who lacked the at-risk and handicapped children (pp. CA: Mayer-Johnson. Reiss. Light. mentally delayed... The autistic spectrum: A guide for parents and administered. 74–83. 4. Building communicative com. Alaska. Collier. Baltimore: Paul H. L.. Beukelman. mentative and Alternative Communication. (1992). (1997). Strand (Eds. Journal of the Alternative Communication. S. 3). 24. Educational inclusion of AAC users. Schalock. strategies (vol. G. J. R. Reichle. Guralnick and to describe a syndrome of ‘‘disturbances in a¤ective F. (1985b). dren Kanner observed did surprisingly well on some Sturm. B. 641–651. on test performance.. Solana Beach.). Brookes. symbolic communica- Light. J. Communica. P. E. Language acquisition in young AAC sys. Elder. mance seen in children with other kinds of retardation. (1999). Brookes. and emergent literacy activities for young. Journal of Applied Behavioral Analysis.. Beukelman and P. Paul. Birmingham. Kanner’s observation about intelligence has been munication disorders in children and adults (2nd ed.. whose scores are comparable across all kinds of tasks. and Swanson. J.. ChalkTalk: Augmentative communication in programs for children with autism. (1998). Baltimore: Paul H. and Parnes. 5(1). Augmentative and practices for beginning communicators: Implications for alternative communication applications for persons with AAC (vol. patterns. P. 3–21. alternative communication: Management of severe com. pp. E¤ects of test adaptations in autism. Beukelman. G. visually based performance often Bedrosian. Brookes.. Autism 115 Dawson. DC: American Association on Mental Retardation. 110–125. 15(2). Kent.. (1998).). 1(2). 179–185. Mental retardation: Definition. 13. individually administered IQ testing is Wing.. the chil- (pp. Early intervention Bristow. J. (1998). R. 27(6).. 1(4). Paper presented at a cation options for persons with severe and profound dis- meeting of the United States Society of Augmentative and abilities: State of the art and future directions. Olley. Assessment procedures nication and interaction that is typically present even in for treatment planning in children with phonologic and motor speech disorders. J. individ- uals with autism do show unusual scatter in their abili- Further Readings ties... behavior: Integrating functional assessment and intervention classification. Engineering the 1(3). Goossens. cation. Augmentative and alternative communi- interaction between young nonspeaking physically disabled cation decision making for children with severely unintelli- children and their primary caregivers: Part I. munication. B. J. R. D. and Williams.. 2). Guidelines for evaluating intervention Culp. K.. Simeonsson. Augmentative and Alternative Com- 369–378. Baltimore: Paul H. 13.. and Parnes. and Light. Exemplary Mirenda. P. Anchorage: Assistive Technology Library of Developmental Disorders. Early The term autism was first used in 1943 by Leo Kanner intervention for children with autism. Storytime just for fun: Stories. E. T. Mirenda (Eds. unlike the perfor- tem users: Issues and directions for future research. The e¤ectiveness of early intervention for contact. Brookes. score in the mentally retarded range.). (1996). alternative communication options for children with devel- Enhancing children’s communication: Research foundations opmental apraxia of speech: Three Case Studies. C. J. D. P. and scores remain stable over time (Rutter et al. and Osterling. 2). Light. and Drager. J. D. P. 125–133.. Baltimore: Paul H. bols. 2).. S. Discourse gible speech.. Modes of King-Debaun. special needs tion. J. Park City. and Mathy-Laikko. J. approximately 80% of people with autism professionals. Collier. G.. (1999).. Augmentative and Alternative Communica. children with severe intellectual deficits. (1997). New York: dysmorphology often seen in mental retardation.). P. (1996). (1990). P. Iacono. (1992).. J. (1988). Exemplary Autism practices for beginning communicators: Implications for AAC (vol. St. Augmentative and Alternative Communication. modified by subsequent research. Reichle. and Drager. Brookes. AL: Southeast Augmentative Communi- interaction between young nonspeaking physically disabled cation Conference Publications. Light. J. Kaiser and D. Caruso and E. Freeman. Aug.. Augmen- for intervention. 98–107. New York: Thieme. Association for Persons with Severe Handicaps. Luckasson. Communication Dowden. and Fristoe. Augmentative and Alternative Communication. UT: Creative Communicating.. and Light. (1989). (2001).. appropriate. Gray (Eds. and systems of support (9th ed. preschool environment for interactive. MN. 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and turn-  Tuberous sclerosis (a disease characterized by abnor. mal tissue growth) is associated with autism with  For people with autism who do develop speech. in which they Autism is considered one of a class of disabilities repeat snatches of language they have heard earlier. and establishing joint attention. and they rarely attempt to direct referents and di‰culty assessing others’ state of others’ attention to objects or events they want to point knowledge are more likely to account for this obser- out. show higher than expected rates of speech distortions showing. Hobson. ac. idiosyncratic meanings. when a child does not verbal mental age (Lord and Paul. radio. depending on the point of view of the use facial expressions. following: 1997). 1984). never develop speech. the greatest challenges to speakers with autism. as in normal development. but language development lags behind non- the end of the first year of life. verbal and nonverbal forms of communication are  The co-occurrence of autism and fragile X syndrome impaired. echolalia. and Howlin. Language and com. Some examples are pulling a and Volkmar (1997) reported the following: person toward a desired object without making eye contact. This vulnerability may be is greatly restricted (Paul. This is the hallmark deictic terms (i. those with other developmental disabilities (Rutter. There may also be unusual preoccupations the same categories that others use (Minshew and with objects (e. or delayed echolalia.. At this period of development. as evidenced by di‰culty with saying I. The range of com- expressed in a range of social. and protesting. acknowledging. children is on par with mental age in children with autism who with autism also show reduced interest in other people. rate of initiation of communication is low (Stone and municative di‰culties are also core symptoms in Caro-Martinez. language production are on par with developmental The primary diagnostic criteria for autism include the level. either immediate echolalia. and di‰culty is seen with Impairment in social interaction. eye contact. however. 1994). and the use of mala-  Approximately 25% of individuals with autism develop daptive and self-injurious behaviors to express desires seizures. decreases. of a large field study conducted by Volkmar et al. instead of pointing. and speech is often idiosyn- autism. Children with autism are similar to mental age– following: matched children in the acquisition of rule-governed Early onset. the condition can and needs are expressed preverbally. communicative. 1995). you/I. here/there).. a direct parroting of speech directed to them. They show only fleeting interest in peers. However. Pointing. Nonverbal communication. Forty percent of people with autism exhibit (the most common heritable form of mental retarda. words may be used with like the preoccupations of other children at this age. and other relatives of individuals with autism. The Impairment in communication. A significant delay in comprehension is one of the The field trial showed that the criteria specified in strongest distinctions between people with autism and DSM-IV exhibit reliability and temporal stability. 1994). Many parents first become concerned at syntax. both higher than expected prevalence. and . whose meaning of the autistic syndrome. appear content to be left on their own to pursue their Pragmatic. Few references are made to mental states. and waving. such as responding to questions they do not diagnostic criteria for autism are more explicitly stated understand (Prizant and Duchan. Showing o¤.. an imitation of speech they have heard— tion) is also higher than would be expected by chance. are absent in this population. interpersonal uses of language present solitary preferred activities. Wants degree to the appearance of autism. 1981). labeling. Both cording to the Diagnostic and Statistical Manual of the kinds of echolalia are used to serve communicative American Psychiatric Association (4th ed. making. The criteria for autism are the result language comprehension. Approximately half of people with autism that there are heritable factors that may convey suscep. Articulation start talking. tures to engage in social interaction as other children do.. 1990). Children with autism do not changes. with increases in opmental disorders. siblings. The functions. 1993).e. municative intentions expressed is limited to requesting nitive di‰culties expressed in varying degrees in parents. an intense interest in vacuum cleaners) Goldsein. 1997). and scores on vocabulary tests are or actions (such as twanging rubber bands) that are not often a strength. and often vation (Lee. 1997). Words are assigned to contexts. and noncommunicative sound (Shriberg et al. body posture. 2001). but forms for ex- also be associated with other medical conditions. and Chiat. Simi. too. lar research on diagnostic criteria for other pervasive Maywood. taking are significantly reduced. 1987). seen in normal pre- Although genetic factors appear to contribute to some verbal children. showing. Communicative di¤erences in autism include the cratic and contextually inappropriate (Lord and Paul. or ges. Echolalia in DSM-IV than the criteria for other pervasive devel. (1994). speak.. This was first thought to reflect a lack of self. speaker). Dykens pression are aberrant. (Donnellan et al. from other people or on TV. 1992). and cog. referred to as pervasive developmental disorders.g. perhaps including echoing that is far in advance Word use is a major area of deficit in those who of what can be produced in spontaneous or meaningful speak (Tager-Flusberg. and so on. Formal aspects of developmental disorders is not yet available.. More recent They are less interested in sharing attention to objects research suggests that the flexibility required to shift and to other people. tibility (Rutter et al. high-functioning adults with autism less use of communicative gestures such as pointing.116 Part II: Speech Recent research on the genetics of autism suggests  Mutism.

