ARTICLE IN PRESS

Effects of Vocal Intensity and Fundamental Frequency on

Cepstral Peak Prominence in Patients with Voice Disorders
and Vocally Healthy Controls
*,†Meike Brockmann-Bauser, ‡,§Jarrad H. Van Stan, *,†,║Marilia Carvalho Sampaio, *,†Joerg E. Bohlender,
‡
Robert E. Hillman, and ‡Daryush D. Mehta, *yZurich, Switzerland, zxBoston, Massachusetts, and ║Salvador, Brazil

Summary: Objective. Cepstrum-based voice measures, such as smoothed cepstral peak prominence (CPPS),
are influenced by voice sound pressure level (SPL) in vocally healthy adults. Since it is unclear if similar effects
hold in voice disordered adults and how these interact with natural fundamental frequency (fo) changes, this
study examines voice SPL and fo effects on CPPS in women with vocal hyperfunction and vocally healthy
controls.
Study Design. Retrospective matched case-control study.
Methods. Fifty-eight women with vocal hyperfunction were individually matched with 58 vocally healthy
women for occupation and approximate age. The patient group comprised women exhibiting phonotraumatic
vocal hyperfunction associated with vocal fold nodules (n = 39) or polyps (n = 5), and nonphonotraumatic
vocal hyperfunction associated with primary muscle tension dysphonia (n = 14). All participants sustained the
vowel /a/ at soft, comfortable, and loud loudness conditions. Voice SPL, fo, and CPPS (dB) were computed
from acoustic voice recordings using Praat. The effects of loudness condition, measured voice SPL, and fo on
CPPS were assessed with linear mixed models. Pairwise correlations among voice SPL, fo, and CPPS were
assessed using multiple regression analysis.
Results. Increasing voice SPL correlated significantly (P < 0.001) with higher CPPS in both patient (r2 = 0.53)
and normative groups (r2 = 0.45). fo had statistically significant effects on CPPS (P < 0.001), but with a weak
relation for the patient (r2 = 0.02) and control groups (r2 = 0.05).
Conclusions. In women with and without voice disorder, CPPS is highly affected by the individual’s voice SPL
in vowel phonation. Future studies could investigate how these effects should be controlled for to improve the
diagnostic value of acoustic-based cepstral measures.
Key Words: Instrumental acoustic analysis−Smoothed cepstral peak prominence−CPPS−Voice diagnostics−Voice
loudness−Fundamental frequency.

INTRODUCTION Cepstral voice analysis technique

Recent recommendations for a comprehensive standard
voice assessment include the cepstrum-based acoustic
voice measure cepstral peak prominence (CPP) to objec-
tively describe voice quality in sustained vowels and
speech. 1 Cepstral measures estimate the proportion
of periodic energy based on a power spectrum, 2 and
thereby indicate the harmonic organisation of an acous-
tic signal. For clinical voice assessment, cepstrum-based
measures have been reported to be reliable indicators of
dysphonia, especially in moderately or strongly dysphonic
voices.1−7
Accepted for publication November 21, 2019.
From the *Department of Phoniatrics and Speech Pathology, Clinic for Otorhino-
laryngology, Head and Neck Surgery, University Hospital Zurich, University of Zur-
ich, Zurich, Switzerland; yUniversity of Zurich, Zurich, Switzerland; zCenter for
Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Bos-
ton, Massachusetts; xDepartment of Surgery, Harvard Medical School; MGH Insti-
tute of Health Professions, Boston, Massachusetts; and the ║Federal University of
Bahia, Institute of Health Sciences, Department of Speech, Language and Hearing
Sciences, Salvador, Brazil.
