Towards evidence based diagnosis of voice disorders
using Phonovibrograms
Jörg Lohscheller
University of Applied Sciences Trier, Department of Computer Science
Trier, Germany
J.Lohscheller@fh-trier.de
Abstract— Clinical diagnosis of voice disorders is based on
examination of the oscillating vocal folds during phonation with
state-of-the-art endoscopic high-speed cameras. Commonly, the
offline analysis is performed in a subjective and time-consuming
manner via slow-motion playback. In this study an objective
method for overcoming this drawback is presented being based
on Phonovibrogram (PVG) images. For a set of normal voices
and subjects suffering from vocal fold paralysis or functional
dysphonia the laryngeal dynamics were captured by specialized
Phonovibrogram features and classified using a support vector
machine (SVM). In case of functional voice disorders a mean
classification accuracy of 78.5% was obtained while in vocal fold
paralysis a classification accuracy of up to 93% could be
obtained. The classification results show that the PVG features
hold a lot of promise in supporting diagnosis of voice pathologies
even in case of muscle tension dysphonia.
Keywords- PVG; Phonovibrogram; Vocal Folds; Dysphonia,
Machine Learning; Diagnosis Support.
I. INTRODUCTION
Human voice is generated within the larynx by two oscillating
vocal folds. Voice disorders are closely related to disturbances
of the dynamic patterns of vocal folds. Hence, distinguishing
between oscillation patterns of healthy and pathological vocal
folds is a fundamental part within the diagnostic of voice
disorders. State-of-the-art technique for examining the
laryngeal dynamics is the high-speed endoscopy which
captures the two dimensional oscillation patterns of vocal
folds during voice production with a frame rate of up to 4,000
images per second. To date the clinical analysis of the
recorded high speed (HS) videos is commonly performed in a
subjective manner via slow-motion playback. The resulting
diagnoses exhibit frequently a high inter/intra-rater variability
which does not satisfy the demands of evidence based
medicine.
To overcome this drawback a computerized method is
presented which allows an objective description of the two-
dimensional vocal fold vibration patterns. It comprises a
precise extraction of vocal fold dynamics from the high speed
videos and further depicts the extracted movement information
into a single image, called Phonovibrogram (PVG), which can
be grasped very intuitively. The occurring geometric structures
within a PVG image depend directly on the individual vocal
fold vibration pattern of a subject. Hence, by describing the
geometric PVG structure an objective analysis of vocal fold
dynamics is obtained.
From particular interest is the identification of voice
disorders (vocal fold paralysis, functional voice disorder)
which occur without abnormal organic changes of vocal folds.
An automatic classification approach is presented which is
capable of differentiating between normal and potentially
disturbed vocal fold vibrations (left/right vocal fold paralysis,
hypo/hyper functional voice disorder). From the PVG images
sets of features are extracted describing quantitatively the
spatio-temporal behaviour of vocal fold (VF) dynamics. By
applying machine learning methods (Support Vector machine,
SVM) to a training set of healthy and pathological voices
models of voice disorders were inductively built and
subsequently used to predict the class membership of the
unseen cases.
II. METHOD
A. Data Collection
The Richard Wolf High–Speed Video System HS
ENDOCAM was used to collect the data which is equipped
with a rigid 90° endoscope optic. The recordings were
performed at a frame rate of 4,000 frames/sec while the images
were captured with a gray scale resolution of 256 x 256 pixels.
Endoscopy was performed as in conventional
videostroboscopy.
B. Clinical Material
The vocal fold movements of hundred and five patients
were analyzed. The diagnoses that subsequently served as a
gold standard for classification and evaluation were made by
clinically experienced and speech therapists according to the
basic protocol of voice pathology assessment of the European
Laryngological Society [1].
In this manner, a population of 50 women with a diagnosed
functional voice disorder was obtained. This clinical picture is
also referred to as primary muscle tension dysphonia (MTD),
and is diagnosed in case of dysphonia given normal vocal fold
morphology and motion, and the absence of organic
pathological conditions [2]. The considered population
included 25 cases with a hyperfunctional and 25 cases with a
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hypofunctional disorder. The distinction between these two
dysfunctional types is clinically made based on the patient's
overall muscle tension status, the amount of laryngeal muscle
tension applied during phonation, the varying degree of
hoarseness during crescendo and abnormal laryngeal posture
during connected speech [2].
The second investigated clinical group consists of patients
with a vocal fold paresis. This relatively prevalent voice
disorder involves the degradation of one VF side’s vibratory
properties, commonly caused by neural damage. While for one
half of the examined patients mainly the left VF side was
affected by paresis, for the other half of the test persons the
pathology was identified at the right side. In contrast to organic
voice disorders (e.g. nodule, polyp, edema), which can be
assessed quite reliably by analyzing laryngeal still images, it is
widely held that among other things, an appropriate paralytic
diagnosis can only be made by considering the overall
oscillation behaviour of the VFs during phonation and relating
both sides’ dynamics to each other.
Furthermore, as a reference population for normal voices,
the laryngeal dynamics of 25 female candidate speech
therapists were recorded. These healthy individuals exhibited
no voice irregularities.
C. Phonovibrogram (PVG)
To identify the dynamics of vocal fold vibrations,
Phonovibrograms were computed. The detailed description of
deriving PVGs was previously introduced and described in
detail [3]. For the ease of readability, a brief description of
deriving PVGs will be given now. Phonovibrographic
visualization first demands the segmentation of the laryngeal
high-speed recording, Fig 1 (left).