There are proponents of operant the three areas that are known to be characteristic of applied behavior treatments (Lovaas. Delays in imaginative play. The use of pragmatic stress in spon. Prizant. Although clinicians see more (Tager-Flusberg and Anderson. there is a great deal of debate about inci- formation to established topics. Schaumann. 1967). In adolescence.. Using this broad definition. Current assess. der. had IQs within normal no definitive study has yet compared approaches or range. into. has proved particularly ment methods make use primarily of multidimensional e¤ective (Rogers. 1996). the precise ratio. social (Mesibov. Rutter. Very talkative people with autism are (Fombonne. 1995). 1998). gainfully employed (Howlin and Goode. Recent innovations (Lord. mental compensatory supports. and Le Conteur. restricted. of the definition of the disorder to include children who There is little awareness of listeners’ lack of interest in show some subset of symptoms without the full-blown extended talk about these topics. 1997). The most widely used for 1997). such as stacking and nesting (Schuler. almost always associated with IQs above 60 (Rutter. Currently. Although there is some debate about impaired in their ability to use language in functional. 2000). to facilitate communication and learning (Quill. and some are structive play. such as visual calendars. did 10 years ago. and Wetherby. Deficits are 1997). repetitive behaviors. lence estimates range from 1 in 500 to as low as 1 in 300 ipants’ purposes. Di‰culty is seen in syndrome. they gener- a major contributor to listeners’ perception of oddness ally progress toward more. As it became recognized that the social and com. 1987).000 (Lotter. cupations with objects or parts of objects are character. good outcome (DeMyer et al. primitive strategies dence and prevalence. image of the autistic child—mute or echolalic. 1998). growth in both language and cognitive skills can be seen Stereotypic patterns of behavior. The classic Paralinguistic features such as voice quality. nor is there one diagnostic test tion. like the classic associated with growth in young children with autism. particularly for lower separate documentation of aberrant behaviors in each of functioning children. this is likely to be due to a broadening conversation is often restricted to obessive interests. 1994) and the Autism focus on the use of alternative communication systems Diagnostic Observation Scale (Lord et al. functional speech by age 5 is also a strong predictor of school period.g.. Stereotyped motor behaviors. As children with autism grow older. It is riod. 1966). children today who receive a label of autism than they For individuals at the highest levels of functioning. autism. although strengths are seen in con. with prevalence estimates of 4–5 per 10. for a review). are also typical but are related to Greenfield.. and istic child-centered approaches (Greenspan and Wieder. when provided with a high degree of intensity that definitely identifies this syndrome. There is ongoing debate about scales. In the vast majority of cases. of natural- the syndrome: social reciprocity. autism is more prevalent in males than communicative ways (Lord and Paul. 2001). (at least 20 hours per week). these prevalence figures were based on Although all of these approaches have been shown to be identifying the disorder in children who. as is a need for routines and rituals high degrees of support in living. particularly about whether inci- such as imitation are used to continue conversations dence is rising significantly. 1998). municative deficits characteristic of autism could be For higher functioning and older individuals with found in children along the full range of the IQ spec. prevalence estimates rose to 1 per 1000 (Bryson. The development of developmental level and are likely to emerge in the pre. that provide the best methods of treatment. pharmacological agents have been tried. Only 1%–2% of cases of speech. unlike in females (Bryson. 1998) and on the use of environ- Until recently. Early interven- used to diagnose autism. have a fully normal outcome (Paul. 1987). and Lockyer. most interventions are derived from more . Out- Children with autism become exceedingly agitated over come in adulthood is related to IQ. Children with autism are Major changes have taken place in the treatments more impaired in symbolic play behaviors than in other used to address autistic behaviors. with nation. other kinds of children with language impairments. either interview or observational. with only about 20% always to be carried out in precisely the same way. 1973). children with autism whose language use improves with increased amount grow up to be adults with autism. (Howlin and Goode. 1997). Although a variety of aspects of cognition. such as hand flapping. though still aberrant. However. measured long-term change. the primary forms of treatment for There is no medical or biological profile that can be autism are behavioral and educational. patients described by Kanner. communication. Bondi and Frost. Autism 117 people with autism have di‰culty inferring the mental trum. Abnormal preoc. current preva- adapting conversation to take into account all partic. Still. 10%–35% of children with taneous speech and speech fluency are also impaired autism show some degree of regression (Gillberg and (Shriberg et al. autism was thought to be a rare disor. seen in providing relevant responses or adding new in. and of approaches that are some hybrid of the research purposes are the Autism Diagnostic Interview two (Prizant and Wetherby. 1998). 1997). Approximately 75% of adults with autism require istic of autism. states of others (Tager-Flusberg. e¤ective at treating certain symptoms (see McDougle. (e. 1997. with continued intervention. 1992).. Monotonic intonation is one of the most sameness—is most characteristic of the preschool pe- frequently recognized aspects of speech in autism. with good outcomes small changes in routine. 1999). 1981). involvement. and stress are frequently impaired in speakers stereotypic behaviors and a great need to preserve with autism. 1991).

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phonemes of the languages should be assessed in dif- Wetherby. Lord. when children who grow up with more than one lan- Matson. Rutter. and treatment. Cambridge. Autism and pervasive developmental dis- neat definition. generally the home language. speech- Delmar. Albany. and Volkmar. when the child goes to school). S. New York: Plenum Press. Journal of Speech. put its imprint on the one acquired later. Autism in children and adults. UK: Cambridge University Press. UK: Cambridge University Press. H. is acquired Catalano. Field trial for autistic disorder in DSM-IV. K. UK: Oxford University Press. S. F. Ameri. New York: Brunner/Mazel. used two languages. To this end.. retardation: Autism. Teaching children with autism. Cambridge. ferent word positions. G. Bilingual children. In the former case.. Speech Issues in 119 tioning adolescents and adults with autism and Asperger Bilingualism. 32. and the other language is acquired. diagnosis. Quill. P. 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(1994). variety of descriptions and interpretations. (1998). R. Thus. New York: Plenum earlier.. and Schopler. Autism. Cambridge. Baron-Cohen. English. H.. Autism: Explaining the enigma. Oxford. and Anderson. Naturalistic obser. it is crucial to Morgan. to the speech of monolingual speakers. Bilingualism defies delimitation and is open to a in the acquisition of language by autistic children. be evaluated. Autism: Nature. L. 437–453. The neurobiology of languages are acquired simultaneously) or successively autism. (1996). New York: because of di¤erent degrees of exposure to the two lan- Wiley. result is interference from the dominant language. Whether a child becomes bilingual simultaneously (two Oxford. Bauman. The di¤erent patterns that a bilingual child reveals in Happe. even if the child seems to be a domi- Cambridge. MA: Harvard University Press. Journal of Autism and Developmental Disorders. (1985–2000). ob- ment of contingent discourse ability in autistic children. It has long been recognized that bilingual indi- can Journal of Psychiatry. G. New York: Appleton.). and Caro-Martinez. More children New York: Guilford Press. (Eds. the great ma- Baron-Cohen. B. D. Hillsdale. T. (1995).’’ (1994). B. and phonotactic patterns should orders. determine whether these nonconforming patterns are due Powers.

processes. or person. within one country (New England variety. An example is final obstruent devoicing in the Last but definitely not least is the desperate need for English language productions of a child with German. and Wei. as in confidence. Thus. This assumes that a bilin- category would be consonant cluster reduction in chil. Dodd. because Spanish Australian. gual individual is two monolingual individuals in one dren whose primary language is Japanese. guage. or Turkish as the first language. disorders had a lower overall intelligibility rating. Holm. it variety. more errors overall. it is also a feature of the lan. Portuguese. made guage as the culprit and label the situation as one of in. and pro- terference. standards (Grosjean. In such instances we must attribute these pat. ever. [b0k] for ‘‘bag. structure of Spanish.. Because none of these varieties or terns to universally motivated developmental processes dialects of a given language is or can be considered a that have not been eliminated according to the expected disordered form of that language.or underdiagnosis. For example. Al. Certain cases lend themselves to obvious identifica. ‘‘tip. However. suspected speech disorder (Dodd. fricative guese interference. In this the client. However. distorted more sounds. may occur in change of /t/ to [tS ] before /i/ is a rule of Portuguese children with phonological disorders. American.. frication of stops. rating. a bilingual guages listed. dialectal variation. and African American Ver- is impossible to refer to the first language as the expla.’’ [bEt] for bilingual children with phonological disorders. 1997) sally phonetically motivated and shared by many lan. then lingual children and bilingual children with phonological it would be very di‰cult to identify the dominant lan. say that these renditions were due to Portu. phonology. Rather. Turkish. the child’s dialectal timetable. we common simplification patterns. we can. as in [v0n] monly observed in developmental phonologies. As for the di¤er- Spanish and English reveals processes such as final ence between normally developing bilingual children and obstruent devoicing (e. British. Indian) and even has no voiced obstruents in final position and no con. Polish. information on phonological development in bilingual Russian. Studies that have examined the phonological patterns The decision is not always so straightforward. In other words. this they will also need to consider not only the languages of particular situation suggests a delay or disorder.’’ whereby target /t/ turns into [tS ].g. and Stubbe. because of the constant interaction of Finnish. and single obstruent coda deletion in children the two languages. Any assessment of the child’s We may also encounter a third situation in which speech must be made with respect to the norm of the the seemingly clear distinction between interference particular variety she or he is learning. 1996) and bilingual children with a developmental simplification processes that are univer. 1987. Just as there are several varieties of English because none of these patterns are demanded by the spoken in di¤erent countries (e. Compared processes. speech-language pathologists must English language productions of a Portuguese-English be watchful for some unusual (idiosyncratic) processes bilingual child forms like [tSiz] for ‘‘tease’’ and [tSIp] for that are observed in children (Grunwell. but also the specific dialects of those lan- case. each phonological system of a bilin- . For example. Not accounting and the developmental processes is blurred. suppressed in normally developing children by age 6. normally developing bi- have the opportunities for such processes to surface. 1992). information is essential. South African. For example. indicate that children in both groups exhibit patterns guages. This occurs for dialect features may either result in the misdiagnosis when one or more of the developmental processes are of a phonological disorder or escalate the child’s severity also the patterns followed by the first (dominant) lan. in normally developing bilingual children (Gildersleeve.120 Part II: Speech appropriate for the other language and may be the cause whose primary language is Japanese. how. and the for ban. as such substitutions are not com. monly occurring developmental processes that occur in As speech-language pathologists become more adept the speech of children in many languages. If a bilingual child’s speech reveals any such di¤erent from matched. these processes are among the com. at di¤erentiating common and uncommon phonological cause these common simplification processes are usually patterns and interference patterns in bilingual children. and if the first language of the child does not with their monolingual peers. Processes such as unusual cluster reduction.g. be. Canadian. over time more slowly. and backing. the result is a natural tendency that child is assessed with two procedures. it appears ‘‘bed’’) and/or deletion of clusters that do not follow so. or of over. language. Spanish. these processes may not have surfaced until age 6 guages. if we encounter in the opmental processes. Language skills in bilingual persons have al- that even occurs in the early speech of monolingual most always been appraised in reference to monolingual English-speaking children. other languages also show nation. Italian. monolingual peers. Other examples that could be included in the same speakers of these languages. children and assessment procedures unique to these in- though final obstruent devoicing is a natural process dividuals. as in [p0k] for pat. and are likely to have uncommon terference. that are designed to evaluate monolingual tem. Southern sonant clusters that do not follow sonority sequencing. gliding. if a 6-year-old child bilingual in duced more uncommon error patterns. that children with phonological disorders manifest more nority sequencing ([tap] for ‘‘stop.’’ [pIt] for ‘‘spit’’). suppress such patterns cannot claim that these changes are due to Spanish in. Accordingly. one for each receives extra impetus from the rule of the primary sys. General American. as in [wIg] for fig. nacular in the United States). [ren] for train (instead of the expected [ten]). substitutions may reflect certain Davis. Besides the interference patterns and common devel- tion of interference. with 1993).

