Ann Otol Rhinol Laryngol 112:2003

CEPSTRAL PEAK PROMINENCE:

A MORE RELIABLE MEASURE OFDYSPHONIA

YOLANDA D. HEMAN-AcKAH, MD REINHARDT J. HEUER, PHD

CHICAGO, ILLINOIS PHILADELPHIA, PENNSYLVANIA
DEIRDRE D. MICHAEL, PHD ROSEMARY OSTROWSKI, MM, MS MICHELLE HORMAN, MA
MINNEAPOLIS, MINNESOTA PHILADELPHIA, PENNSYLVANIA PHILADELPHIA, PENNSYLVANIA

MARGARET M. BAROODY, MM JAMES HILLENBRAND, PHD ROBERT T. SATALOFF, MD, DMA

PHILADELPHIA, PENNSYLVANIA KALAMAZOO, MICHIGAN PHILADELPHIA, PENNSYLVANIA

Quantification of perceptual voice characteristics allows the assessment of voice changes. Acoustic measures of jitter, shimmer,
and noise-to-harmonic ratio (NHR) are often unreliable. Measures of cepstral peak prominence (CPP) may be more reliable predic-
tors of dysphonia. Trained listeners analyzed voice samples from 281 patients. The NHR, amplitude perturbation quotient, smoothed
pitch perturbation quotient, percent jitter, and CPP were obtained from sustained vowel phonation, and the CPP was obtained from
running speech. For the first time, normal and abnormal values of CPP were defined, and they were compared with other acoustic
measures used to predict dysphonia. The CPP for running speech is a good predictor and a more reliable measure of dysphonia than
are acoustic measures of jitter, shimmer, and NHR.
KEY WORDS - acoustic analysis, cepstral peak prominence, cepstrum, dysphonia, voice.

BACKGROUND AND SIGNIFICANCE sure. The CPP is calculated from the Fourier trans-
There is an increasing need for the quantification formation of the voice spectrum.
of abnormalities of the voice. The currently avail- The process of calculating the CPP begins with an
able methods of acoustic analysis have not been as understanding of the voice signal."? The primary unit
successful as originally hoped in their abilities to of the voice signal is the sine wave (Fig 1). This wave
quantify the voice consistently and reliably. 1-3 Jitter has both a frequency and an amplitude. The frequency
(frequency perturbation), shimmer (amplitude pertur- is the number of cycles the wave makes per second.
bation), and noise-to-harmonic ratio (NHR) are the The amplitude is the magnitude of deflection of the
most frequently used measures for acoustic analy-
2.0,--------------------,
sis. These measures rely on the ability to accurately
identify and track changes in fundamental frequency.
In the mildly dysphonic yet reasonably periodic voice,
this is possible. However, as the voice becomes in-
creasingly more dysphonic and less periodic, track-
ing changes in fundamental frequency becomes in-
creasingly difficult, and measures that rely on fre-
quency tracking are less reliable.
An ideal acoustic measure should be able to quan-
tify the voice signal independently, without relying
on frequency tracking or other variables that may
influence the accuracy of the measure. Such a mea- ·2.0~-,..___, _ __.-_....-~- .........-...._-..,_-~~
.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00 50.00
sure should be reliable, should correlate with the se-
Time(seconds)
verity of dysphonia, and should be reproducible. Cep-
stral peak prominence (CPP) may be one such mea- Fig 1. Graphic representation of simple sound wave.
From The Voice Center, Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago, Chicago, Illinois (Heman-
Ackah), the Department of Speech and Hearing Sciences, Temple University (Heuer), the American Institute for Voice and Ear Research
(Ostrowski, Horman, Baroody), and the Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University (Sataloff), Phila-
delphia, Pennsylvania, the Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota (Michael),
and the Department of Speech and Hearing Sciences, Western Michigan University, Kalamazoo, Michigan (Hillenbrand).
Presented at the meeting of the American Laryngological Association, Palm Desert, California, May 12-13,2001.
CORRESPONDENCE - Yolanda D. Heman-Ackah, MD, The Voice Center, Dept of Otolaryngology-Head and Neck Surgery, University of
Illinois at Chicago, 1855 W Taylor St (MC 648), Chicago, lL 60612.