Address correspondence and reprint requests to M. Brockmann-Bauser, Depart-
ment of Phoniatrics and Speech Pathology, Clinic for Otorhinolaryngology, Head
and Neck Surgery, University Hospital Zurich, Frauenklinikstrasse 24, Nord II, 8091
Zurich, Switzerland. E-mail: meike.brockmann-bauser@usz.ch
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2019.11.015
In a popular diagnostic application of CPP, the computation
is derived from the power spectrum of the power spectrum of
an acoustic voice signal. CPP indicates the difference (in dB)
between the first rahmonic gamnitude and the point of a
regression line fitted across the cepstrum that crosses the que-
frency of the first rahmonic.2,4 The Smoothed Cepstral Peak
Prominence (CPPS) is a variant of CPP with an additional
processing step of smoothing the individual cepstra in the
temporal and spectral domains before calculating the peak
prominence.2,8 In regular or Type 1 voice signals, the first
cepstral peak (also first rahmonic) corresponds to the funda-
mental frequency period.1,2,4,9 Acoustic signals with a clear
harmonic structure show a more prominent cepstral peak,
whereas dysphonic, aperiodic, or breathy voice signals have a
reduced cepstral peak. In a variety of studies, CPP has been
shown to be correlated with dysphonia severity and was
described as an index of the harmonicity of an acoustic
signal.1−6
In practice, researchers and clinicians often compute CPP
using custom algorithms, as provided in commercial soft-
ware packages such as ADSV (PENTAX Medical Corpora-
tion), or freely available software such as Praat.10 For these
two software systems, Watts et al reported a strong parallel-
forms reliability for CPP. The authors concluded that
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2019
regardless of the language analyzed, CPP values could be
transformed between programs with relatively small predic-
tion errors.3 Sauder et al reported an accuracy of 82% for
CPPS in predicting the presence of a voice disorder in con-
nected speech samples when applying the software Praat, and
a 75% accuracy for the software ADSV. Despite slight differ-
ences in sensitivity and specificity, Sauder et al described
CPPS as highly predictive of voice disorder regardless of
analysis strategy.11 Thus, both CPP and CPPS have a high
applicability in clinical practice, but should be communicated
with detailed measurement characteristics.
Clinical application of cepstral measures
Cepstral analysis has been recommended in both connected
speech samples, such as in recordings of a standard reading
passage, and sustained vowels.1,7,12 For both contexts, signifi-
cant differences for CPP and CPPS between healthy and dys-
phonic voices have been reported.13−16 Several authors found
a similar discriminatory power for the detection of perceptual
dysphonia for both sustained vowels and vowels from speech.
Based on this, it was argued that the speaking context does
not significantly affect CPP measurements .7,17,18,19 However,
also a better correlation between perceptual overall dyspho-
nia and breathiness with CPP and CPPS in connected speech
than in sustained vowels was reported,6,14,20,21 or a better dis-
criminatory power of extracted vowels as compared to
speech.15
Watts et al found a higher Cepstral Spectral Index of Dys-
phonia (CSID) in older as compared to younger men, but
only in tokens from read text and not in vowel phonation.
The authors concluded that the clinical voice task might elicit
different information about voice function and the underly-
ing vocal physiology.22 Hasanvand et al reported significant
differences for CPP and CPPS scores in reading tasks in both
vocally healthy as compared to voice disordered women and
men. However, in sustained vowels there was a significant
difference for women only.16 Further, CPP and CPPS scores
were lower in both sustained vowels and reading tasks for
dysphonic females as compared to the control group and
either group of males. This literature review shows that both
cepstral measures CPP and CPPS are relatively reliable and
objective assessment tools in distinguishing between dys-
phonic and normal voices with a high clinical applicability.
However, to date it is not yet fully established, which sample
(phonation) type is more representative for perceptual dys-
phonia or voice pathology, and how we best investigate the
underlying vocal physiology.
