ARTICLE IN PRESS

The Value of Vocal Extent Measure (VEM) Assessing

Phonomicrosurgical Outcomes in Vocal Fold Polyps
*Tatjana Salmen, †Tatiana Ermakova, ‡Andreas Möller, *Matthias Seipelt, *Sebastian Weikert,
*Julius Rummich, *Manfred Gross, *Tadeus Nawka, and *Philipp P. Caffier, *†Berlin, Germany and ‡Greifswald, Germany

Summary: Objective. This study aimed to present vocal extent measure (VEM), demonstrate its changes with
phonomicrosurgical treatment in patients with vocal fold polyps (VFPs), and to compare its performance to that of
established vocal parameters.
Study Design. This is an individual cohort study.
Methods. Microlaryngoscopic ablation was executed in 61 patients with manifestation of VFP (28 male, 33 female;
45 ± 13 years [mean ± SD]). Analysis of treatment outcome was based on pre- and postoperative voice function diag-
nostics and videolaryngostroboscopy. Examination instruments were: auditory-perceptual voice assessment (roughness,
breathiness, and overall hoarseness [RBH]-status), voice range profile (VRP), acoustic-aerodynamic analysis, and pa-
tients’ self-assessment of voice using the voice handicap index. The VEM, a parameter not yet commonly established
in phoniatric diagnostics, was calculated from area and shape of the VRP to be compared with the dysphonia severity
index (DSI) concerning diagnostic suitability.
Results. All polyps were completely excised. Three months postoperatively, mucosal wave propagation had
recovered. All subjective and most objective acoustic and aerodynamic parameters showed highly significant
improvement. The VHI-9i-score decreased from 15 ± 8 to 6 ± 7 points. The average total vocal range extended
by 4 ± 5 semitones, the mean speaking pitch decreased by 1 ± 2 semitones. The DSI increased on average from 2.6 ± 2.1
to 4.0 ± 2.2, VEM from 83 ± 28 to 107 ± 21 (P < 0.01). VEM and DSI correlated significantly with each other (rs = 0.65;
P < 0.01).
Conclusion. Phonomicrosurgery of VFP is an objectively and subjectively satisfactory therapy for voice improve-
ment. The VEM represents a comprehensible and easy-to-use unidimensional measure for objective VRP evaluation.
This positive measure of vocal function seems to be a compelling diagnostic addition for objective quantification of
vocal performance.
Key Words: Vocal extent measure–Phonomicrosurgery–Vocal fold polyp–Vocal function–Videolaryngostroboscopy.

INTRODUCTION
According to the basic protocol of the European Laryngological
Society, instrument-assisted measuring procedures expand the
options within phoniatric diagnostics by quantifying the con-
dition of the voice.1 The standardized voice range profile (VRP)
and the data thereby ascertained to calculate the dysphonia se-
verity index (DSI) are core elements in objective voice diagnostics.
However, the DSI quantifies dysphonia as a negative criterion
and entails the risk of inaccurate results due to its multidimen-
sional acquisition.2 Therefore, we developed the vocal extent
measure (VEM) as a unidimensional, comprehensible, and easy-
to-use positive measure of vocal function. This novel parameter
was designed for objective VRP evaluation and quantification
of vocal performance.3,4
The VEM parameter used in this study is not yet commonly
established in phoniatric diagnostics. It was calculated as relation
Accepted for publication March 30, 2016.
The manuscript was presented in part at the 32nd Annual Meeting of the German Society
of Phoniatrics & Pedaudiology (DGPP) in Oldenburg, Germany, September 24–27, 2015.
The authors have no funding, financial relationships, or conflicts of interest to disclose.
From the *Department of Audiology and Phoniatrics; Charité—University Medicine Berlin,
Campus Charité Mitte, Charitéplatz 1, D-10117 Berlin, Germany; †Department of Infor-
mation and Communication Management, Technical University Berlin, Straße des 17. Juni
135, D-10623 Berlin, Germany; and the ‡Max-Planck Institute for Plasma Physics,
Wendelsteinstraße 1, D-17491 Greifswald, Germany.
Address correspondence and reprint requests to Philipp P. Caffier, Department of Audiology
and Phoniatrics; Charité—University Medicine Berlin, Campus Charité Mitte, Charitéplatz
1, D-10117 Berlin, Germany. E-mail: philipp.caffier@charite.de
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.03.016
of area and perimeter of the VRP. The underlying idea was that
the VRP shape should not show abrupt differences in the dynamic
range of notes produced by the patients along their frequency
range. Well-balanced dynamic extent approximates the shape of
VRP to a circle where the area is biggest for a given perimeter
compared to other geometric figures. In this ideal conception,
the dynamic range is evenly distributed over the tonal extent.