324
 Heman-Ackah et al, Cepstral Peak Prominence 325

1O.;.Wa~v.::.e...:1~ ...,

A .'0'.&.- -'

Wave 2
10,......~--------------_,

Fig 2. Graphic representation of complex sound signal and its com-

ponent sound waves.

B .'0"-- -'

Wave 3
'o,:-:-:~---------------,

Complex Wave
0Nave 1 + Wave 2 + Wave 3 + Wave 4)
c ·'0-'--- --' 15-r--------------------,
Wave 4
10.,-------------------, 10

-10

·,0+-_-~_-~_-~_-~ _ ____l .15 ......_...-_...-_...-_ _- _ -......--,......--,...---....---1

00 500 1000 1500 20.00 2500 3000 3500 40,00 4500 5000 .00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00 SO.OO
Time (seconds) Time (seconds)
o E
wave in the positive and negative directions. The am- changing frequency is said to be periodic. If the fre-
plitude of the wave varies with intensity (which cor- quency varies inconsistently over time, the signal is
responds with loudness); more intense signals pro- said to be aperiodic.
duce larger amplitudes, and softer signals have small-
er amplitudes. The frequency of the wave correlates Most sounds in nature, including the human voice,
with the pitch. A signal that has a constant and un- are complex signals; that is, they consist of several
326 Heman-Ackah et al, Cepstral Peak Prominence

Harmonic
Fundamental Frequency
110
I 110

100
Frequency
I 100

""'"' 90 90
/Xl ""'
/Xl"'
"'0
'-" ~
;;... 80
...;;... 80
.'::: .iii
en
c
....sc
-
sc 70

60
0 70

60

50 Background Noise 50

40 40
0 1 234 5 0 1 2 3 4 5
Frequency (kHz) Frequency (kHz)
A B
Fig 3. Spectral representations of A) normal and B) severely dysphonic voice signals.

sine waves of different frequencies and amplitudes
that, when added together, produce one complex sig-
nal (Fig 2). Each ofthese component sine waves has
an amplitude and a frequency. When the amplitudes
of each of the component waves are added together
at any given moment in time, the amplitude of the
complex wave at that moment in time is derived. If
the amplitudes of the component waves are graphed
as a function of frequency, the amplitude (or power)
spectrum is produced (Fig 3A). The representation
ofthe complex wave is graphed in the "time domain";
that is, amplitude is graphed as a function of time.
The representation of the spectrum is graphed in the
"frequency domain," in which amplitude is graphed
as a function of frequency. The process of transfor-
mation of the initial voice signal from the time do-
main to the frequency domain is called Fourier trans-
formation.s? Often, the amplitude in the spectral rep-
resentation is a logarithm of the amplitude rather than
the absolute amplitude. By use of the logarithm,
greater resolution of the difference between smaller
amplitudes and larger amplitudes is obtained.
The human voice is modified, in part, by resona-
tors in the vocal tract. Each voice has a fundamental
frequency that is determined primarily by the vocal
folds. The fundamental frequency has the largest am-
plitude of all of the frequencies in the voice spec-
trum and corresponds to pitch. There are also other
frequencies that are amplified by the resonators in
the vocal tract and that are usually multiples of the
fundamental frequency. These also produce charac-
teristic amplitude peaks in the spectrum and are re-
ferred to as the harmonic frequencies. Because the
human voice is not perfectly periodic, there are usu-
ally low-amplitude sound energies in a continuum
of frequencies in the spectrum. With a relatively pe-
riodic voice, the peaks of the fundamental frequency
and the harmonic frequencies are distinctly higher in
amplitude than the background noise energy (Fig 3A).
With an aperiodic voice, there is no definable funda-
mental frequency, and the amplitude is relatively
equally distributed across many frequencies (Fig 3B).
If a Fourier transformation of the spectrum is per-
formed, a cepstrum is produced (Fig 4). Thus, the
cepstrum is a spectral representation of the spectrum.
In producing a cepstrum, the spectrum is thought of
as a complex waveform that is the summation of
many smaller component sine waves. Each of these
sine waves also has an amplitude and a "frequency."
To avoid confusion in terminology, No1l4,5 renamed
the "frequency" of each of the component waves of
the spectrum, and called it "quefrency." Quefrency
is the frequency of the occurrence of the frequency
in the power spectrum; the unit of measurement is
cycles per frequency, which is seconds. When the
amplitude of each of the component waves of the
spectrum is graphed as a function of quefrency, the
cepstrum is produced, and the resultant Fourier trans-
formation has taken the information in the spectrum
(the frequency domain) and transformed it to a time
(quefrency) domain.
The predominant peak in the cepstrum is the fun-
damental period of the spectrum. The fundamental
period is the quefrency ("frequency") of the domi-
nant sine wave of the complex wave termed the spec-
trum, just as the fundamental frequency is the fre-
quency of the dominant sine wave of the complex
wave termed the voice signal. The smaller-amplitude
peaks in the cepstrum are called rhamonics.t-' A high-
ly periodic voice signal will have a strong peak at
 Heman-Ackah et al, Cepstrai Peak Prominence 327