Cantonese Segmental Phonology Test. Hewlett (Eds.). L. B.. (Eds. and Hearing In order to characterize bilingual phonology accu. E. C. M. from one individual to another. Clinical Lin. B. (1998). So. in children. CA: Singular Publishing Group. Phonological patterns rately. (1977). Croom Helm. Clinical phonology (2nd ed. In J. F. as information on phono. P. L. Mahwah.).. (2000). —Mehmet Yavas Magnusson. Bialystok (Ed. and Goldstein. tin. Cambridge. Watson. Grunwell. New in programming of sequential speech movements based York: Oxford University Press. A. L. Phonological processing in two languages. (1993).. J.. Wallesh (Eds. Motor-based or pre-motor cations. not necessarily be Goldstein. 82–90. American Jour- Weinreich. Sweden: Gleerup. Yavas. Seminars in Speech and Language. Kelly. The acquisition of phonology by lingual rules don’t apply: Speech development in a bilingual Cantonese speaking children. W. Berlin: Nettelbladt. MA: Allyn and Bacon. References Mann. W. (1968). Bloomfield. B. I.. data cal disorders. 5. and Leonard. Phonological assessment of child speech. Sciences. 341–350). Because bilingual Hodson. (1982). L. ordered phonology in children. (1992). Hernandorena.. Alatis (Ed. (1976). Theo- Ferguson. (1995). CA: San Ysidoro J. (1995). Services in the Schools. Another view of bilingualism. 473–495. and Stubbe. The Hague: nal of Speech and Language Pathology. 27. Kong University. Developmental Apraxia of Speech guistics and Phonetics.). and Lamprecht. 367– on the developmental patterns in two languages sepa. 51–62).. Mason. Dodd. School District. The speech of phono- logically disordered children acquiring Italian. A. 1991).. the American Speech-Language-Hearing Association.). A. (1998). L.. Developmental Apraxia of Speech 121 gual child may. TX: Pro-Ed. CA: Singular Publishing See also bilingualism and language impairment. B. Interference. Gildersleeve. Speech sound di¤erences In E. Group. Phonological development: Models. (1994). Cognitive processing in bilinguals (pp. phonologies: Assessment and remediation of disorders. Marshall. Goldstein. Yavas.. (1998). and Paden. Bilingualism: Basic principles. E. 15.. Timonium. 1–12. TX: Pro-Ed. B. U. chronic fallacy. (1985). (1933). 7. M. R.). Targeting intelligible tools for phonological development is a huge task.and 4-year-olds child (Watson. UK: Cambridge University Press. W. (2002). (1983). U. haps the biggest challenge for the field. (Ed. However. and Dunn. Grimm. of Puerto Rican descent. NJ: Erlbaum. Medida Dodd. Deuchar. Mouton. Assessing Asian language performance: Developmental apraxia of speech (DAS) is a devel- Guidelines for evaluating limited-English-proficient students. W. P. TX: National Education Laboratory Publishers. speech (2nd ed. Yavas. L. and Dodd. Speech disorder in So. M. H. C. (1985). Lund. and in most cases will. Hong preschool children exposed to Cantonese and English. and C. Language. Normal and dis- tle. C. and Iglesias. Smith. In R. San Diego. Cheng. Aus- Harris (Ed.. When mono.. E. (1991). (1970). Paper presented at the annual convention of 22. retical constructs motivating understanding of DAS (1992). Dittman. (1996b). M. San Ysidoro. (1987). M. Menn. 29. and Stoel-Gammon. J. (1991). environment. R. Bilingual speech-language pathology: An Hispanic focus. Speech disordered children. Speech.. Austin.). velopment. planning speech output deficits (e. Davis. (1996a). impli. detailed information on both languages being in Puerto Rican Spanish-speaking children with phonologi- acquired by the children is indispensable. C.). New York: Elsevier. Bilingualism and language Investigations in clinical linguistics (pp. C.. E.).. London: Diego. 825–834). 11. rately would not be adequate. Austin.). Bilingual acquisition. M. (1996). L. logical development in bilingual children is the real key London: Nfer-Nelson. Language processing in bilingual chil. Needham Heights. Assessment of phonological processes in speakers’ abilities in the two languages vary immensely Spanish. Jordon. VOT patterns in bilingual phonological de- Mackey. and Bankson. L. DC: Georgetown University Press. Journal of Communication Disorders. Washington. Bortolini. Avaliacao fonologica da Crianca (Phonological assessment tool for Brazilian Portuguese). Swe- den: Gleerup. to understanding bilingual phonology. Blanken. (1987).. San Grunwell. Holm. H.. and Iglesias. (1986). Windsor. and N. (1997). B. Bernthal.. Theoretical issues and clinical applications.). B. opmental speech disorder frequently defined as di‰culty Rockville. Keyser. The phonology of language disordered children: Production. Brazil: Artes Further Readings Medicas. D. integration and the syn. In F. and Hodson. Developmental studies of dysphonology De Gruyter. Phonological patterns acquired in a way identical to that of a monolingual in normally developing Spanish speaking 3. S. A. Lund. San Diego. CA: Los Amigos. and Hinshaw. Hall. (1991). Articula- tion and phonological disorders (4th ed. A. have been quite diverse. Languages in contact. Espanola de Articulacion. H. (1992). B. and Quay. UK: Tieto. 387. Toronto. Phonology: Development and disorders. Porto Alegre. contact.). (1983). MD: Aspen. per. Stoel-Gammon. J.g. and . 137–147. Journal of Child Language. U.. New York: Wiley. and disorders in first and second language acquisition: dren. MD: York Press. M. 229–243. Department of Speech and Hearing Clinical Linguistics and Phonetics. Southwest Spanish Articulation Test. (1991). B. C. M.. developing assessment Hodson. Linguistics: Disorders and pathologies (pp. Spanish-speaking children’s Beatens-Beardsmore. Clevedon. Language. Grosjean. In G. (Eds. on presumed underlying neurological di¤erences. perception and awareness. B. WA. research. and Wei. N. Yavas. Seat.

relates presently in use is of crucial importance to careful The characterization of DAS was originally derived definition and understanding of DAS. p. be based on awareness of the Kwiatkowski. no currently define DAS are outlined. opmental behaviors appropriate to the client’s chrono- behavior relations (see Bennett and Netsell. neurological basis. or empirical evidence precisely defining as di¤erential diagnostic correlates in some studies behavioral correlates. sistently reported and di¤ering criteria are included opmental disorder categories such as hearing impair. Velleman and Strand. Morley. others do not (Horowitz. developmental verbal dyspraxia. DAS has most often to cloud the issue of precise definition of the pres- been defined by exclusion from functional speech disor. (e. the LeNormand et al. a continuum of severity is explored. observed behaviors need to be evaluated against devel- cated instrumental techniques for understanding brain. and speech disorders for di¤erential diagnosis (Stackhouse. sized that behavioral inclusion criteria are not con- Jakielski. represents an incompletely understood disorder that the basis for assigning severity judgments is inconsistent poses important challenges both to practicing clinicians across studies. In some reports. thus achieving a circular argument Some studies include control populations of functional structure for neural origins (Marquardt.g. regardless of the have been employed: developmental apraxia of speech. and developmental 1992. de.g. the defining characteristic is nosis for clinical intervention and research investiga. 30) is to be avoided. see Vihman. Hall. the norm. Stackhouse. In every instance. latter conceptualization. achieving a theoretical base with behavioral correlates results in an circularity that is not helpful for producing valid char- ‘‘etiological’’ disorder label with no clearly established acterization of the disorder (Stackhouse. Thoonen current state of empirically established data regarding et al.g. and Kwiatkowski. specific issues with available available theoretical constructs specifically disprove research will be reviewed briefly. 1995). 1992. 1999. even with increasingly sophisti. Shriberg.g. 1993). conclusively delineated.. or deficits in and valid theory building to understand the underlying neural tissue with organizational consequences (e. founded on a clear understanding of positive Despite the foregoing critique. a review of the range of behavioral cor- kowski. Associated language and praxis behaviors are included tion. 1992. Shriberg.g. phonologically based deficits in represen. and Marquardt. at the onset of meaningful speech. lack of a link of underlying cause or come recognized symptoms of involvement. Evidence for a neurological etiology for DAS is ages vary widely.... Sussman. Subject basis. and Miller (1954) first applied the term dyspraxia functional speech disorder. di¤erential diagnostic be normal aspects of earliest periods of speech and correlates and range of severity levels characterizing language development (e. 1988) have been posited. the utility of the label is seriously questionable for etiology was implied by the analogy but has not been either clinical or research purposes. 1997. predominant use of simple DAS remain imprecisely defined.. accordingly. Guyette and Deidrich syllable shapes or variability in production patterns (1981) have suggested that DAS may not be a theoreti. tation (e. logical age. 1984). 1996) to adults (Ferry. Jordon.. ence and prevalence of the disorder in child clinical der or delay using a complex of behavioral symptoms populations. Hall. In the case of very young clients. overlapping with other categories of developmental Before the clinical symptoms presently employed to speech disorder or delay. a disorder category of behavioral correlates to di¤erential diagnosis from based on acquired brain damage resulting in di‰culty in ‘‘functional’’ speech disorder or delay is of primary im- programming speech movements (Broca. for children with persisting and serious speech di‰culties ing these varied views of causality. 1997). DAS can manifest as mild. these deficits (e. precise nature of their unintelligibility’’ (Stackhouse.. 1998). Cautious application of the diagnostic label should be moderate. 2000).. Clinically. An ethical di¤erential diag. Despite the lack of consensus on theoretical motiva.g. etiology. there is some consensus among (Crary and Towne. A consequence of this inconsistency is and to the establishment of a consistent research base lack of consensus on severity level appropriate to the for overall understanding. and Kwiat. from preschoolers (Bradford and based on behavioral correlates that are ascribed to a Dodd. 1984. In other reports (e. 2000). across studies. Some listed characteristics may spite nearly 40 years of research. Davis. and Hicks. severe and persistent disorder (e. and Robin. the large available benefits to the client in discerning long-term prognosis. It should be empha- other possible theories for the origins of DAS (see Davis. appropriate decisions regarding clinical intervention. 1997) that DAS exists. 1997).g. 1984). 1997). 1992). Use of DAS as an ‘‘umbrella term Crary.g. A neurological DAS. Such practice continues articulatory dyspraxia. Reflect. while others explicitly exclude practicing clinicians as well as researchers (e. In contrast to devel. 1993). a variety of terms in the absence of obvious causation. The relationship from apraxia of speech in adults. portance to discriminating DAS as a subcategory of Court. 2000). Accordingly. If no single defining charac- to children based on a proposed similarity in behavioral teristic or complex of characteristics emerges to define correlates with adult apraxic symptoms. In addition. Shriberg. Sussman. 1975). 1861). It thus verity is not reported consistently. and Velleman.122 Part II: Speech Robin. literature on DAS suggests some consensus on behav- . In addition. or severe speech disorder. nature of the disorder. In the theories and behavioral correlates defining this disorder. cally or clinically definable entity. and tions should. Criteria for inclusion in studies then be- ment or cleft palate.. DAS label. When it is reported. as current empirical for a review of normal phonetic and phonological evidence does not produce any behavioral symptom not development). Dodd. Little coherence and consensus di¤erential diagnosis of DAS is complicated (Davis is available in this literature at present. Aram. Aram. 1993). Se- Aram..