Figure 1. PVG visualization of vocal fold vibrations.
As the quality of the image data, in terms of manual focus,
lighting condition, and image contrast varies considerably
between different high-speed images, a special image
segmentation procedure was developed allowing the highly
accurate reconstruction of vocal fold edges from high-speed
recordings even in movies with low image quality. The
accuracy of the segmentation procedure was evaluated within
an extensive study [4]. There, it was applied to 372 different
high-speed movies each comprising 500 frames. The procedure
showed a mean information flow-rate of approx. 100 images
per second and can thus be applied directly after the recording
of a high-speed movie. Image processing yields the glottal
main axis and the vocal fold edges for both vocal folds.
The principal steps in the procedure to derive a PVG are
shown in Figs. 1: Firstly, for each image the absolute values of
the distances between the glottal symmetry axis and the vocal
fold contours are computed (Fig. 1, middle). In a further step,
the glottal axis is longitudinally split and the left vocal fold is
turned 180° around the posterior ending P, (Fig. 1, middle).
The computed distances are finally stored within a column
vector (Fig. 1). For visualization, the vector elements are color
coded (Fig. 1, right). The value of each vector element is
represented by the pixel intensity (red); black denotes no
distance of the vocal fold edge towards the glottis midline.
By iterating the above described procedure for an entire
sequence within a high-speed movie the resulting set of vectors
can be consecutively arranged in a matrix as shown in Fig.1 on
the right. The posterior endings of the vocal folds P are mapped
to the horizontal centre line. In contrast to other approaches the
PVG image visualizes the entire dynamical characteristics of
vocal fold vibrations along the full vocal fold length over [5-7].
D. PVG feature extraction
To objectify the criteria underlying the clinical diagnosis of
voice disorders using HS videos, the resulting PVG data matrix
was subsequently analyzed to extract a set of numerical
features describing the contained laryngeal movement
information. As VF vibrations exhibit periodically recurring
movement patterns (see Fig. 1), it is appropriate to take these
individual oscillation episodes comprising distinct opening and
closing phases as a starting point for further
analysis.
Figure 2. Extraction of characteristic contour lines for all cycles allow to
describe the mean spatio-temproal vibration pattern of both vocal folds.
The dynamic opening and closing properties of the VFs are
characterized through the geometric shapes within each PVG
cycle, which can be seen in Fehler! Verweisquelle konnte
nicht gefunden werden.. Here, according to the ELS
classification given in Fehler! Verweisquelle konnte nicht
gefunden werden., the depicted movement patterns exhibit a
dorsal triangular shape. This relevant shape information can be
represented using so-called contour lines.
In this manner these PVG contour lines serve as numerical
features to describe the oscillation patterns of both vocal folds
individually.
E. SVM Classification
The derived feature sets were subsequently taken as a basis
for inductively building models of normal and pathological VF
vibrations, which can potentially support clinical decision
making. For this purpose each patient’s VF oscillation patterns
were represented by numerical feature vectors computed from
the corresponding PVG. By attaching the underlying clinical
diagnoses to this representative set of feature vectors, a training
set was obtained which was then analyzed with a support
vector machine (SVM) [8].
In this study the following clinically relevant classification
tasks were examined, wherein for each classification task a
balanced group size was used.
• Healthy versus Paresis (all)
• Healthy versus Paresis (Left / Right)
• Paresis Left versus Paresis Right
• Healthy versus functional dysphonia (all)
• Healthy versus Hyper/Hypo functional dysphonia
• Hypo versus Hyper functional dysphonia
III. RESULTS AND DISCUSSION
The results of classifying different types are dysphonia are
given in Fig. 3 and Fig. 4. In case of functional voice disorders
a mean classification accuracy of 78.5% was reached while in
vocal fold paralysis an average classification accuracy of 93%
could be obtained.
Figure 3. Classification accuracy of classifying vocal fold paralysis using
PVG features.
While for both clinical pictures (paresis, functional dysphonia)
the differentiation healthy versus a pathological case achieved
a relatively high classification performance the differentiation
within the pathological groups does not show such high
classification accuracy.
In case of left/right paresis is can be concluded that the
relation between the vibrations of the left and right VF side is
quite balanced – none of the two VFs can be characterized as
being functionally inferior to the other. Hence, for these
particular pathological cases the common diagnostic criterion
of lateral vibration dissimilarity does not hold – by all
appearances they rather resemble cases from the healthy
control group. Thus, an automatic distinction between theses
pathological cases is quite difficult.
Figure 4. Classification accuracy of classifying functional dysphonia using
PVG features.
In case of functional dysphonia the subsumption of the two
pathological (hyper/hypo) disorders into one pathology class
has been shown to be obstructive in terms of differentiating
between healthy and pathological vocal fold movement.
Therefore, it can be stated that it is beneficial to analyze and
model hyper- and hypofunctional diagnoses individually, as
the corresponding classification results are better than in the
class pooling approach.
Overall, the classification results show that the PVG features
hold a lot of promise in automatic supporting diagnosis of
voice pathologies in non-organic case as in paresis and muscle
tension dysphonia. In future, further clinical studies with a
higher number of subjects will be conducted to improved
training step of the applied machine learning approaches.
ACKNOWLEDGMENT (HEADING 5)
This work was supported by the German Research
Association DFG project number LO 1413/2-1.
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