Fundamental
Frequency Harmonic
Freq~nCieS
110 \ / 95
/
Cepstral Peak
(fundamental period)
(CPPS-IaJ = 12.3 dB)
100
--.
~ 90
"0
'-'
...>.
'iii 80
Q
2 Rhamonic periods
.s 70
80
/' J
60

50 75
0 1 2 3 4 5 o 5 10 15 20
Frequency (kHz) Quefrency (ms)
Spectrum Cepstrum
Fig 4. Spectral and cepstral representations of normal voice signal. ePPS-lal - smoothed cepstral peak prominence for sus-
tained vowel phonation.

the fundamental frequency and at multiples of the quefrencies (Fig 6).

fundamental frequency in the voice spectrum (Fig
4). These peaks will occur at regular intervals. This
interval corresponds to the fundamental period of the
cepstrum. Thus, a large-amplitude peak is seen at
the fundamental period.
An aperiodic or weakly periodic voice signal will
have multiple similar-amplitude peaks in the voice
spectrum at many frequencies, without any definite
pattern or defined intervals. A weakly periodic sig-
nal will produce a very low-amplitude cepstral peak
(Fig 5). The cepstrum of an aperiodic signal will dem-
onstrate multiple similar-amplitude peaks at many
The cepstral peak is the peak in the cepstrum with
the highest amplitude. When a linear regression line
that represents the average sound energy is drawn
through the cepstrum, the distance from the cepstral
peak to this linear regression line is termed the CPP.
This linear regression line is drawn to normalize for
variability in amplitude of phonation from one per-
son to another, as well as from one testing situation
to another within the same person.s-? Without this
linear regression line, a speaker with a weakly peri-
odic voice who is talking at 70 dB will produce a
cepstral peak that is greater in absolute amplitude

110 95

100
--. 90 Cepstral Peak
--. ~ / (CPPS-IaJ = 5.6 dB)
~ 90 "0
"0 '-'