Each deviance from the circular shape indicates a decrease in
the vocal performance. Therefore the VEM multiplies the area
of the VRP by the quotient of the perimeter of the profile and
the theoretical perimeter of a circle with the same area as the
profile itself. Figure 1 shows the mathematical derivation of the
equation of this measure. The VEM quantifies the patient’s
dynamic performance and the frequency range. It is scaled one-
dimensionally to a range of 0 to 150. A high vocal capacity is
characterized by a high VEM; conversely, a small VRP results
in a small VEM. To examine changes of this measure and to
provide some early validity and responsiveness data, we chose
to investigate patients with vocal fold polyps (VFPs) who planned
to undergo surgical excision.
VFPs fit into the group of benign vocal fold lesions which
are responsible for a major number of voice disorders
worldwide.5–7 They are one of the most common non-neoplastic
changes of the larynx.8,9 In most cases, they appear unilateral.10
Located at the free margin of the vocal folds, they are exten-
sions of the lamina propria, which can be clearly differentiated
from the surrounding epithelium.9,11 Polyps are formed at the point
of greatest mechanical stress during phonation, ie, between the
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2 Journal of Voice, Vol. ■■, No. ■■, 2016
FIGURE 1. Derivation of VEM equation.
anterior and the middle third of the vocal fold.8,9,11 Being diag-
nosed almost exclusively among adults,12 phonotrauma such as
excessive or inappropriate use of the voice has the greatest in-
fluence on the development of VFP.5,8,12 Overstress leads to
chronical irritation and results in a change of the microstruc-
ture of vocal fold mucosa.8 Induced vessel trauma results in
hemorrhage, fibrin exudation, thrombosis and proliferation of
capillaries.9,13 Other promoting factors are smoking, chronic in-
fections of the upper airways, allergies, or gastroesophageal
reflux. 5,10,12 There are two main types of VFP: First, the
teleangiectatic polyp of red color filled with a convolute of cav-
ernous blood compartments with clots. It can enlarge to a
pedunculated mobile polyp. Second, the hyaline translucent polyp
consisting of a swelling of the lamina propria, which is mostly
broad-based and therefore sessile.11 The associated symptoms
are hoarseness and fast vocal fatigue as well as reduced voice
volume, resulting in an impaired quality of life.8,14 Surgery is
indicated either if patients suffer from dysphonia and do not
respond sufficiently to conservative treatment like voice therapy,
or if there is a risk of hemorrhage.6,15,16 Phonomicrosurgery is
regarded as the best way to remove small glottal pathologic
changes,17,18 and several studies show that it is a beneficial therapy
for VFP.8,10,19–21 Yet, there are still few data showing to which
exact extent patients eventually benefit from the operation, taking
into account both objective and subjective examination instru-
ments. Thus we aimed to investigate the magnitude of the impact
of phonomicrosurgery in VFP on subjective and objective pa-
rameters of vocal function. Here, among other criteria, the VEM
was considered. The intention of this study was to present the
VEM, to demonstrate its changes with phonomicrosurgical treat-
ment in VFP patients, and to compare its performance to that
of established vocal parameters including the DSI.
MATERIALS AND METHODS
Study design and patients
In a clinical prospective study, patients diagnosed with the man-
ifestation of a VFP underwent phonomicrosurgery. Clinical
examination and data acquisition took place at the initial pre-
therapeutic visit, during operation, and at regular follow-ups 2
weeks and 3 months after surgery. The clinical effectiveness was
evaluated at the 3-month interval by comparing the pre- and post-
operative data. Patients missing this appointment were scheduled
for later follow-up examination.
Study participants were patients from the Clinic of Audiol-
ogy and Phoniatrics at Charité—University Medicine Berlin,
Germany. After taking their medical history, the patients under-
went a standard ear-nose-throat examination. Altogether, 61
consecutive patients were recruited. Selection criteria com-
prised unambiguous videolaryngostroboscopic finding, suffering
from dysphonia, absence of spontaneous resolution of the polyp,
lack of improvement under conservative therapy, risk of bleed-
ing, complete treatment documentation, and informed consent.
The trial was conducted in accordance with the Declaration of
Helsinki and approved by the local ethical review board. In all
patients, surgery was performed via direct microlaryngoscopy
in intubation narcosis between January 2010 and April 2015.