Effects of voice SPL and fo on cepstral measures
In clinical assessments, patients will produce a compara-
tively large sound pressure level (SPL) and fo range between
individuals in response to the usually applied voice task to
sustain a vowel “at habitual voice pitch and loudness.”1 In
phonation during both sustained vowels and speech utteran-
ces, an association of higher voice SPL with increased fo has
been described.23−28 During sustained vowels, phonation
with increased voice SPL has been shown to significantly
reduce vocal perturbation in individuals with and without
vocal pathology. Similarly, increased fo was associated with
a reduction in measures of vocal perturbation.24,26,27,29,30
However to date, there is only limited evidence available
regarding the effects of natural voice SPL and fo differences
on spectral measures in a clinical population. Awan et al
found increased CPPS in louder phonations in an investiga-
tion of vowel and voice SPL effects in 92 vocally healthy
women and men between 18 and 30 years of age.31 Also, an
increase of CPPS in louder voice intensities was reported for
sustained vowel and connected speech samples from func-
tionally healthy teachers.32,33 These results indicate that
natural variations in voice SPL may confound the interpre-
tation and therefore diagnostic usefulness of cepstral meas-
ures in voice assessment. To the best of our knowledge, fo
effects on CPPS in voice patients have not been comprehen-
sively assessed so far. In theoretical studies using synthe-
sized vowel stimuli, Skowronski et al showed a decrease in
CPP as fo increased.34 However, natural shifts in speaking
voice fo require complex adaptations in source properties,
which have been shown to affect the acoustic spectrum.35
Therefore, the main objectives of the present work
were to investigate the effects of voice SPL and fo on the
cepstral parameter CPPS computed from sustained vow-
els produced by individuals with and without diagnosed
voice disorders.
METHODS
Study design and subject characteristics
In a retrospective matched case-control study, data from 116
adult women aged between 18 and 64 years was drawn
from a larger project studying vocal hyperfunction using
ambulatory voice monitoring.36 Laboratory voice record-
ings were analyzed from 58 patients diagnosed with pho-
notraumatic vocal hyperfunction (67.2% with vocal fold
nodules, 8.6% with polyps) or nonphonotraumatic vocal
hyperfunction (24.1% with muscle tension dysphonia,
MTD). Each patient was paired with a vocally healthy
control subject who was matched according to sex,
approximate age (§5 years), and occupation/profession.
The mean age of the participants with voice disorders
was 27.8 years (18−64 years, SD 12.1 years), and the
mean age of the matched-control subjects was 27.8 years
(18−61 years, SD 11.8 years). There was no statistical
difference in age distribution between the groups.
Clinical voice assessments were conducted by a team of
laryngologists and speech-language pathologists at the Mas-
sachusetts General Hospital Voice Center and included (1) a
case history, (2) endoscopic examination of the larynx, (3)
aerodynamic and acoustic assessment, (4) the patient-
reported Voice-Related Quality of Life (V-RQOL) ques-
tionnaire, and (5) clinician-administered Consensus Audi-
tory-Perceptual Evaluation of Voice (CAPE-V) assessment.
The normal voice status of all vocally healthy participants
was confirmed via interview and a laryngeal stroboscopic
 ARTICLE IN PRESS
Meike Brockmann-Bauser, et al Effect of SPL and fo on CPP in Voice Patients
examination. All experimental protocols were approved
by the institutional review board of Partners HealthCare
System at Massachusetts General Hospital.
The level of voice use related to profession was described
using the classification scheme of Koufman and Isaacson,
modified by do Amaral Catani.37,38 This classification
scheme is based on voice training and demands and distin-
guishes four levels. Among the 116 participants, 70 (60%)
were rated Level I elite vocal performers (such as singers
and actors). Twenty (17%) participants were classified as
Level II professional voice users (such as teachers) and 16
(14%) as Level III nonvocal professionals (such as social
workers). The remaining 10 (9%) were Level IV nonvocal
nonprofessionals, such as administrators and librarians.
Voice recording technique and selection
All participants were asked to sustain a prolonged vowel /a:/
at a comfortable pitch in their typical speaking voice mode
at “soft,” “comfortable,” and “loud” voice loudness condi-
tions. Voice recordings were done in a silent room, using a
head-mounted microphone integrated in a pneumotacho-
graph mask in an off-axis position at 10 cm distance from
the lips (MKE104, Sennheiser, Electronic GmbH, Wenne-
bostel, Germany). The microphone signal was input to a
preamplifier (Model 302 Dual Microphone Preamplifier,
Symetrix, Inc., Mountlake Terrace, WA), followed by pre-
conditioning electronics (CyberAmp Model 380, Axon
Instruments, Inc., Union City, CA) for gain control and
anti-alias filtering at a 3 dB cutoff frequency of 8 kHz. The
analog signal was digitized at a 20 kHz sampling rate, 16-bit
TABLE 1.
Description of Acoustic Measures and Commands Used in Praat
Measure Unit Description*,†
SPL dB SPL @10 cm Sound pressure level of an acoustic signal,
calibrated values were determined with
comparison method.
fo Hz Main waveform repetition rate (cycles per
second), forward cross-correlation method.