-
'-' a.l
>.
'r;;
Q
80 ...
"0
;:j

'2
85
2
-
0()
c:: ell
70 ::E
80
60

50 75
o 1 2 3 4 5 o 5 10 15 20
Frequency (kHz) Quefrency (ms)
Spectrum Cepstrum
Fig 5. Spectral and cepstral representations of moderately dysphonic voice signal.
328 Heman-Ackah et ai, Cepstral Peak Prominence
110
100
r-.
a:l 90
~
0 Cepstral Peak
';ji 80
t:
-
~
t:
70
60
50
0 1 2 3 4 5
Frequency (kHz)
Spectrum
Fig 6. Spectral and cepstral representations of severely dysphonic voice signal.
than a speaker with a very periodic voice who is talk-
ing at 50 dB because of the loudness of phonation
rather than because of the prominence of the peak.
Thus, the addition of the linear regression line al-
lows one to determine the magnitude of the cepstral
peak in relation to the amplitude of phonation and
allows for objective comparison from one testing
situation to another without having to account for
differences in loudness of phonation, microphone dis-
tance, or recording level. A highly periodic voice sig-
nal will have a high-amplitude CPP, and a weakly
periodic or aperiodic voice signal will have a low-
amplitude CPP.
Although the idea of the cepstrum was first intro-
duced by No1l4,5 in 1964, the lack of high-speed com-
puters made calculating the cepstrum cumbersome
and time-consuming. In 1994, Hillenbrand et a1 6 de-
veloped an automated method of calculating the cep-
strum using the high-speed capabilities of modern
computers. In addition, the concept of the linear re-
gression line was added as a means of normalizing
the measure for purposes of comparison, and the use
of the CPP was introduced.v A smoothing feature was
added in 1996 to produce the smoothed CPP (CPPS),
in which the individual cepstra are averaged over a
given number of frames before and after the frame
of interest. 7
Both CPP and CPPS were shown to be reliable
indicators of breathiness in 2 separate samples of 20
voice signals that were analyzed perceptually with
regard to the quality of breathiness.v-? Subsequently,
in a sample of 38 dysphonic voices, it was found
that the CPPS reflected overall dysphonia most
strongly, although it continued to correlate well with
breathiness.I" The limitation of each of these earlier
95
....-- (CPPS-faf = 0.\ dB)
80
75
o 5 10 15 20
Quefrency (ms)
Cepstrum
studies was that the small number of voice samples
did not provide sufficient information regarding a
wide range of dysphonic and normal voices; thus,
the range of CPP values in the population remains
unknown, as does the ability of the CPP to differen-
tiate normal from abnormal voices in the general pop-
ulation reliably. The purposes of this study were to
determine the ability of the CPP to predict severity
of dysphonia reliably, to determine the reliability of
the CPP in predicting dysphonia relative to other
acoustic measures, and to determine the range of nor-
mal and abnormal values of CPP.
METHODS
Voice samples from 281 consecutive patients who
presented for objective voice analysis during 1999
at the senior author's (R.T.S.) private laryngology
and professional voice practice were used in this
study. The patients ranged in age from 7 to 80 years;
the mean age was 43 years. Of the 281 patients, 176
were female and 105 were male. The voice samples
had been recorded on an analog tape recorder at the
time of initial patient presentation. All recordings
were performed with the microphone positioned 6
inches from the mouth and consisted of sustained
vowel and running speech phonation. I I The sustained
vowel samples were digitized at a 50-kHz sampling
rate with the Computerized Speech Laboratory (CSL)
system (Kay Elemetrics, Pine Brook, New Jersey).
The samples were edited to include only the second
I-second portion of the /a/. Samples of running speech
were taken while the patients were reading the "Mar-
vin Williams" passage. All patients had been in-
structed to begin the reading of the passage with reci-
tation of the title. The running speech samples were
digitized at a 25-kHz sampling rate and edited by