Surgical procedure and postoperative regimen
VFPs were removed phonomicrosurgically via a truncation ap-
proach. After inspection and palpation under the operation
microscope, the polyp was grasped with a small triangular forceps
(Bouchayer). Incision was performed with a microscissor at the
junction of the polyp and the vocal fold, whereby at first the
cranial and subsequently the caudal adhesion site were severed.
After excision of the polyp it was examined visually as well as
by palpation if there was any leftover abnormal mucosa. The re-
maining fibrous or gelatinous material was carefully removed
to prevent a rapid reappearance of the pathology. This part of
the surgery required great care, as too aggressive excision of that
material can lead to unwanted scar formation. The surgical aim
at the end of the operation was that the free edge of each vocal
fold should be completely straight.17 Postoperatively, patients were
set on voice rest for 3 days, followed by careful vocal reestab-
lishment (“confidential speech”). In addition, all treated patients
received vocal hygiene counseling and were told to show up in
case of recurring voice impairment.
Examination instruments and criteria
The analysis of the treatment outcome was based on pre- and post-
operative voice function diagnostics and videolaryngostroboscopy.
Generally established objective and subjective methods were used
as examination instruments.
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Tatjana Salmen et al VEM Assessing VFP Phonomicrosurgical Outcomes
Digital videolaryngostroboscopy was carried out using a high-
resolution rigid videolaryngoscope with integrated microphone
connected to the Endo-STROB control unit (XION Medical,
Berlin, Germany).22 Laryngoscopy enabled a specification of the
polyps. They were classified according to their size in relation
to the vocal folds (in %), their shape (broad-based vs peduncu-
lated), their appearance (hemorrhagic vs hyaline), and if they
were located on the right or left side or on both vocal folds. During
examination, digital videostroboscopy was activated via foot
switch to visualize the vocal fold vibrations during phonation.
Polyp-associated impairment was seen when the vocal folds
showed reduced or absent mucosal wave propagation as well as
in the case of reduced or eliminated phonatory vibration.
Auditory-perceptual voice evaluation was assessed by using
the RBH-system,23 where the perceived patient’s roughness,
breathiness, and overall hoarseness (RBH) have to be scored on
a scale from 0 to 3 (0 = not existing, 1 = mild, 2 = moderate,
3 = severe). The pre- and postoperative RBH-status was de-
tected on the basis of the standardized text, “The north wind and
the sun” (German version), which was read by the patients and
recorded before and after surgery. To optimize evaluation ob-
jectivity, the resulting 122 audio recordings were shuffled and
blinded regarding patient assignment and pre-/postoperative status.
Six raters (three phoniatric physicians, two medical students, one
medical technical assistant) independently rated all audio files
consecutively in one session. The mean group rating of every
audio recording was used for further evaluation.
The voice handicap index (VHI-9i) was used for the patients
to provide self-assessment of their own voice.24 It captured the
patients’ subjective ratings of nine questions on a scale from 0
to 4 (0 = never, 1 = almost never, 2 = sometimes, 3 = almost always,
4 = always). After answering these questions, they had to assess
the self-perceived impairment of their voice (VHIs) at the present
time on a scale from 0 to 3 (0 = normal, 1 = mild, 2 = moderate,
3 = severe). The questionnaires were filled out pre- and post-
therapeutically to quantify the functional, physical, and emotional
impact of the voice disorder on the patient’s quality of life as
well as subjective perception of vocal changes and voice quality.
VRP and acoustic-aerodynamic analysis are well-established
procedures25,26 that were performed to obtain objective quanti-
tative measurements of speaking and singing voice. These
recordings were conducted with the DiVAS software (XION
Medical, Berlin, Germany). The following frequency, intensi-
ty, and derived parameters were measured: lowest vocalization
(I_min), highest tone (F0_max), lowest tone (F0_min), vocal range,
mean speaking pitch (MSP_dB(A), MSP_Hz), semitones related
to the hearing threshold of 16 Hz (ST_max, ST_min, ST_MSP),
maximum phonation time (MPT), jitter, DSI, and VEM.
Data analysis
Descriptive statistics were used to characterize the basic quan-
titative features of the data. Minimal and maximal values, medians,
first and third quartiles, means and standard deviations were cal-
culated for all subjective and objective vocal function parameters
pre- and postoperatively and their changes. To gain insights into
and compare distributions of pre- and postoperative values, various
graphical techniques such as boxplots, histograms, and kernel
3
densities were applied. Furthermore, being appropriate for both
continuous and ordinal variables, Spearman’s rank-order cor-
relation (rs) was used to investigate the strength and direction
of association between the pre- and postoperatively measured
characteristics and their differences. Fleiss kappa was used for
assessing the reliability of agreement between all six raters when
assigning categorical RBH ratings to the blinded patient’s voices.