CPPS dB Difference, in gamnitude (amplitude),
between the cepstral peak and the corre-
sponding value on the regression line
through the cepstrum directly below the
peak. The Power Cepstrogram is smoothed
by averaging cepstra across time first, and
then across quefrency.
* Baken and Orlikoff (2000).
†
Boersma and Weenink (2015).
‡
Maryn and Weenink (2015).
Abbreviations: dB, decibel; dB SPL @ 10 cm, dB SPL measured at 10 cm mouth-to-microphone distance; Hz, hertz; s, seconds.
3
quantization, and §10 V voltage range (Digidata Model
1440A, Axon Instruments, Inc.).
The acoustic signal from all participants was perceptu-
ally examined for instability and visually displayed using
the software Praat (version 5.4.1.4) with an oscillogram
and “Show intensity” and “Show pulses” settings turned
on.10 Recordings were excluded if they exhibited Type 2 or
Type 3 signals, incorrect or unstable fo and voice SPL rec-
ognition in Praat, signal clipping, or a phonation time of
less than 1.5 seconds.9 Each vowel sample was saved as an
individual file. Calibrated voice SPL levels were obtained
using the comparison method with a complex tone stimu-
lus of known SPL.39
Instrumental acoustic analysis and outcome
measures
Praat was used to conduct acoustic analysis of the sus-
tained vowel samples using a custom analysis script.
Table 1 summarizes how the acoustic outcome measures
mean voice SPL, mean fo, and smoothed cepstral peak
prominence (CPPS) were analyzed. To exclude the
increased variability of the voice onset and offset phases,
only the signal segment from 0.5 second to 1.0 second
from voice onset was analysed.
Statistical analysis
Data were analyzed with the software SPSS version 25 (IBM,
Armonk, NY). Descriptive analysis comprised of computing
the mean (M), standard deviation (SD), 95% confidence
Commands in Praat†,‡
1. Sound object: To Intensity (standard
settings);
2. Intensity object: Get mean, dB method.
1. Sound object: Analyze Periodicity;
2. To Pitch (cc) (standard settings);
3. Pitch object: Get mean.
1. Sound object: Filter (stop Hann Band).
Settings: 0 to 34 Hz, Smoothing 0.1 Hz;
2. Filtered sound object: To Power
Cepstrogram (standard settings);
3. Power Cepstrogram object: Get CPPS.
Settings: Subtract tilt before smoothing:
“no,” Time averaging window: 0.01 s,
Quefrency window: 0.001 s, Peak search
pitch range: 60−330 Hz, Tolerance: 0.05,
Interpolation: Parabolic, Tilt line quefrency
range 0.001−0.0 s, Line type: Straight, Fit
method: Robust.
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2019

interval (CI), and frequency distribution through contingency
tables and scatter plot graphics. Normality of the CPPS distri-
butions were assessed by Shapiro-Wilk and Levene`s test. The
Shapiro-Wilk test indicated normal distributions for CPPS
within both the group with patients [W (167) = 0.99, P = 0.18]
and healthy controls [W (163) = 0.99, P = 0.30]. Furthermore,
Levene’s test of equality of variances showed homogeneous
distributions of CPPS in both groups [F (1,328) = 1.1,
P = 0.30], and for the categorical voice loudness condition
(soft/comfortable/loud) [F (2, 327) = 0.97, P = 0.38]. Further-
more, distribution was homogenous for voice SPL [F
(1,328) = 0.8, P = 0.78] and fo [F (1,328) = 0.1, P = 0.92] in
both groups, and for loudness condition, with SPL [F
(2,327) = 2.5, P = 0.09] and fo [F (2,327) = 0.25, P = 0.78].
A multiple regression analysis was applied to investigate
the effects of voice SPL (dB SPL@10 cm), fo (Hz), loudness
condition, and presence of a voice disorder (presence and
absence) on CPPS. Since repeated measurements tend to be
more similar within individuals than across individuals, lin-
ear mixed models (LMMs, compound symmetry covariance
type) with loudness condition as repeated measures were
applied. Post hoc analysis was conducted with Bonferroni
method to prevent Type 1 errors for multiple comparisons
of loudness condition and participant group (confidence
interval of 95%, significance level ≤ 0.05).