11). Developmental apraxia of speech: Advances in theory and Clearly.. (1954).g. Re- characteristics. M. L. cognition. K. Impaired tongue strength and endurance in . and receptive language.-T. long been a focus of research and a subject of intense Morley. 463–467.. P. S. 27–37. and (9) Speech and language advances in basic practice (No. characteristics are in common with functional disorders Devlopmental apraxia of speech: Determiners of di¤erential and thus do not constitute a di¤erential diagnostic char. 17. Di¤erential diagnosis and persistence of clinical symptoms in spite of intensive treatment of children with speech disorders. British Medical Journal. (2) poor volitional oral nonverbal ing in developmental dyspraxia: A follow-up case study.. Co-occurring LeNormand. B. Language. com. although frequently cited. Sussman. B. S. (4) a high incidence of vowel errors. (1995). Seminars in Speech and Language. Accordingly. (e. P. 6. and Towne. Velleman and Shriberg. syntactic development.. Ex. omission of errors. L. (8) groping postures. lack of willingness or ability to imitate a model. W. Procedures for classification of sub-groups of show ‘‘groping postures of the articulators’’). Jordan. 71–83. E. Vaivre-Douret.. 1999. K. A.. H. 25–45.. Clinical Linguistics and Phonetics. Bulletin de la Societe d’Anatomique. Payan. 2nd série.. Ozanne.. 11–18. W. practicing clinician based on emerging research. W. References clusionary criteria frequently noted include (1) no peri- pheral organic disorder (e.. A. Do all speech-disordered Phonological and phonetic correlates have also been children have motor deficits? Clinical Linguistics and Pho- listed. pitch. (2000).. B. plicating understanding of the nature of the disorder and 330–337. Descriptive terminology varies from phonetic netics. R. DAS is a problematic diagnostic category practice. (2) Forrest. (1975). (1981). errors on longer sequences. M. 1995) to phonological (Forrest and Broca. M. J.. Devel- interest to clinicians. and (5) normal receptive language. L. T. cerebral palsy).).e. A. 77–101. (1996). and Hicks. B. diagnosis. and Marquardt. M. T. Vogel and M..). J. M. 12.g. M.. M. Developmental Apraxia of Speech 123 ioral correlates that should be evaluated in establishing a behavioral correlates have been described and studied di¤erential diagnosis. B. (2) no sensory Bennett. delays. Crary. not all symptoms are consistently reported as being Infant Toddler Intervention. 10. guage. and Robin.. and Deidrich. M. However. (1999). and Stokes. D. has not been search utilizing consistent subject selection criteria is specified quantitatively. (1984). what types and severity of suprasegmental errors man Communication Disorders. See also motor speech involvement in children. sis. (3) no peripheral muscle insula in speech and language processing: Directions for re- weakness or dysfunction (e. in vision or hearing). M. skills. correlates. Devel- Co-occurring characteristics of DAS in several related opmental apraxia of speech. 42. Hall. (7) increased of developmental apraxia of speech..). London: Whurr. and Dodd. and characterization of behavioral or neural Murdoch. Long-term speech disorder... areas have also been mentioned frequently. Possible roles of the deficit (i. dysarthria. comparison across studies. loudness. are necessary or su‰cient for the diagnosis?). because these characteristics have not been con. Treating dis- for both research and clinical practice.. 12.g. and Miller. (1995). D. speech: Developmental verbal dyspraxia. 6(2). Journal of Medical Speech-Language Pathology.g. A. necessary to a diagnosis of DAS (e. Dilapidated therapy has also frequently been associated with DAS. E. 432–455. C. suives d’une observation d’aphemie (peste de ing to the theoretical perspective of the researcher. In N. H. characteristics frequently cited include (1) delays in gross H. Neuromotor development and language process- and fine motor skills. TX: Pro-Ed. K. Journal of Hearing. (1999). (2000). 10(3). Marquardt. sistently tracked across available studies. not all clients Dodd. D. D. In addition. P. (1861). and Davis. C. how limited does the consonant or vowel Davis. B. 7. and Velleman. limited consonant and vowel phonetic inventory. L. In addition.e. Neurological findings in developmental co-occurrence may be optional for a di¤erential diagno. M. (1993). (1998).. (4) normal IQ. Australian Journal of Hu- (i. (2000). M. and Morrisette. search. 177–192.. Developmental Phonological/phonetic correlates reported include (1) Medicine and Child Neurology. cleft palate). these behaviors needed to begin to link understanding of DAS to ethical should not be considered definitive but suggestive of clinical practices in assessment and intervention and to directions for future research as well as guidelines for the elucidate the underlying causes of this disorder. (1984). Court. Hall. A. S. Di¤erential diagnosis repertoire have to be to express DAS?). J. Some Davis. Although it has orders of speech motor control.. opmental dysarthria. and Cohen. (4) delay in Journal of Clinical and Experimental Neuropsychology. Dodd (Ed. and (5) reading and spelling 408–417.. Davis sensory function. little consensus exists on definition. TX: Pro-Ed. Remarques sur le siege do la faculte du lan- Morrisette. Cannito (Eds. etiology.. L. (3) inconsistent diadokokinetic rates. (3) frequent segmental errors in children with phonological disorders. S. la parole). 255–272. verbal apraxia. L. Bradford. In D. Lass (Ed. E. 1. acteristic (i. L.. A critical review consistent patterning in speech output. Austin. L. Ferry. 1999) accord.. Feature analysis of predominant use of simple syllable shapes. and nasality). (1984). (5) altered suprasegmental characteristics (including rate. 187–194. Jakielski.. of developmental apraxia of speech in infants and toddlers. and Speech Research. Circularity in the way in which etiology and P. R. Seminars in Speech and Lan- varied subject pools and di¤ering exclusionary criteria. London: Academic Press. 22. guage articule. Phonological characteristics of devel- relates have been established across studies with highly opmental verbal dyspraxia. Horowitz.. The range of expression of symptoms is not established Crary. T.. The asynergistic nature of developmental verbal dyspraxia. J. Exclusionary criteria for a di¤erential diagnosis have been suggested in the areas of peripheral motor and —Barbara L. Murdoch et al.e. Austin. behavioral cor. (6) variability and lack of Guyette. The range of expression of these does not lend to precision in understanding DAS.. In B. and Netsell. 6(2). Aqttard.

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Speakers from the tinction should be considered relative to the territories of eastern region of England settled in New England. eventually. or a bundle of isoglosses. niques were used as primary mechanisms of data col- tinguish dialect from language. the concept those from Ulster settled in western New England and in of mutual intelligibility appears valid. Norwegian. The bundle of speakers of these languages can easily understand one isoglosses on a linguistic map would indicate that people another. may Several factors contribute to the formation of regional not be mutually intelligible. features was produced and where people stopped using the two lack mutual intelligibility since those who speak this same set of features. the dialect continuum refers to a distribution of sequentially dialect was more distinctive. others may be more dra. region in which they settled. These methods have the same language. or ‘‘She was a-tellin’ the story’’ appears to be a retention guage characteristics that are distributed across a speci. Theoretically. and between Detroit. and investigators began to explore di- be mutual intelligibility between dialects spoken in A versity of dialects within large cities. some of the intermediate dialects. Dialects exist in all languages and are often discussed Regional dialect formation may also result from in terms of social or regional varieties. forms that contributes some of the unique characteristics guage patterns of the same speaker. whereas it is not Appalachia. . C is adjacent to B and D. Although Can. It is also possible that sets with large numbers of contrasts. matic. When multiple isoglosses. For many years. between C and D. B. On the other hand. traverse the Appalachian mountain range. linguistic maps displaying geographical distributions of ber of dialects. or grammatical forms. whose state capitol is ‘‘Napolis’’ (Annapolis). linguistic forms across a broad geographical area. cal a-prefix in utterances such as ‘‘He come a-running’’ Regional dialects constitute a unique cluster of lan. existence of specific features. Assume widely dispersed territories are labeled Recordings allow a greater depth of analysis because towns A. thereby creating a continuum. audio and. However. A those who lived outside the boundary. Commerce and culture also play important roles in or linguistic geography. speak only Mandarin. the morphologi- cial and regional dialects are not mutually exclusive. The field worker would then manually quently employed to di¤erentiate dialect from language. this and Danish are thought of as di¤erent languages. Social dialects the presence of natural boundaries such as mountains. would encourage the speaker to produce the distinctive Although the construct of mutual intelligibility is fre. Swedish. Data were used to determine where a selected set of tonese and Mandarin speakers consider these dialects. and interest. Mutual intelligibility lection. inhabitants of ciated with geographical location or where speakers live. Strong extremes. and interview tech. For example. Chinese has a num. Regional dialects are asso. such as B and D. each language characteristics. B is adjacent to technological advances. tual intelligibility. Technological devel- D and E. ings were made of speakers in designated regions. Surveys. A field worker would visit an area and talk to means that speakers of one dialect can understand residents using predetermined elicitation techniques that speakers of another dialect. and vice versa. the dialects of the two towns at the opments also led to more quantitative studies. note whether the individual’s speech contained the dis- there are counterexamples. Dialect. The selected features could in- only Cantonese do not easily understand those who clude vocabulary. and B. land). dialects spoken influencing regional dialects. on one side produced a number of lexical items and A dialect continuum or dialect continua may account grammatical forms that were di¤erent from the speech of for lack of mutual intelligibility in a large territory. Exploration of regional dialectal seventeenth century. as can be observed in the in cities were thought of as prestigious. Therefore. For instance. in the United States. in unique dialect of people in Baltimore. the mountains were isolated and retained older English Regional and social dialects may co-occur within lan. Each contributed di¤erent variations to the completely valid in many other countries. represent a speaker’s social stratification within a given rivers. questionnaires. of Appalachian English. New York. there was increased interest in A and C. For instance. were drawn on a map to indicate the speakers may produce di¤erent languages but have mu. traditional dialect studies. yet is used to designate dialect boundaries. it is tion patterns. A and E. Concurrent with these another. with a greater amount of arranged dialects that progressively change speech or bundling. For example. dialect geography. began to appear in the United States as speakers immi- Using mutual intelligibility as a primary marker of dis. Some After the 1950s. D. Lines. video record- speech shifts may be subtle. Because it was extremely di‰cult to society or cultural group. between B and C. and so on. surround a specific region. or isoglosses. On one hand. Regional 125 ignated standard linguistic system is often used to dis. There will urban dialects. spoken in di¤erent geographical regions. so. Among these factors are settlement and migra- Because di¤erent conditions influence dialects. items of interest. and E and are serially adjacent to one they can be repeatedly replayed. C. such as Boston. speakers may tinctive linguistic features of interest. specific sounds. from older forms of English that were prevalent in the fied geographical area. such as Cantonese and Mandarin. systems is referred to as dialectology. and London. For example. but the dialects may not be generated a number of linguistic atlases that contained mutually intelligible. may not be mutually intelligible. dialects. grated from di¤erent parts of Britain. data were mainly collected in Speakers of ‘‘Bawlamerese’’ live in ‘‘Merlin’’ (Mary- rural areas. In other words. statistical analysis (dialectometry) has evolved since the owing to the continuous speech and language shifts that 1970s and allows the investigator to explore large data have occurred across the region. Maryland. and swamps. regional English varieties not easy to discriminate dialect precisely from language.