Mann-Whitney-Wilcoxon test was used to test whether vocal func-
tion parameters significantly improved as the result of the
treatment. Mean values and 95% confidence intervals (CI) for
these changes were calculated. Regression analysis was per-
formed to evaluate the influence of age, gender, size, and
appearance of polyp on the outcome of surgical intervention. We
checked and made sure that our data meet all statistical assump-
tions underlying the ordinary least squares regression models.
All statistical tests and graphics were done using R version 3.2.2
(GNU project, Free Software Foundation, Boston, MA). The fol-
lowing abbreviations are used to show the significance levels:
* = 5%; ** = 1%; *** = 0.1%.
RESULTS
Sample description and preoperative assessment
A total of 61 patients with the confirmed diagnosis of VFP entered
microlaryngoscopic ablation and underwent further evalua-
tion. There were 28 male and 33 female patients aged between
21 and 84 years (45 ± 13 years [mean ± SD]) who were treated.
Subjects of both sexes were comparable in terms of age and so-
ciodemographic characteristics (Table 1). Whereas 37 patients
mainly used their voice in a non-professional manner (eg, busi-
ness (wo)men, clerks, laborers), 24 patients declared to be
professional voice users (eg, teachers, lecturers, clergy). Of the
latter group, nine patients were elite vocal performers (eg, singers
and actors).
Laryngoscopy revealed that all polyps were located on the free
edge of the vocal folds, which were more or less bulged de-
pending on the size of the lesion. Activated stroboscopy
demonstrated in all patients (except in one singer with a quite
small and soft polyp) that the bulged vocal folds impaired glottal
closure and lacked a normal mucosal wave. There were almost
as many hemorrhagic polyps as hyaline ones (32 vs 29). Inter-
estingly, among female patients, hyaline polyps (n = 22) were
more common than hemorrhagic ones (n = 11), whereas there
were more male patients with a hemorrhagic polyp (n = 21) than
those with a hyaline one (n = 7). Broad-based polyps (n = 55)
were much more common than pedunculated ones (n = 6). In
54 cases, the polyp was located on one vocal fold (right side
n = 26, left side n = 28) and only in 7 cases on both sides. The
polyp covered on average 15 ± 8% of the surface of both vocal
folds (range 3.0%–38.5%). In the group of professional voice
users, an average polyp was smaller than among non-professional
voice users (13 ± 9% vs 17 ± 6%). Remarkably, professional voice
users had on average smaller hemorrhagic polyps (8.6 ± 5.4%,
n = 10 vs 19.3 ± 6.2%, n = 22) and slightly larger hyaline polyps
(16 ± 10, n = 14 vs 13.7 ± 5.3, n = 15) than non-professional voice
users. Unilateral polyps covered a smaller mean area of the vocal
folds than bilateral polyps (14 ± 7% vs 24 ± 8 %).
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4 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 1.
Patient Characteristics. Unless Otherwise Specified, Data Expressed as Number of Patients and Percentage of Group
No. of % of Total No. of Male % of Male No. of Female % of Female
Characteristics All Patients Group (n = 61) Patients Group (n = 28) Patients Group (n = 33)
Gender
Male 28 46% — — — —
Female 33 54%
Age (in years; mean ± SD) 45 ± 13 — 48 ± 13 — 42 ± 13 —
Main voice use
Non-professional 37 61% 20 71% 17 52%
Professional 24 39% 8 29% 16 48%
Appearance of polyp
Hemorrhagic 32 52% 21 75% 11 33%
Hyaline 29 48% 7 25% 22 67%
Shape of polyp
Sessile (broad-based) 55 90% 25 89% 30 91%
Pedunculated 6 10% 3 11% 3 9%
Occurrence of polyp
Left vocal fold 28 46% 13 46% 15 46%
Right vocal fold 26 43% 12 43% 14 42%
Both vocal folds 7 11% 3 11% 4 12%
Size of polyp (in relation 15 ± 8 — 16 ± 8 — 15 ± 8 —
to both vocal folds; in %)
Follow-up (in days; mean ± SD) 275 ± 288 — 272 ± 245 — 278 ± 323 —

Concerning preoperative vocal function, auditory-perceptual
evaluation of patient’s voices was categorized with a mean of
R1 B1 H1 (range 0–3). The VHI-9i had an average score of
15 ± 8, corresponding to moderate self-assessed patient com-
plaints. The objective acoustic and aerodynamic parameters also
revealed mild to moderate impairment (eg, MPT 12 ± 4 seconds;
DSI 2.6 ± 2.1; VEM 83 ± 28). Correlation analysis performed
on preoperative values showed that both DSI and VEM corre-
lated with age (rs = −0.35** and rs = −0.32*, respectively), R
(r s = −0.50*** and r s = −0.30*), B (r s = −0.51*** and
r s = −0.43***), H (r s = −0.50*** and r s = −0.32*), MPT
(rs = 0.49*** and rs = 0.46***), and with each other (rs = 0.65***).