RESULTS
Effects of SPL, fo, and loudness condition on CPPS
Table 2 reports group-wide descriptive statistics for mean
vocal SPL, mean fo, and CPPS within the patient and con-
trol groups. Signal stability criteria led to the inclusion of an
unequal number of recordings per loudness condition in the
patient group.
Table 3 reports the results of the LMM model. When
assessed as single factors, both SPL and fo had highly signifi-
cant main effects on CPPS in the patient and control groups
(P ≤ 0.001). The loudness condition had a highly significant
effect on CPPS in the control group only (P ≤ 0.001).
Further, the interactions between SPL and fo, fo and loud-
ness condition, and SPL and loudness condition all had a
highly statistically significant effect on CPPS (P ≤ 0.001).
These interaction effects were stronger in the patient group
relative to the control group.
Figure 1 displays the pairwise relationship between CPPS
and SPL, and between CPPS and fo, within both patient and
control groups. In Figure 1A, speakers in both groups exhibit
strong correlations for CPPS and SPL (r2 = 0.53 and 0.45).
Figure 1B shows a more spread distribution of fo values
across CPPS results with a weak relation (r2 = 0.02 and 0.06).
On average, there was a 2.2 dB increase in CPPS for a 10 dB
increase in SPL. This corresponded to an average CPPS of
13.8 (SD 1.7) for a voice SPL of 80 dB SPL@10cm.
Effects of voice disorder on SPL, fo and CPPS
There was no significant effect of voice disorder on voice
SPL and fo between the patient and control groups for any
of the three loudness conditions (soft, comfortable, and
loud, P > 0.5). Considering all loudness conditions
together, there was no effect of voice disorder on CPPS [F
(1,111) = 1.8, P = 0.18]. When additionally controlling
loudness conditions separately, there were no significant
differences between the patient and control groups in com-
fortable (P = 0.30) and loud conditions (P = 0.94). How-
ever, in soft phonations CPPS was significantly higher for
the control group [t (103) = 2.3, P = 0.02, Table 2].
DISCUSSION
In the present study, CPPS increased with increasing voice
intensity in sustained vowels of both female speakers with
and without a voice disorder. Although both voice SPL and
fo exhibited statistically significant effects on CPPS, the
effect of fo was far less strong. As with previous studies of
perturbation measures, it is hypothesized that the observed
strong effect of voice SPL on CPPS will be present in multi-
parametric indices incorporating CPPS, such as the

TABLE 2.
Descriptive Statistics for CPPS, SPL, and fo per Loudness Condition in the Patient and Vocally Healthy Control Groups
Patient Group Control Group
Acoustic Measures Soft Comfortable Loud Soft Comfortable Loud
SPL (dB SPL)
Mean (SD) 79.5 (5.4) 88.0 (4.5) 95.9 (4.3) 81.1 (6.0) 87.7 (5.6) 95.8 (4.7)
CI 78.0−81.0 86.8−89.2 94.8−97.1 79.4−82.7 86.2−89.2 94.5−97.1
fo (Hz)
Mean (SD) 248.4 (43.9) 243.3 (41.9) 253.4 (37.8) 244.1 (41.2) 249.2 (36.5) 266.6 (43.6)
CI 236.3−260.5 232.2−254.4 243.4−263.5 232.6−255.6 239.3−258.8 254.7−278.5
CPPS (dB)
Mean (SD) 12.3 (2.4) 15.6 (2.0) 18.0 (2.1) 13.3 (2.2) 16 (2.3) 18.0 (2.0)
CI 11.6−12.9 15.1−16.1 17.4−18.5 12.7−13.9 15.4−16.6 17.5−18.5
(N) 53 57 57 52 57 54
Results for mean vocal SPL (dB SPL@10 cm), fo (Hz), and CPPS (dB) with 95% Confidence Interval (CI) per group and loudness condition. N indicates the num-
ber of included tokens per loudness conditions in each group.
 ARTICLE IN PRESS
Meike Brockmann-Bauser, et al Effect of SPL and fo on CPP in Voice Patients 5

TABLE 3.