and but vascular. and duration of voice. and degenerative diseases are refer to Bethlehem Steel as ‘‘Bethlum. tone. with nearly double that preva- Two other types of geolinguistic variables are often lence during the acute phase (Sarno. observations of asymmetry. and it can be (you singular). subacutely. 1986. language has causes are also possible. and ana- bases can be present congenitally or they can emerge tomical imaging methods are available for assessment. as well as performance Labov. for example. has been a pri. pitch..g. K. sures are available for clinical and research purposes Endogenous or exogenous events as well as genetic (Enderby. Dialect acquisition. —Adele Proctor dysarthria was the primary communication disorder in 46% of individuals with any acquired neurological dis- Further Readings ease seen for speech-language pathology evaluation over Chambers.. (1998). or articulatory speech movements. but other mea- progressive. injury may be dysarthric. and it probably working ‘‘down a point’’ live in ‘‘Dundock’’ (Dundalk). 1996). For example. neo- ‘‘Bethlum’’ mill. Visual and physical examination of the speech mechanism at rest Classification and during nonspeech responses (e. Romaine.C.g. dysarthria often is present in a number of fre- ‘‘har and far’’ (hire and fire) people. 1977. Their neurological A wide variety of acoustic. MA: Blackwell. 1992). Beukelman. resonatory. Buonaguro. J. speech. ‘‘yens’’ (you plural) and ‘‘yens boomers’’ among the most disabling symptoms of the disease in (a group of people). AMRs permit judgments about the rate and rhythm of repetitive movements and are quite useful in distinguishing among certain dysarthria types (e. repetition of ‘‘puh. and Tice. but sometimes they are the ligibility in Dysarthric Speakers (Yorkston. pho. physiological. Their course and Traynor. improving. dysphagia. tory support for speech as well as the quality. represents a significant proportion of all acquired neu- some may live as far away as ‘‘Norf Abnew’’ (North rological communication disorders.’’ where the boss will known. Vol. (1992). 1. they are typically slow but regular in spastic dys- Dysarthrias: Characteristics and arthria. or stationary. Beukelman. 68. 1983. The clinical diagnosis is based primarily on auditory Chambers. Dysarthria proba- linguistic characteristics that are unique to a geographi. The second variable is the frequency some cases (Dewey.. Some are easily used clinically. D.. evolved to discuss employment. located in Fells Point. on tasks such as vowel prolongation and alternating nal factors. Kent et al.. Mlcoch. and Trudgill. For instance. traumatic. acutely. D. 1989). New perceptual judgments of speech during conversation. and reading. ‘‘Habberdy Grace’’ (Harve de Grace). The most commonly used intelligibil- They are often accompanied by nonspeech impairments ity measures are the Computerized Assessment of Intel- (e. and inflammatory mary employer of many individuals. system conditions that adversely a¤ect respiratory. K. Language. 1990). ap- Avenue). but mainly used in central and western Pennsylvania. Studies using them have often . but quantitative measures usually focus on intelligibility natory. (1998).). speakers say ‘‘youse’’ (Logemann et al. a 4-year period (Du¤y. infectious. acoustic. or even proximately one-third of people with traumatic brain ‘‘Klumya’’ (Columbia). 1999). adventi- The dysarthrias are a group of neurological disorders tious movements.. New York: Oxford University Press. and speaking rate. or accuracy of movements nec. Many will say they work Although incidence and prevalence are not precisely ‘‘down a point’’ or ‘‘down a mill. York: Cambridge University Press. weakness. 1995). sentence repetition. ease.. with increased prevalence as the disease progresses unique to western Pennsylvania. Handbook of dialects and language varia- tion. 673–705.g. but irregular in ataxic dysarthria). or insidiously at any time of life. (2000). (Yorkston. W. New York: Academic Press. exacerbating-remitting. One variable is a set of Levita.. whereas others are pri- They are associated with many neurological conditions.126 Part II: Speech located next to ‘‘Warshnin’’ (Washington. Yorkston et al. Cambridge. 2000). e‰cient and intelligible tory diagnostic evidence. atrophy. range. marily research tools. They result from central or peripheral nervous Dysarthria severity can be indexed in several ways. Dysarthria emerges very fre- of occurrence of regional linguistic characteristics in a quently during the course of amyotrophic lateral sclero- specific geographic area. P. M.. timing. endoscopic. Language in society: An introduction to Vowel prolongation permits judgments about respira- sociolinguistics.’’ Linn. toxic-metabolic. formation from instrumental measures (e. While most people quently occurring neurological diseases. S. Dialectology. bly occurs in 50%–90% of people with Parkinson’s dis- cal area or that occur only in that area. only manifestation of neurological disease. and signs in over 20% (Rose. and associated with regional dialects. the expression sis (ALS) and may be among the presenting symptoms ‘‘take ’er easy’’ is known throughout the United States. It occurs in 25% of patients with lacunar stroke (Arboix and Marti-Vilata. (1994). Principles of linguistic change. 1978.’’ and ‘‘kuh’’ as rapidly and steadily as possible). plastic. In a large tertiary care center. pathological oral reflexes) and in- that reflect disturbances in the strength. videofluorographic) often provide confirma- essary for prosodically normal. 1985).g.’’ Because the their most common cause in most clinical settings. Gubbay et al. For example. steadiness. J. Inter. ‘‘tuh. hemiplegia). 1984) and the Sentence Intelligibility Test can be transient. influences can cause dysarthrias. speed. fasciculations. motion rates (AMRs.

. or hypoglossal has received little systematic study. dys- articulation and prosody. stridor. voice. Distinguishing characteristics usually Flaccid dysarthria is due to weakness in muscles reflect regular or unpredictable variability in phrasing. electroencephalography. what we understand about the anatomical and phys. for example. short phrases. present. accelerating. their primary distinguishing perceptual only during speech. movements may be a nearly constant presence. All components of speech produc. and they are perceived most readily in is high and their functional e¤ects are significant. or short phrases when the laryngeal and Folger. Parkinson’s disease is the prototypic disorder associated iological underpinnings of the dysarthrias include with hypokinetic dysarthria. nance imaging. and their presumed underlying localization of speech production. Its manifestations vary across auditory-perceptual method developed by Darley.g. facial. the method iden. slow rate.g. irregular speech researchers. When spinal respiratory nerves Mixed dysarthrias reflect combinations of two or are a¤ected. Characteristics often include arthrias draw considerable attention from clinicians and irregular articulatory breakdowns. or ataxic dysarthria (Du¤y lophonia. which can range Aronson. because the e¤ects on speech. Hyperkinetic dysarthria is also associated with basal 1997. These teristics that presumably reflect underlying pathophysi. dip. The directions of clinical and more basic . articulation. ganglia control circuit pathology. Some diseases are associated only with a produce relatively mild deficits. prevalence in frequently occurring neurological diseases ordination. Its distinguishing characteristics include tromyography. palatophar- ferred to as the Mayo Clinic system. or prosody. to irregular but relatively sus- tifies dysarthria types. and etiology. 2001). slow dysarthria). reduced loudness. locus of lesions they cause is less predictable (e. or lingual movement. Often re. highly variable. with each type representing a tained (dystonia). but ology and locus of lesion. It most commonly nerve lesions are associated with imprecise articulation results from stroke a¤ecting upper motor neuron path- of phonemes that rely on jaw. Trigeminal. glia control circuit pathology. 1975). but the most widely uct of involuntary movements that interfere with in- used classification system in use today is based on the tended speech movements. yolaryngeal myoclonus). action myoclonus. correspondence between perceptual attributes and phys.. and because their ing characteristics are attributed primarily to inco. AMRs. severity usually Vagus nerve lesions can lead to hypernasality or weak is rarely worse than mild to moderate. and physiology from auditory-perceptual classification. functional magnetic resonance imaging. so sometimes the presence of a mixed dys- but regular speech AMRs. more of the single dysarthria types. ciated with flaccid. Unlike hypokinetic The dysarthrias can be classified by time of onset. The following summarizes the sometimes they are worse during speech or activated major types. whereas bilateral lesions specific mix. and imprecise and sometimes rapid. Dys- positron emission tomography. Hypokinetic dysarthria is associated with basal gan- iology cannot be assumed (Du¤y and Kent. laryngeal. but other conditions can acoustic. ing of the neural control of speech. loudness. They occur more ations in breath patterning for speech may be evident. and magnetoencephalography (McNeil. unilateral lesions and lesions of a single nerve cal settings. Its distinguishing is very uncommon or incompatible with some diseases characteristics are attributed to spasticity. or ‘‘blurred’’ articulation and AMRs. face. monopitch tomography. or articulatory Unilateral upper motor neuron dysarthria has an ana- structures. single-photon emission fluency and palilalia also may be apparent. tics). from relatively regular and slow (tremor. and monoloudness. elec. dysarthria. Because the damage is unilateral. inappropriate variations in pitch. site of lesion. Its characteristics pressure consonant production when the pharyngeal often overlap with varying combinations of those asso- branch is a¤ected or to breathiness. and Brown (1969a. may be associated lesions of upper motor neuron pathways that innervate with virtually any mix. unpredictable (chorea. ways. breathy-tight dysphonia. kinematic. its distinguishing characteristics are a prod- course. myasthenia gravis is associated only with flaccid include a strained-harsh voice quality. The presence of mixed dysarthria relevant cranial and spinal nerves. and its features seem Methods that show promise or that already have refined mostly related to rigidity and reduced range of motion. but duration. Hartman and Abbs. 1992). Its distinguish. piratory. to relatively rapid and predictable or perceptually distinguishable grouping of speech charac. Its specific characteristics depend on which tomical rather than pathophysiological label because it nerves are involved. In frequently than any single dysarthria type in many clini- general. They may a¤ect any one or all levels attributes. tomography. mul- Spastic dysarthria is usually associated with bilateral tiple sclerosis. reduced loudness. spastic. flaccid-spastic dysarthria is the or multiple nerve involvement can have devastating only mix expected in ALS. 1996. several causal movement disorders. branches are involved. Dysarthrias: Characteristics and Classification 127 yielded results consistent with predictions about patho. radiography. 2001). computed tomography. traumatic brain injury). and they often (e. and aerodynamic methods. 1969b. and their e¤ects on speech can be and distinguishing neurophysiological deficit. supplied by cranial or spinal nerves that innervate res. or raise the possibility that more than a single disease is tion are usually a¤ected. and alter. velopharyngeal. and sometimes excess and equal stress across discrepancies that have been found make it clear that syllables. Other diseases. hoarseness. Ataxic dysarthria is associated with lesions of the Because of their potential to inform our understand- cerebellum or cerebellar control circuits. also cause it. Kent et al. magnetic reso. and restricted pitch and arthria can make a particular disease an unlikely cause loudness variability..