In addition, DSI correlated with polyp size (rs = −0.27*). MPT
correlated with R (rs = −0.30***), B (rs = −0.42***), and H
(rs = −0.33***). The correlation between R and H tended to be
almost perfect (rs = 0.96***), these criteria further correlated with
B (rs = 0.72*** and rs = 0.79***) and polyp size (rs = 0.41** and
rs = 0.36**). B correlated also with VHI (rs = 0.26*).
Postoperative assessment
As planned, all polyps were completely excised intraopera-
tively. Videolaryngostroboscopic checkups showed that during
healing a stable epithelium grew on the preserved lamina propria
to close the defect without scarring. Three months postopera-
tively, normal vocal fold anatomy with straight margin was seen
in all patients. Within the mean postoperative observation period
of 275 ± 288 days (median: 151 days), no side effects or rele-
vant recurrences were observed, except for one patient with an
excessive voice usage who developed another vocal fold pro-
trusion located in the area of the previously removed polyp.
Concerning functional aspects, complete glottal closure was re-
established in all patients and normal mucosal wave propagation
of the operated vocal folds was restored in all but two patients.
These exceptions were the aforementioned woman with the re-
current vocal fold swelling and one man who had been operated
on that vocal fold elsewhere before. Figure 2 gives an impres-
sion of pre- and postoperative videolaryngostroboscopic findings
with videostrobokymographic illustration of vocal fold oscillations.
Three months postoperatively, considerable improvements in
the vocal function could be observed in comparison to the pre-
operative measurements. With respect to the auditory-perceptual
evaluation with the RBH-system, the (blinded) pre- versus post-
therapeutical comparison revealed that the voices were less rough
(1.1 ± 0.8 vs 0.4 ± 0.5), breathy (0.8 ± 0.7 vs 0.2 ± 0.4), and hoarse
(1.1 ± 0.8 vs 0.4 ± 0.5). The inter-rater reliability indicated mod-
erate agreement between the ratings of all six raters (κ = 0.42).
The subjective self-assessment of the voice using the VHI-9i ques-
tionnaire demonstrated a drop of the score from an average of
15 ± 8 to 6 ± 7 points. According to the VHI’s criterion, an average
improvement of current voice assessment from moderately dis-
turbed (2 ± 1) to normal voices (0 ± 1) was seen. The improvements
regarding all these subjective parameters were found significant
at the 0.1% level. The subjective vocal parameters both pre-
and postoperatively are graphically displayed by histograms in
Figure 3.
Regarding objective measures, all acoustic and aerodynamic
parameters apart from jitter (P = 0.99) and MSP_dB(A) (P = 0.18)
significantly improved at the 0.1% level and in the case of
MSP_Hz at the 1% level. The mean MPT rose from 12 ± 4
seconds preoperatively to 16 ± 6 seconds postoperatively
(P < 0.001). DSI increased on average from 2.6 ± 2.1 to 4.0 ± 2.2,
VEM from 83 ± 28 to 107 ± 21 (P < 0.001). VEM and DSI cor-
related significantly with each other preoperatively (rs = 0.65***),
as well as in terms of their pre- and post-therapeutical differences
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Tatjana Salmen et al VEM Assessing VFP Phonomicrosurgical Outcomes 5

FIGURE 2. Videolaryngostroboscopic pictures and videostrobokymographic illustration of vocal fold anatomy and function, preoperative (upper
row) versus postoperative (lower row). A. (Left side): A 54-year-old female professional opera singer with a small polyp of the right vocal fold. B.
(Right side): A 34-year-old male hobby singer with a large polyp of the left vocal fold. Findings 3 months postoperatively show polyps completely
removed, healing process finished (scar-free), vocal folds have a straight margin, glottal closure is complete, and normalized vocal fold oscilla-
tions (mucosal wave propagation regular and symmetric).

(rs = 0.35**). However, there was no significant correlation
found between DSI and VHI (P = 0.57) or VEM and VHI
(P = 0.97).
Furthermore, the average total vocal range extended from
22.15 ± 6.60 to 26.51 ± 5.77 semitones, ie, patients postopera-
tively gained an average of 4.36 ± 4.73 semitones (P < 0.001).