Main Effects and Interactions of Voice SPL, fo, and Loudness Condition on CPPS within the Patient and Control Groups
Patient Group Control Group
Effect F Estimates (CI) SER df F Estimates (CI) SER df
SPL (dB SPL@10 cm) 112.6* 0.31 (0.25−0.36) 0.029 162 34.4* 0.18 (0.13−0.24) 0.026 158
fo (Hz) 81.7* 0.036 (0.04−0.03) 0.003 110 17.6* 0.02 (0.03 to 0.02) 0.004 152
Loudness condition 1.6 0.85 (1.9−0.16) 0.51 160 49.9* 2.50 (3.4 to 0.24) 0.459 151
SPL £ fo 27.2* 0.001 (0.001−0.001) 6.01 84 19.7* 0.001 (0.001−0.001) 4.50 160
fo £ loudness condition 119.4* 0.03 (0.4 to 0.001) 0.004 91 78.6* 0.30 (0.04 to 0.01) 0.005 143
SPL £ loudness condition 206.3* 0.26 (0.20−0.32) 0.04 161 116.5* 0.18 (0.13−0.23) 0.03 156
* P ≤ 0.001
Results of LMM analysis with ANCOVA. Abbreviations: CI, confidence interval; df, degree of freedom; SER, standard error.

FIGURE 1. Scatterplots with linear regression analysis for CPPS versus SPL (dB SPL @10cm) (1A) and CPPS versus fo (1B) within the
patient and control groups. CPPS strongly increased with rising voice SPL, while there was a weak negative correlation between voice fo
and CPPS.

cepstral-spectral index of dysphonia (CSID) and acoustic
voice quality index (AVQI).40,41 Based on the results of the
current study, it is recommended that voice SPL be con-
trolled for during the clinical assessment of voice and voice
quality. Other likely influencing factors such as sex, age,
and voice training status should be investigated at a larger
scale on patients with a variety of voice disorders.
How relevant are voice SPL and fo in clinical
measurements of CPPS?
In sustained vowel phonations, CPPS increased with
increasing voice SPL in women with and without hyperfunc-
tional voice disorders. These effects are similar to results
reported for sustained vowel and connected speech samples
from functionally healthy teachers with and without laryn-
geal pathology.32,33 Thus, patients and vocally healthy indi-
viduals with a lower habitual speaking voice SPL will
present with reduced periodicity in voicing, which is not
related to impairment (ie, aberrant voice quality). The direct
relationship between CPPS and SPL may be a consequence
of the stronger harmonic source with increasing voice SPL.
Also, electroglottographic investigations in male singers
suggest that glottal closure varies systematically with SPL.42
Louder and higher-pitched voicing requires a higher tonus
and medial compression of the vocal folds, which may result
in improved glottal closure and signal periodicity, as indi-
cated by a higher CPPS.31,35. Consequently, the relation
between an aberrant CPP and physiology still needs to be
fully established, since lower (or even higher) CPP is not
necessarily associated with the presence of a voice disorder.
This puts the application of normative values and thresholds
in acoustic voice quality measurements without control of
voice SPL in question.
Notably, in the patient group there was significantly
lower CPPS in the soft loudness condition. As already
described in studies applying the Soft Phonation Index
(SPI) and phonation threshold pressure, there may be dis-
tinct differences especially in soft voice production between
speakers with and without voice disorders.43,44 Thus, CPPS
might have indicated increased dysphonia or breathiness in
soft phonations of the patient group. As already discussed
previously, voice tasks may highlight specific physiological
or pathological characteristics.22 However, to date it is not
yet fully established, which sample (phonation) type is more
representative for perceptual dysphonia or voice pathology,
 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2019
and how we best investigate the underlying vocal physiol-
ogy. In the present study, fo was not systematically elicited,
and covered only a small part of the human pitch range.
Therefore, the present results regarding fo effects are only
valid in relation to the described voice SPL changes in
response to the voice task. Again, this emphasizes the poten-
tial importance of controlling for voice intensity and the
task type during clinical voice assessment.