R. E. and Workinger. Language. Dysarthria associated 209–222. and stroke.. Kent... M. speech disorders. M. Journal of Medical Speech-Language Pathology. K.g. B. (1994). Darley’s contributions Kent. Aronson.. 43. Dif. Lacunar infarctions perception and acoustics for a high-low vowel contrast and dysarthria. and Weismer. Philadelphia: Saunders. 273–302. Dysarthria associated Pathology. speech-language pathology.. R. ment. F. E. Kent. 15. Weismer. K. (1999). 44. G. B. Archives of Neurology. Aphasiology. G. 6. 3. R. Clinicoanatomic studies in dysarthria: Review. K... speech.. R. A. J. 141–186. 157–176. E.). Amyotrophic lateral sclerosis: A study of its presentation The dysarthrias: Speech-voice profiles. L... V. TX: Pro-Ed.. New York: Thieme. Murdoch. R.. with focal unilateral upper motor neuron lesion. European Kent. and Weismer. Austin. A. 275–289. and Theodoros. produced by speakers with dysarthria. dysfunction in neurological disease: Amyotrophic lateral Logemann. R. W. Kent. repetition. Zilber. H. Quantification of motor speech abili- study of the dysarthrias. Journal of Communica- motor speech disorders. Laryngeal Journal of Speech and Hearing Disorders. Electropalatographic assessment of articulatory timing Du¤y.. cri. J. Buonaguro. Toward phonetic intelligibility testing in dysarthria. and Folger. 127. (1994).. J. R. oping more e¤ective treatments for the underlying 67. P. and potential. (1969b). Journal of Medical Speech-Language Pa- In C.. and movement disorders (pp. R. Medical Speech-Language Pathology. A. Neuromotor speech disorders: Nature. Kent. related dysfunctions... D. and Stun- Journal of Disorders of Communication. Adler and J. more Rose.. and Blonsky.. and Clift.. M. E. New York: Grune and Stratton. ferential diagnostic patterns of dysarthria.. 249–269. Du¤y. correlates of dysarthria types and intelligibility. R. S. (1996). NJ: Humana Goozee. A. C. Frenchay dysarthria assessment. 482–499. R. Vorperian. (1992). J. Boshes. 221–238. Kent.. (1990). E. and Brown. Kent. (Eds. R. patterning and variability in dysarthric speech. J. precisely establishing the relationships among perceptual Sarno. J. Some aspects of parkinso- Dewey.. 83–90. Handbook of Par- indices of severity. assess- Darley. M. 1215–1228.. and Bell. Austin. 232. D. and scientific Thomas. J. L. E. and Hearing Research. (1999). R. M. nian dysarthria.. (2000). S. Journal of Speech Cannito. tion in the speech of a large sample of Parkinson patients. R. D. Fischer. (2001). (1998). and Levita. Kent. Methods. Kent. Speech. K. and Marti-Vilata. S. Ataxic dysarthria. J. (1995). 227–254).). G. children and adults. D.. Louis: Mosby. but many current e¤orts are aimed Mlcoch. (1994). impairments and functional limitations imposed by Yorkston. Char- dysarthria types. J. In W. Totowa. and Abbs. The relationship between Arboix. Journal of Medical Speech-Language Pathology. (1999). B.128 Part II: Speech research are broad. J. J.. D.. 400–405. and directions for research. Kent.. G.. 28. F. New York: Marcel Dekker. Rosenbek. N... neurology) working in concert to integrate clinical. L. Weismer. (1977). H. and Hearing Research. and Brown. Yorkston.. Vorperian. R. F. D. 3. Baltimore: Paul H. tique.. P. L. G.. 57–70. 32. T.. and neuropathology.. 2. Kahana. K. G. F. (2001). J. C. (1999). and Hearing Research. K. J. Frequency and cooccurence of vocal tract dysfunc. Kent. Sentence Intelligibility Test. NE: Tice Technology herent understanding of the clinical disorders and their Services. and Beukelman. M. M.). Parkinson’s disease. and prognosis. Journal of 4. Computerized Assessment of Intelligibility of Dysarthric See also dysarthrias: management. Weismer. A. Gentil. R. R. cal Speech-Language Pathology. H. Weismer. J.. and physiological observations into a co. Journal of Phonetics. Slama. D. 77–84). Beukelman. sclerosis. C.. Darley. F. J. Motor speech disorders: Substrates. R. and devel. 187–196. Archives of Physical Medicine and Rehabilitation. Yorkston. Motor neuron disease.. (2000). D. D. Du¤y. di¤erential diagnosis. underpinnings. Yorkston. (1996). Emerging and future concerns in motor Speech and Hearing Research.. R. and Pollack. K. Kim. (1992). Weismer. F. Parkinson’s disease thology. 7. —Joseph R.. R. D. ties in stroke: Time-energy analysis of syllable and word Enderby. What dysarthrias can tell us about the neural control of guage. Clinical features of Parkinson’s disease. J. (1969a).. progress. A. R. J. and Tice. G. Acoustic studies of dysarthric speech: McNeil. 54. R. Journal of Speech- Kent. 462–496. Beukelman.. H. H. them. R. Respiratory tive study. American Journal of Speech-Language Darley.. (1998). J. delineating acoustic and physiological kinson’s disease (pp. 47. C. 253–262. H. N. Journal of Du¤y. D. Du¤y.. (Ed.. 44. Kent. D.. (1997). Advances are likely to come from several dis. R.. Clinical management of sensori. 43. anatomical. Journal of Speech.. Journal of Neurology. V. G. J. Journal of Medi- (1978). R. Brookes. J. Kent. A. 36–39. Du¤y. Journal of Medical Speech-Language Hartman. E. (1995). D. . J. R. G. (1975). R. Du¤y. Gubbay. San Diego. F. tebeck. and Yorkston. Journal of Speech.). Language-Hearing Research. jury. (1986). J.. and Rosenbek. F. R. patients. D. (1985). (2000). and Traynor. R. and management. B. E. J. 7. A. St. neural structures and circuitry. M. 535–551.. (1984). M. F. Management of motor speech disorders in ciplines (e.. Motor Pathology. Lincoln. H. 47–57.. Beukelman. F. Journal of Medical Speech-Language Pathology. Hammen. E. R. (1983). K. and Brown. F. 12. and Kent. (1989). J. 12. Kent. with unilateral central nervous system lesions: A retrospec. 27. tion Disorders. P. Strand. J. (2001). B. K.. Press. Brooks. and Du¤y. TX: Pro-Ed.. R. R. Du¤y.. 295–300.. CA: College-Hill Press.. Aronson. Du¤y Further Readings References Bunton.. and acteristics of verbal impairment in closed head injured acoustic and pathophysiological correlates. J. J. and Journal of Speech and Hearing Disorders. di¤er.. D. and Cooper.. 1275–1289. speech disorders. speech science. M. Ahlskog (Eds.. characteristics in dysarthria following traumatic brain in- ential diagnosis. J. F. and management. Du¤y. L. Diagnosis and treatment of parkinso- at the following: refining the di¤erential diagnosis and nian dysarthria. Aronson. Lan. Koller (Ed.. 165–211. G. 2. A. E. E. A. and to the understanding. Clusters of deviant dimensions in the dysarthrias.

D. and Hearing Research. (1999). J.). severity.. communication. Comprehensibility Kleinow. 8(4) (entire issue). Dysarthria and apraxia of speech: Perspectives on on the severity of the dysarthria. J. E.. Till. C. Language. Finally. individuals are speech.. Later in the disease progression. L. C. D. Rodnitzky.). A. Baltimore: Paul H. D. a number of issues are considered when devising length of breath groups (Yorkston et al. and Stokes. get progressively worse (e. B. E. These to improve respiratory support (Netsell and Daniel. 2. early treatment may focus on maintaining in- and Luschei. M.. R. R. Hawley.. A. K. the physiological processes having the speaker blow and maintain target levels of involved.. Sustained Management of the dysarthrias is generally focused phonation tasks are also used. L.g.. nicative intent using speech plus the environment. Yorkston.g. Intelligibility refers to the parameters of phonation. The relationship of logical recovery is likely to occur (e. and Horii. 1999). contextual information becomes more deficits with anatomical lesions: Post-traumatic speech dis. topic. management of Language Pathology. and Stokes. Thompson. accident) versus one in which the dysarthria is likely to eral sclerosis. Strand. communicative interaction.. resonance. (1994). 7(2) (entire issue). Lemke.. acoustic signal (Kent et al. depending on cuses on achieving and maintaining a consistent sub- the particular neuromotor systems involved. Smith. and behavioral interventions are used to improve cal speech disorders caused by damage to mechanisms the function of those physiological systems. C. nication. pharmacological). amyotrophic lateral sclero- thology. L. Brookes.. of motor control in the central or peripheral nervous Behavioral intervention for respiratory support fo- system. (Eds. con- Parkinson’s disease: Longitudinal changes in acoustic text. Duckworth (Eds. 15–26.g. arthrias associated with a number of di¤erent neurolog- Ziegler. Yorkston (1996) provides a comprehensive (1994). critical for maintaining comprehensibility... B. Methods a management approach for a particular patient. prosthetic (e. issues include the type of dysarthria (reflecting the under. E. levels of severity benefit from both intelligibility and tor neuron vascular lesions. 1982) often involve lying neuromuscular status). 1996). M. Journal of Medical treatment is less on the acoustic signal and more on Speech-Language Pathology. 3. E. vey communicative intent. 1–14. R. using the acoustic signal plus 1041–1051. D. Journal of Medical Speech-Language ston. and Beukelman. 2. and Weismer. interaction. the situation.. Y.). sis [ALS]). Disorders of motor speech: Assessment. Motor speech disorders: Advances in assessment and review of the treatment e‰cacy literature for the dys- treatment. P. degree to which the listener is able to understand the Language Pathology. Ramig. Finally.g. In conversational Pathology. D. methods in the evaluation of dysarthric speech. encouraged to produce sentences with appropriate . M. D. (Eds. Ball and M. J. (2001). maximizing listener support Thompson.. telligibility and naturalness. 1989). Management focus also depends on whether the dys- and clinical characterization. Yorkston.. R. Amsterdam: John Benjamins. Brookes. K. R. W. (1994).. (1995). (2000). and Hartmann. 27–40.. Journal of Medical Speech-Language Pa. 1979. O.. 4. mildly dysarthric individuals focuses on improving in- Murdoch. orders and MRI.. 2. water pressure (i. glottal air pressure level. (1996). (1995). and so on. P. and Kennedy. 29–42. (1991). Perceptual and acoustic ical disorders. S. For patients with degenerative diseases such Solomon. palatal Dysarthria is a collective term for a group of neurologi. Decisions regarding whether to focus treatment on thology. Robin. and Wilson. L. giving the speaker feed- on improving the intelligibility and naturalness of back on maintained loudness.. very severe dysarthria often focuses on augmentative Robin. as ALS.. arthria is associated with a condition in which physio- Samlan. Journal of having to use augmentative and alternative commu- Medical Speech-Language Pathology. Individuals with moderate Phonatory and laryngeal dysfunction following upper mo.. Management for management. L. R. M. D. Baltimore: Paul H. 91–114).. D. listeners take advantage of environmental LaPointe. allowing the patient to continue Tongue function in subjects with upper motor neuron type to use speech for a much longer period of time before dysarthria following cerebrovascular accident. P. and articulation. A. intelligibility or on comprehensibility depend largely Moore. Hixon. The dysarthrias vary in nature. Journal of Speech. Advances in clinical pho- netics (pp. 9–13. Yorkston. and Ramig. Intelligibility Deficits in intelligibility vary according to the type of dysarthria as well as the relative contribution of the basic Dysarthrias: Management physiological mechanisms involved in speech: respira- tion. K. In M.e. Correlation of clinical more degraded. Baltimore: Paul H. 5 cm H2 O) for 5 seconds. the Pathology.. American Journal of Speech-Language Pa. 3. Speech motor refers to the dynamic process by which individuals con- stability in IPD: E¤ects of rate and loudness manipulations. cerebrovascular selected perceptual measures of diadochokinesis in speech intelligibility in dysarthric speakers with amyotrophic lat. Journal of Medical Speech. D. and Netsell. (Eds. Tongue strength and endurance telligibility. and augmentative aids. phonation. (1994). E..). J. and the expected course. N. E. B. allowing adequate loudness and quently. all information available from the environment (York- LaPointe. (1996). G. As the acoustic speech signal becomes Lefkowitz. L. Dysarthrias: Management 129 King. Brookes. Medical (e. R. treatment. and environmental cues.. Journal of Medical Speech-Language cues such as facial expression. (1994). and Beukelman.. Journal of Medical Speech.. O. comprehensibility approaches.. J. lift). L. A. 177–190. and Beukelman. 44. the focus of in mild to moderate Parkinson’s disease. Conse. gestures. surgical. H. Lorell. or on helping the speaker convey more commu. Murdoch.