This effect was stronger in women (5.70 ± 4.20) than in men
(2.79 ± 4.83). The mean speaking pitch (MSP_Hz) decreased on
average by 0.77 ± 2.40 semitones (P = 0.01). This effect was stron-
ger in men (1.32 ± 3.02) than in women (0.30 ± 1.61). The
selected objective acoustic and aerodynamic parameters before
and after polyp removal are graphically displayed via boxplots
and kernel densities in Figure 4.
To provide insights into the magnitude of improvement induced
by phonomicrosurgical removal of VFP and thus the extent of
the operation-related benefit, Table 2 presents the mean differ-
ences between pre- and post-therapeutic values of both objective
acoustic/aerodynamic parameters and subjective VHI-9i/VHIs
vocal parameters and the 95% CI for them. These measures were
calculated for the total group as well as separately for men and
women. Our further analysis showed that age did not signifi-
cantly correlate with changes in the investigated parameters, and

FIGURE 3. Subjective vocal parameters before and after polyp removal. Upper row: Comparison of pre- and postoperative voice parameters
according to the RBH-system. Lower row: Comparison of pre- and postoperative VHI-9i and VHIs scores.
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6 Journal of Voice, Vol. ■■, No. ■■, 2016

FIGURE 4. Selected objective acoustic and aerodynamic parameters before and after polyp removal (MPT, DSI, VEM, and VR). Upper row:
Pre- and postoperative comparison via boxplots, which display the median, quartiles, range of values covered by the data, and any outliers (single
spots). Lower row: Pre- and postoperative comparison via kernel density curves (Gaussian smoothing), in which histograms were shifted and over-
laid with smooth density estimates to illustrate the different distributions.

polyp size only correlated with the difference between pre- and
postoperative R-values (rs = −0.29*). The regression analysis re-
vealed that gender had a significant influence on the pre- and
post-therapeutical differences of semitones in terms of ST_max
(5.55*** − 3.87***x, where x = 1 for males and 0 for females,
R 2 : 18.61%, adjusted R 2 : 17.24%; P = 0.45) and VR
(5.7*** − 2.91*x, R2: 9.58%, adjusted R2: 8.05%; P = 0.61).
DISCUSSION
We examined the outcome of phonomicrosurgery in VFP by
evaluating its impact on subjective and objective voice parameters.
Our results showed a substantial postoperative improvement of
vocal function with increased efficiency of phonation in most
patients. This is in concordance with other studies concluding
that phonomicrosurgical excision of VFP improves perceptual
and acoustic voice parameters.
Zeitels et al19 prospectively studied the outcome in 71 pa-
tients with polyps among 185 singers and performing artists
undergoing phonomicrosurgery with a various number of vocal
fold lesions. Voices were evaluated on the basis of patient per-
ception, videostroboscopy, and objective acoustic and aerodynamic
measurements. In all patients who could be re-examined during

TABLE 2.
Mean Values and 95% CI for Changes in Vocal Measures After Polyp Removal
Total Group (n = 61) Male Group (n = 28) Female Group (n = 33)
Vocal Measure Mean 95% CI Mean 95% CI Mean 95% CI
VEM 23.17 17.60; 28.74 22.36 14.67; 30.05 23.86 15.51; 32.21
DSI 1.43 0.95; 1.90 1.17 0.38; 1.95 1.65 1.05; 2.24
MPT 4.42 3.21; 5.63 5.65 3.91; 7.40 3.37 1.70; 5.04
VR 4.36 3.15; 5.57 2.79 0.89; 4.68 5.70 4.21; 7.19
I_min −1.43 −2.84; −0.02 −1.64 −4.25; 0.96 −1.24 −2.78; 0.29
F0_max 108.51 72.99; 144.03 28.46 −3.19; 60.12 176.42 126.17; 226.68
F0_min −4.16 −7.98; −0.35 −6.00 −11.10; −0.90 −2.61 −8.37; 3.16
ST_max 3.77 2.62; 4.92 1.68 −0.01; 3.37 5.55 4.17; 6.92
ST_min −0.64 −1.23; −0.05 −1.14 −2.13; −0.15 −0.21 −0.93; 0.51
ST_MSP −0.77 −1.38; −0.16 −1.32 −2.49; −0.15 −0.30 −0.87; 0.27
MSP_Hz −7.20 −12.27; −2.12 −10.29 −18.92; −1.65 −4.58 −10.75; 1.60
MSP_dB(A) −0.41 −1.62; 0.80 −1.07 −3.02; 0.88 0.15 −1.42; 1.73
Jitter 0.14 0.01; 0.27 0.22 −0.01; 0.44 0.07 −0.08; 0.22
VHI −8.94 −11.46; −6.43 −6.50 −10.61; −2.39 −11.02 −14.12; −7.91
VHIs −1.30 −1.54; −1.05 −1.11 −1.51; −0.71 −1.45 −1.76; −1.15
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Tatjana Salmen et al VEM Assessing VFP Phonomicrosurgical Outcomes
follow-up, postsurgical objective vocal function measurements
fell within normal limits. By analogy, most of them reported also
subjective improvement in their vocal function. In another study
with 51 VFP patients, Karasu et al8 compared the effects on voice
of endolaryngeal microsurgery with cold instruments versus diode
laser. They concluded that endolaryngeal microsurgery with both
diode laser and traditional cold knife is effective. With each tech-
nique they could report a significant difference in the voice
analysis values as well as in the VHI scores measured pre- and
postoperatively. VHI changes after treating different voice
disorders were also investigated by Rosen et al.20 Their study
included 37 patients; among these, 8 VFP patients underwent
phonomicrosurgery with pre- and postoperative voice therapy.