It has been proposed that voice training may lead to a bet-
ter production and control of vocal fold tonus, and different
acoustic characteristics in vowel phonation, speech, and read-
ing tasks.45−49 In the present study, 60% of participants were
vocal performers; ie, all had undergone professional voice
training and were probably subjected to a high vocal
demand. Thus, the present results may not be representative
for a clinical caseload with mostly untrained voices. Further,
men tend to speak louder in the same clinical task under iden-
tical measurement conditions.26,28 As shown by Hasanvand
et al, CPP and CPPS scores may be systematically lower in
both sustained vowels and reading tasks for females with dys-
phonia compared to cepstral measures in men. This may be
partially due to systematic differences in habitual voice SPL
between males and females.16 Therefore, the present results
allow a preliminary estimate of voice SPL and fo effects in
vowel phonation of vocally healthy and voice disordered
women. However, further studies including gender, age, and
training status in a variety of voice tasks including speech
should be conducted to understand the interrelation between
voice SPL, fo, and cepstral measures.
Recommendations for the clinical measurement of
CPPS
As implied by the linear regression results of Figure 1A, SPL-
related effects may be controlled for by using a correction fac-
tor/formula or by reporting CPPS in reference to a standard
voice intensity level. However, this should also include an indi-
cation of the expected natural variation such as by stating the
95% confidence interval. Also, in our study investigating vowel
phonations, we found an average increase of 2.2 dB per 10 dB
increase, which was higher than the increase of 1.2 for speech
as reported by Phadke et al. The estimated standard value in
the present work was 13.8 dB (SD 1.7 dB) for CPPS at 80 dB
SPL (@10cm), which was also higher than the previously
reported 11.1 dB.32 This may be explained by differences in
measurement and analysis techniques, but also by the large
voice SPL range covered by our participants. Therefore, a
comparison even for SPL-standardized values including confi-
dence intervals is only useful when technically identical mea-
surement methods are applied or when data is transformed
between programs.3 Further, the voice tasks and the totally
produced SPL ranges should be comparable to each other.22
Another possible approach may be to examine vowels at
different loudness conditions such as individually “soft,”
“comfortable,” and “loud” levels for each speaker to evaluate
changes in CPPS over a large SPL span within an individual.
Also, we could measure SPL during the first voice
examination and ask patients to match the same SPL level in
the following assessments. Further, as already discussed for
the clinical application of jitter and shimmer measurements,
all patients may be asked to produce an identical predefined
voice SPL.27 These approaches would minimize the use of a
correction formula that has its own uncertainty. However,
the voice tasks themselves, and especially controlling for
voice SPL, may influence natural voice behavior, which is
presumed to contribute to the voice disorder. Future work
should investigate how to best control for technical and
procedural confounding factors in the clinical application
of CPP and CPPS, to improve the instrumental acoustic
assessment of voice quality.
CONCLUSION
In a group of women with and without a voice disorder, the
acoustic measure of smoothed CPPS was significantly
affected by the sound pressure level of the vowel produced.
CPPS increased as voice SPL increased. A similar effect has
been reported for cepstral measures derived from phonation
in vocally healthy individuals and is reproduced here in a
group of patients diagnosed with hyperfunctional voice disor-
ders. Since popular voice assessment indices incorporate ceps-
tral measures, it is recommended that the clinical assessment
of voice control for variations in voice SPL. Such control
may be performed by applying SPL-corrected values for
CPPS or by taking care to elicit similar voice SPL levels
throughout a patient’s stage of treatment for robust
CPPS comparisons. Other potentially confounding fac-
tors such as sex, age, and voice training status should be
investigated in the future on patients across a larger
spectrum of voice disorders.
Acknowledgment
The authors acknowledge Melissa Cooke, Amanda Fryd,
and Molly Bresnahan for help with signal segmentation.
This work was supported in part by the NIH National Insti-
tute on Deafness and Other Communication Disorders
under Grants R33 DC011588 and P50 DC015446 (PI: Hill-
man) and in part by the Voice Health Institute. Its contents
are solely the responsibility of the authors and do not neces-
sarily represent the official views of the NIH.
Part of this work was presented by M. Brockmann-
Bauser at the 47th Annual Symposium of The Voice Foun-
dation, Philadelphia, PA, USA in 2018.
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