but it may be appropriate dystonia pose similar problems. either hypophonia. or the hypokinetic dysarthria that accom. initiate phonation at appropriate inspiratory lung vol. should be considered for patients who are consistently coordination (e. Medical management. by facilitating more appropriate breath group units. for individuals with other types of dysarthria as well. and Ishikawa. ness. enth cranial nerve (Daniel and Guitar. 2001). Botulinum tion (Rosenbek and LaPoint. used (DeFao and Schaefer. often with contrasts (tie/sigh) or intelligibility drills (having the arytenoid adduction (Isshiki. are helpful. Okamura. Compensatory strat- involving the laryngeal muscles may benefit from surgi. resistance exercise program to strengthen the velopha- ally speakers may release too much airflow during ryngeal muscles. However. toxin has been used to improve speech in speakers with man Voice Therapy Program (Ramig et al. Medications to decrease dysarthria.130 Part II: Speech phrase lengths. taking the next breath at the appropriate uses the hierarchical practice of selected syllable. This medical and has the capacity to increase strength with e¤ort. changes in speech intelligibility for some individuals. which is a rigid appliance that covers atory checking. has been shown to be e‰cacious for individuals with 1991). Although pharmacological treatment is frequently Parkinson’s disease and is a commonly used therapy used to decrease limb spasticity. (1999) point out facilitate head and neck relaxation as well as laryngeal that this variable alone may result in the most dramatic relaxation.g. The Lee Silver. is frequently used to Rate reduction improves intelligibility by facilitating improve the vocal quality of individuals with spasmodic increased precision of movement through the full range. strategies to maximize e‰ciency of the respi. its e¤ects on articulation technique to reduce the hypophonic aspects of their are less clear (Du¤y. focusing on maintaining adequate respi. and Behavioral approaches to the treatment of resonance by allowing listeners more time to process the degraded problems focus on increasing the strength and function acoustic signal.. For individuals who exhibit dis. or hyperphonia. and the use of postural control may be Rate control is most e¤ective for individuals with hypo- helpful. 1983). Palatal lifts the respiratory system. Nasseri and Maragos. respiratory treat. velopharyngeal insu‰ciency. E¤ort closure techniques such as improve function to a damaged nerve. usually the sev- pushing and grunting may maximize vocal fold adduc. or rate control. sometimes advocated. Patients with phonatory deficits due to laryngeal kinetic or ataxic dysarthria. Neural anastomosis is sometimes used to tension. In each case. Kuehn and Wachtel (1994) sug- the speaker’s attention and e¤ort toward taking in more gest the use of continuous positive airway pressure in a air and using more force with exhaled air. Occasion. but only when the speaker is ha- thenia gravis are typically successfully treated with anti. Yorkston et al. is di‰cult. bitually generating less force than is necessary for speech cholinesterase drugs or with a thymectomy. 1996) orofacial and mandibular dystonias (Schulz and Ludlow. ulatory imprecision may be due to reduced respiratory Laryngeal system impairment frequently results in support. because artic- level. Patients with myas. ratory system. tacts. the clinician works to focus as to their e¤ectiveness. but it also requires that the activity causes increasing weakness. and for patients patient maximize respiratory pressures. 1978). Techniques to dysarthric individuals. unable to achieve velopharyngeal closure and who have ment is focused on helping the speaker consistently relatively isolated velopharyngeal impairment. Netsell (1995) has suggested the use of inspir. without extraneous supraglottic articulation. ataxic dysarthria). 1995). Individuals with lower motor neuron deficits bigger and stronger movements. When specific work on improving articulatory panies Parkinson’s disease). in which patients are taught to use the the hard palate and extends along the surface of the soft inspiratory muscles to counter the elastic recoil forces of palate. The use of minimal dure for medialization is a type I thyroplasty. dysphonia and laryngeal dystonias. flaccid dysarthria. in which function is warranted. behavioral approaches involve the vocal folds exhibit too much closure (as in spastic focusing the speaker’s attention on increased e¤ort for dysarthria). words) focus the speaker’s attention on making specific nous fat are also used to increase the bulk of a paralyzed sound contrasts salient and clear. 1998). and behavioral intervention typically is Rate control is frequently the focus of treatment for not successful for this group of patients. given the expiratory lung volume and phrases (Robertson. in which muscular increasing glottal closure. use a palatal lift. Surgical and medical management may also improve cient glottal adduction. in which the vocal folds do not the treatment of articulation is not always focused on achieve adequate closure for phonation (as in flaccid improving the place and manner of articulatory con- dysarthria. . egies such as using a di¤erent place of articulation or cal intervention either to medialize the vocal fold or to exaggerating selected articulatory movements may be augment the bulk of the fold. 2000). it is contraindicated for patients with Behavioral treatment for hypophonia focuses on disorders such as myasthenia gravis. exercises to increase the patient’s awareness of e‰. Teflon and autoge. Strength training is or atrophied fold (Heikki. A common prosthetic approach is to speech. but researchers and clinicians disagree ratory pressure. 1985). tremor or chorea sometimes help improve speech by Treatment of phonation due to laryngeal spasticity reducing the extraneous movement. The most common proce. such as botulinum toxin injection. management usually results in improvement in their Strengthening is most appropriate for speakers with voice and vocal fatigue. raising it to the pharyngeal wall. For mild weak.. of the soft palate. Treatment focused on improving articulation often ume levels. 1995. with degenerative disorders such as ALS. speaker produce a carefully selected set of stimulus 1975. words phrase boundary.

Technology Services. Clinical management of motor speech disorders. or resonating velopharyngeal systems. articulatory. (1998). Computer screens can be used Baltimore: Paul H. S. Weismer.. M. 55–66. 165–190). York- diagnosis. using predictable nal of Language and Communication Disorders. In D. (2000). 502. K. Yorkston. Journal of Speech and Hearing providing (or asking for) the topic. 5. CPAP therapy for treating improves intelligibility. 9–20. Netsell. and Bell. —Edythe A. Brown. 36(Suppl. T. Robertson. Archives of Physical of management. and using alphabet 292–297. 207–212). M. Combination thy- roplasty and the ‘‘twisted larynx’’: Combined type IV and tion of pauses (Beukelman. R. R. S.. and management. K. Aronson. 1496–1504. wording. (1995). An around-the. and increasing Isshiki. (1991).. L. Strand. L. EMG feedback and recovery prehensibility of dysarthric speech: Implications for as- of facial and speech gestures following neural anastomosis.. (1996). 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Laryngoscope. and Tice. and cation interaction between the dysarthric speaker and his Thompson. rate by increasing consonant and vowel duration. creasing interword interval durations. and Maragos. 108. 97–152). that cue the speaker to a target rate and mark the loca. Nasseri. Botulinum treatment to use speech as a primary mode of communication. 482–499. Vocal fold augmentation by injection of Advances in assessment and treatment. and Tice. S. the speaker’s own voice is fed back to ward phonetic intelligibility testing in dysarthria. The e‰cacy of oro-facial and articulation changes. J. Motor speech dis- rate.. and Hearing Research. fication. R. and LaPoint. Okamura. (1978). C. autologous fascia. Brown. as the severity of dysarthria Medicine and Rehabilitation... S46– References S57. C. Baltimore: Paul H. Further Readings istics. Lincoln. (1990). (1994). (1997). Louis: Mosby. Yorkston. Countryman. 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1999). Sensation of food sticking in the throat or sternal region Among young adults. Wet. signs can be indicative of a serious medical illness. delayed initiation of the pharyngeal stage of the swallow ration in only 66% of patients (Linden. when lying down Neurological disorders take a particular toll: it has been Heartburn or indigestion estimated that 300. clinical evaluation identified only Weak sign of the cough 18 (42%) of the aspirators (Splaingard et al. radiation to the head and neck. young adults are also suscep- without a diagnosis of aspiration pneumonia Tightness or pain in the chest. 1995). and (Langmore. Wet-sounding cough (4) In a study of 107 patients in a rehabilitation facility. Dysphagia. and the presence of spillover or of cators resulted in identification of the presence of aspi.. disease. cervical spine disease. medication e¤ects. while only 13. The clinical examination provides im- commonly observed clinical signs that are suggestive of portant information that assists in the decision-making dysphagia in the adult population. Food or liquid leaking from a tracheostomy site studies such as these support the argument that money. pyriform sinus stasis. 1993). Schatz. Videofluoroscopy is the most frequently used assess- Therefore. For example. Oral and Pharyngeal 133 Table 1. and larynx. Therefore. motor end-plate disease. pharynx. 1988). this examination provides no information rel- quate number of calories by mouth to remain properly ative to the pharyngeal stage of the swallow and does nourished. indication. the view of velar function is superior to .6% of patients and neurological disease. gurgly voice quality 43 (40%) were found to aspirate on videofluoroscopic Decreased oral sensation examination. Many of these imaging modalities or other specific techniques. Be- Prolonged oral preparation with food Inability to clear the mouth of food after intake cause of the additional expense encountered in caring for Absent gag reflex patients with respiratory or nutritional complications. and the greatest percentage of these experience dysphagia secondary to stroke (Doggett et al. with or without drooling (Smith et al. 276 (59%) of the 469 patients Di‰culty triggering the swallow who aspirated were found to have silent aspiration Di‰culty managing oral secretions. service. therapy... the assessment begins with a clinical examination (Perl- viders to the likely presence of dysphagia. traumatic brain injury. The already comprised patient can There are various methods for studying the swallow. 1988). Table 1 lists man et al. In a study of the dysphagia in adults include muscle disease. and the di‰culty of detecting it is suggested by the status of vocal fold function. The incidence of silent aspiration is very Endoscopy permits the examiner to evaluate the high. After stroke tal were malnourished. head and nutritional status of patients admitted to a rehabilitation neck surgery. For a relationship to laryngeal penetration. choice of method for a particular patient depends on the pital length of stay and increases medical costs. however. and Olsen. (2) In a heterogeneous group of 1101 Additionally. systemic phagia were malnourished (Finestone et al.. When a patient is first seen. and impaired gastro- intestinal function. can be saved when patients are properly Food or liquid leaking from the nose evaluated.. is performed after observation of no less than two dozen Although clinical indicators have been found to have events within the oral cavity. thermore. of those 24 patients. traumatic brain injury is a not Xerostomia (dry mouth) uncommon cause of acquired dysphagia. information that is sought. Patterson. Fullness or tightness in the throat (globus sensation) as well as life. dementia. 2001). 24 (51%) of the attempts patients were found to aspirate. whereas elderly Odynophagia (pain on swallowing) individuals are more likely to acquire dysphagia as a Repeated incidents of upper respiratory infections with or result of illness. However. the extent of vallecular or following: (1) Discriminant analysis of 11 clinical indi. the Evaluation and Treatment formation of decubitus ulcers. particularly after eating or tible to the same causes of dysphagia as the elderly. a diminished or absent gag has not elicit adequate information to determine proper not been found to distinguish aspirators from non. the most frequent causes of without dysphagia were malnourished. The absence of any or process. Clinical Signs Suggestive of Dysphagia in Adults patients with dysphagia. 11 Choking or coughing during or after intake of food or liquid (46%) were silent aspirators (Horner and Massey. patients who exhibit these signs and who have ment technique because it provides the most complete not been seen by a physician should be referred for body of information. Aviv et al. a significant most patients. Certain clinical signs help to alert health care pro. 1988. (3) When 47 stroke patients with Abnormal or absent laryngeal elevation during swallow mixed sites of lesions were examined. Interpretation of this examination medical examination..000–600. The become increasingly comprised. Regurgitation of food Dysphagia can occur at any age across the life span. 2000). 1991). this is the only instrumental procedure number of patients who aspirate do so with no clinical that will be performed. Kuhlemeier. 1988).000 persons per year experi- Unintended weight loss not related to disease ence dysphagia secondary to neurological disorders. but it is not intended to identify the underlying all of these signs does not indicate that a patient has a variables that result in di‰culty with oral intake. the clinician will turn to one or more aspirators (Horner and Massey. which prolongs the hos. 65% of patients admitted with stroke and dys. the immune system to fight disease and contributes to the development of respiratory and cardiac insu‰ciency. Fur- safe swallow or that the patient is able to ingest an ade. and Inadequate nutrition negatively a¤ects the ability of senescent changes in the sensorimotor system.