Post-treatment VHI scores were statistically significantly lower.
Furthermore, Uloza et al21 conducted perceptual and acoustic
analysis in 32 VFP patients. This study revealed significant
improvement of voices 2 weeks after endolaryngeal
phonomicrosurgery. Patients stated high satisfaction after the op-
eration and the voice evaluation with the GRB scale (which is
comparable to the RBH-status) showed significantly decreased
rating of G (grade of hoarseness), R, and B. In an investigation
by Petrović-Lazić et al,10 voice quality got better in all 46 VFP
patients after phonomicrosurgery. All measured acoustic param-
eters improved significantly and tended to reach normal values.
Regarding the data of our study, all subjective and objective
parameters except jitter and MSP_dB(A) improved signifi-
cantly. MSP_dB(A) was postoperatively decreased in most patients,
indicating the ability to produce the voice with less pressure and
more untensioned at a lower volume. However, loudness of relaxed
mean speaking voice depends on many influencing factors and
conditions outside the scope of vocal capability (eg, different
mental and physical activation, individual intention to express
or declaim the standardized text during reading). Most patients
reported better subjective voice stability after polyp removal, stro-
boscopically visualized by harmonized vocal fold vibrations with
regular and symmetric mucosal wave propagation. However, in
terms of jitter we cannot explain why this vocal parameter did
not improve. With otherwise identical measuring conditions, one
reason for this fact might be the different time of day during pre-
and postoperative voice recordings. According to the process of
our clinical routine, preoperative measurements were done about
noon, when patients had time to use their voice (and therefore
unconsciously “trained” their vocal stability) for several hours.
The appointments for postoperative checkups after 3 months took
place in the morning without a similar vocal warm up in most
patients. Furthermore, we have the experience from repeated mea-
surements that jitter in general seems to be a quite sensitive
parameter resulting in different consecutive intra-individual values.
According to our results, jitter as a measurement of the irregu-
larities in the frequency seems to be less appropriate to evaluate
the success of phonomicrosurgery compared to other objective
acoustic and aerodynamic parameters.
Among these acoustic measurements we investigated the DSI
and VEM. Although the VEM is not yet commonly estab-
lished in phoniatric diagnostics, the calculation of the DSI, based
on a weighted combination of highest possible frequency
(F0-High), lowest intensity (I-Low), MPT, and jitter, is a core
7
part of instrumental voice evaluation.2 The DSI is described as
a useful parameter to measure the severity of dysphonia.2,27,28
However, previous studies could show that the DSI is influ-
enced by differences of measurements of the registration programs
as well as by age or gender.3,27,29 Therefore, we saw the need to
develop and investigate the VEM as an objective parameter un-
impaired by these interacting factors. The vocal quality of patients
was modeled by means of VEM, which was designed to estab-
lish a new objective and quantitative correlate of the vocal
performance symbolized by the VRP. Unlike DSI, the VEM uses
the area of the VRP as a guide value. Further on, the perimeter
of the VRP is included in its calculation. Neither the pure tonal
range nor the dynamic range may be used to document the vocal
performance due to obvious reasons. The area of VRP seems
to be a better value for quantification. However, the area gives
an inaccurate impression of the actual usable voice perfor-
mance. This becomes particularly clear considering artistic use
of voice. Singers with a large VRP but tight restrictions in their
dynamic range on single tones may not be able to use their whole
frequency range artistically. Therefore, the VEM takes both cri-
teria duly into account: as described above in detail, it is
constructed as VEM ≈ area (VRP)⁄rel.perimeter (VRP). Thus, the result
is not influenced by extreme measurements like F0_max and
I_min, which are likely to be influenced by age or gender.29 A
large total intensity range and a large total fundamental fre-
quency range results in a high VEM value. One limitation of
this procedure is the fact that in aphonic patients, no perimeter
of the VRP can be measured. However, it has to be noted that
in our study, no patient suffered from aphonia.
Regarding comparison of VEM and DSI, both measure-
ments as well as their pre- and post-therapeutical differences
correlated highly significantly with each other. Thus, both mea-
surements can be seen as comparable parameters being related
to each other. However, whereas the DSI aims particularly at de-
scribing the severity of dysphonia as a negative criterion, the VEM
reflects the vocal abilities and enables a classification of the voice
performance as a positive criterion. As described in other studies,
we found no correlation between VEM and VHI or DSI and
VHI.28 Therefore, DSI, VEM, VHI, and RBH seem to repre-
sent different aspects of the voice and are complementing
objective or subjective measurements either for evaluation of voice
quality, vocal performance, or perceived vocal handicap. As ex-
pected, VEM as well as DSI correlated negatively with age and
RBH-status, but positively with MPT. Our results also demon-
strated a correlation between VFP size and R as well as between
VFP size and H. Therefore, the roughness of the voice deter-
mines the impression of overall hoarseness in VFP. MPT
correlated most significantly with B, confirming the clinical
impression that greater breathiness means larger air consump-
tion and shorter phonation time. The limited reliability of
agreement between all six raters when assigning categorical
RBH ratings to the blinded patients’ voices seems to be related
to the reduced experience and training level in three of the
participants (two medical students, one medical technical
assistant).
Considering the influence of VFP size, Cho et al30 found out
that the size of the polyp is the most influential factor in the quality
 ARTICLE IN PRESS
8 Journal of Voice, Vol. ■■, No. ■■, 2016
of voice. Shin et al31 investigated persistent dysphonia after
laryngomicrosurgery for benign vocal fold disease and also re-
ported that patients with worse preoperative acoustic parameters
had a worse voice outcome. However, according to our results,
the VFP size did not influence the operative outcome. Preop-
eratively, the difference of the size of hemorrhagic polyps in
professional voice users compared to the size of hemorrhagic
polyps in non-professional voice users was significant. It appears
that people who depend on their voice in their job are more sen-
sitive to pathologic changes and therefore go earlier to see a
medical voice specialist. According to our experience, the most
important prerequisite to avoid postoperative dysphonia in VFP
is not the extent of the preoperative finding but the use of the
appropriate microsurgical technique. Therefore, we investi-
gated the quantitative changes in vocal measurements induced
by phonomicrosurgery. The mean differences between pre- and
post-therapeutic voice parameters and the 95% CI show the level
of enhancement and the exact extent of operation-associated ben-
efits. The resulting range of improvement of VEM (from 18 to
29), DSI (from 1.0 to 1.9), MPT (from 3.2 to 5.6 seconds), VR
(from 3 to 6 semitones), ST_MSP (from −1.4 to −0.2 semitones),
and VHI (from −11 to −6) could be used as reference range for
subjective and objective expectation values. Further studies must
show if the enlargement of this database by filling it with pre-
and postoperative voice parameters of future VFP patients allows
more precise predictions for vocal outcome. Thus, these values
could serve for quality control after phonomicrosurgical removal
of VFP.
CONCLUSION
With a correct preoperative diagnosis, a competent and precise
phonomicrosurgical procedure such as protection of vocal fold
margin and preservation of the lamina propria, a normal post-
operative course with regular wound healing, and obeying voice
counseling (eg, 3 days of voice rest, careful vocal rehabilita-
tion), the microlaryngoscopic excision of VFP is a safe,
subjectively and objectively satisfactory therapy for the resto-
ration or at least the improvement of vocal function. The VEM
demonstrates significant changes with phonomicrosurgical treat-
ment in VFP patients and proves to be a comprehensible and
easy-to-use novel parameter for objective evaluation of the VRP.
This positive measure of vocal function seems to be a compel-
ling diagnostic addition to other established voice measurements
and suitable to objectively quantify the vocal performance.
Acknowledgments
The authors cordially thank Prof. Eleanor Forbes for proofread-
ing the manuscript and our staff nurses Karin Lehwaldt, Ruth
Gerlach and Theresia Schikora for their cooperation and orga-
nization of patient investigation.
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