9.. functional and diagnostic testing of deglutition. (1997)... D. J. 1997. (1988). J. Austin. Kaplan. 938–950... J. and Pauloski. (1993). (1997). Spitzer. P. et al. 310–316.. S. J. M. J. Tappe. Smith. J.. lar electromyography (Cooper and Perlman. G. Lau.. R... Gati. Mikulis. (2000). and pharyngeal muscles during swallowing.. Holas. 30–34. Further Readings orders. E. Sulton. Miller. 7. (2001). A.. This technique volitional swallowing in humans. D. (1995). and Brazer. S.. Gray.. Information relat. and Chaund- An analysis of 500 consecutive evaluations. eofluoroscopy vs bedside clinical assessment. the shadow ature. E. San Diego. J. S. —Adrienne L. Decisions regarding behavioral. (1999).. D. food while the examination is being performed. E.. (1996).. K. A. Crawley. Molins. and Pelletier. Iglesia. ionizing radiation and the fact that the parent can hold 76. Logemann. Ettema.. 1–7. J.. Dysphagia.. Comprehensive clinical exami- nation of orophayngeal swallowing function: Veterans Ad- completed. A.. characteristics associated with silent aspiration in the acute Dysphagia. A... Logemann. Dysphagia... B.. and Patterson. S. W. American Jour- good ultrasound image. E..). disorders (2nd ed. D.. Cortical activation during human volitional cheotomy tube. Perl. J. C. care setting. G. 246–254. TX: Pro-Ed.. M. Ricart. Soler. and Teasell... S. gat. Milianti. and Zenner. L. Henry. Perlman Videofluoroscopic evidence of aspiration predicts pneumo- nia and death but not dehydration following stroke. (1991). Dysphagia. and Olsen. S. Evaluation and treatment of swallowing Journal of Stroke and Cerebrovascular Disease. (1988).. lowing stroke. Dysphagia. because cedure. Normal and abnormal swallowing: Imaging in and Close. Ettema. B. medical. Prevention of pneumonia in elderly stroke with endoscopy.. Neurology. Diamond. J. or surgical Perlman. an infant or small child and feed the child a familiar Hamdy. W... Schulze-Delrieu (Eds. Greene-Finestone. Perlman. Gonzalez-Huix. formation obtainable with ultrasound is restricted to the Hamdy. 15. 6. patients by systematic diagnosis and treatment of dyspha- Ultrasound allows for observation of the motion of gia: An evidence-based comprehensive analysis of the liter- the tongue (Sonies. Sonies. Respirodeglutometry (RDG) is a method for assess.. or information on the larynx or acute stroke on clinical outcome. Archives of Cooper. R. 1991). Mitchell. Stroke. Journal of Applied Physiology.. Specific treatments are beyond the scope of this discus. A. 89–94. The probability of correctly predicting subglottic penetration may alter the swallowing pattern. The safety of flexible endoscopic diagnosis and therapy. H. the pharynx. 91–97.. G. Daniels. S. Marru- ing to the oral stage of deglutition. Aziz. (2001).. Readings. and Barkmeier. 14. and VanDaele. F. 38. (1994). 637–640. N.. ing the coordination of respiration and deglutition (2001). B. Halvorson. 69.. L. R. B. Neural Plast. Foundas. L. 2000). et al. Seminars in Speech and Language. V. Rademaker. function of the anatomical and physiological observa. L. oral stage of deglutition. R. Horner. 12. G219–G225.. and Perlman. from clinical observations. F. Q. T. and Barkmeier. 8. CA: Singular Publishing Daniels. Archives of Physical Medicine and Rehabilitation. K.. R.). Alberts. reflected from the hyoid bone permits the examiner to Finestone. 170–173. 279–295. 170–179. 86. San Diego. K. tions that were made during the evaluation process. 216–219. 15. L. (1991). logy. S. McCulloch. M. logical correlates of RDG output and to determine Perlman. S. E¤ect of malnutrition after tion of the hyoid bone. L.. Electromyography in the Physical Medicine and Rehabilitation. Schatz. 146–156. prohibits good transducer placement. Goodyear. H. J. W. Dysphagia. and Reding. neurogenic dysphagia.. In A. 2. A. S. A. Fiberoptic man et al. Dysphagia. and Coates. When a small child has a tra. Malnutrition in stroke patients on the reha- The advantages to using ultrasound for assessing the bilitation service and at follow-up: Prevalence and pre- oral stage of the swallow are the absence of exposure to dictors. S. and Rothwell. Additionally. A. The in. A.. S. P. M. M.. and acoustic signals associated with bolus passage through tion of age and various medical diagnoses. Dysphagia. 16. J. Horner.134 Part II: Speech that obtained with videofluoroscopy. intervention are made once the evaluation has been H. M. (1992). K. C. observe and to measure the displacement of the hyoid. evaluation of swallowing with sensory testing (FEESST): Splaingard. Deglutition and its dis. M. Cerebral cortical representation of automatic and (Perlman. Management of adult cortex in dysphagia.. In the examination of swallowing.. Mills. it is often extremely di‰cult to obtain a swallowing: An event-related fMRI study. it is endoscopic examination of swallowing safety: A new pro- advisable to use bipolar hooked wire electrodes. Thomson.. Xue. P. Kuhlemeier. B. 85.. Langmore. Aspiration in rehabilitation patients: Vid- 39–44. 1999). 277.. Journal of Neurophysio- is presently being investigated to determine the physio. Perl- man and K. H.. 27. 12. the extent of eleva. (1999). S. Chapell. Respiratory changes in the respiratory-swallowing pattern as a func. 1028–1032. (1999). D. Martin. Langmore. because the tracheostomy tube nal of Physiology. pharynx during the moment of swallow is not observed Doggett. D.. needle electrodes can cause discomfort and the subject Linden. (1999).. S. sion but can be found in textbooks listed in Further laryngeal. huri. Incidence and patient Aspiration after stroke: Lesion analysis by brain MRI. and Raiv. 8. New York: Springer-Verlag. Physiology and pathophysiology of the swallowing area of the human motor cortex. R. Group. and Sullivan. Aviv..... A.. (1988)... M. . Lesion site in unilateral stroke patients with dysphagia. 1663–1669. and Massey. L. The role of the insular Huckabee. 7–11. Schmidt. A. (1996)... Colangelo.. CA: Singular Publishing Group. C. Davalos. J. Hutchins. A.. Electromyographic activity from human submental. (1998). and Foundas. Wilson. 317–319. Palmer. (2000). Dys- References phagia. Thompson. Silent aspiration fol- Muscle paralysis is best determined with intramuscu. Therapeutic intervention is determined as a ministration procedure.

. after any necessary outcomes tool for oropharyngeal dysphagia in adults: II. and Schulze-Delrieu. frequency or duration of episodes of OME is poor even (1992). (1999). the terms otitis media with e¤usion MEE fall between 21 and 30 dB (mild to moderate (OME) and middle ear e¤usion (MEE) are often used. Shri- yngeal dysphagia. (1997). the presence (Scheidt and Kavanagh.. Mayrand. Sullivan. Shriberg. Coordination of respiration and swallowing: E¤ect of bolus volume in normal adults. and Diamant. Studies also vary with respect to their ability to sepa- The prevalence of OME in young children is remark.). Several MEE was 20. measures used to document the outcome variable of The literature addressing the hypothesis that early speech development and in the extent to which e¤ect recurrent OME poses a threat to children’s speech and sizes for significant di¤erences on outcome measures are language development is large and contentious (for reported (cf. rate the contribution of OME to poor developmental ably high. 1986). 474–478. and the validity of parental judgments concerning the Preiksaitis. (Eds.. C. J. (1997) reported that nearly 80% privileged counterparts (Paradise et al. Bluestone Perlman. N. J. K. nosing OME is an examination of the tympanic mem- Rosenbek. with the mann. Paradise et al.. ports or chart reviews. resulting from an infectious process fashion (e. Kramer. Shriberg. A. removal of cerumen. Instrumental imaging technologies and found to have OME on otoscopic assessment (Bluestone procedures. J. into the hearing thresholds for the majority of children with middle ear cavity. E. being critically important. Friel-Pa