TABLE 1. INTER-RATER RELIABILITY
Rater Grade Breathiness Roughness
1 0.92 0.91
2 0.87 0.79
3 0.92 0.84
4 0.87 0.83
5 0.94 0.88
6 0.88 0.80
7 0.92 0.86
8 0.92 0.89
9 0.94 0.87
10 0.92 0.90
Mean 0.91 0.86
Cronbach's coefficient 0:, p < .001 for each.
means of the CSL to consist only of the portion of
the passage containing the first sentence ("Marvin
Williams is only nine").
Perceptual Analysis. Ten individual speech-lan-
guage pathologists and voice specialists performed
perceptual ratings of the samples of running speech
in a blinded fashion. Each of the raters had a mini-
mum of 3 years of professional experience special-
izing in voice disorders; the range was 3 to 25 years.
Three of the raters had their professional practices
in Philadelphia, Pennsylvania; the other 7 had their
professional practices in Minneapolis, Minnesota,
and its surrounding areas. The raters were separated
into 3 groups of 3, 3, and 4 raters each. The 3 raters
in Philadelphia constituted I group, and the Minne-
apolis area raters constituted the other 2 groups. Rat-
ers whose experience and expertise in voice analy-
sis were well known to the authors were chosen to
rate the samples. The raters were chosen from 2 geo-
graphically separate areas of the country to help to
minimize the effect of regional bias on the percep-
tual ratings.
Each of the groups underwent an initial training
session separate from the other groups. During the
training session, the raters were given general defi-
nitions of grade, roughness, breathiness, and strain.
Nineteen standardized voice samples with various de-
grees of overall dysphonia (grade), roughness, breath-
iness, and strain were presented, and the raters were
asked individually to rate these samples. Each of the
voice samples was rated in the categories of grade,
roughness, breathiness, and strain by means of a
GRBAS-like scale. Severity in each category was
quantified by a mark on a 100-mm line from most
normal (0) to most abnormal (100). The distance in
millimeters from the end of the line designated "most
normal" to the rater's mark represented the numeri-
cal rating of the voice sample. After the raters made
their initial judgments of the training samples, they
were asked to discuss their ratings with the other
members of their group and to come to a consensus
Heman-Ackah et al, Cepstral Peak Prominence 329
regarding the definitions of grade, roughness, breath-
Strain iness, and strain, as well as the relative severities of
0.85 0.82 each in the training voice samples. The separation of
0.76 0.79 the raters into 3 groups allowed for the possibility of
0.83 0.87 greater variability of definitions of grade, roughness,
0.83 0.84 breathiness, and strain that were based more on the
0.84 0.89 background of the raters than on a single unified group
0.83 0.82 definition. The goal of doing so was to gain percep-
0.73 0.83 tual ratings more representative of many speech-lan-
0.82 0.87 guage pathologists and voice specialists than of one
0.92 0.88
particular region or style of analysis.
0.82 0.83
0.82 0.84 After the initial training period, the 3 groups were
asked to rate the running speech portions of the study
voice samples. The Philadelphia group rated each of
the 281 voice samples. However, because of time and
scheduling constraints, the 2 Minneapolis groups
each rated only the first 145 of the voice samples.
The samples were arranged randomly and presented
to the raters in a blinded fashion. There were no sig-
nificant differences in the quality or character of the
voices between the first 145 voices that were ana-
lyzed by all of the raters and the second 136 voices
that were rated only by the Philadelphia group. Each
of the 10 raters analyzed the voice samples individu-
ally. None of the raters were allowed to discuss their
ratings of the study voice samples with any of the
other raters in their group. Each of the groups rated
the samples on separate occasions so that none of
the members from one group ever had contact with
the members of the other groups. Each of the voice
samples was rated in the categories of grade, rough-
ness, breathiness, and strain in a manner similar to
the methods used in the training session.
Acoustic Analysis. Each of the 281 sustained vowel
samples underwent acoustic analysis using conven-
tional measures of jitter, shimmer, and NHR. Per-
cent jitter, relative average perturbation (RAP), and
smoothed pitch perturbation quotient (sPPQ) are
measures of jitter; the RAP measures short-term fre-.
quency perturbation, and the sPPQ measures long-
term frequency perturbation. The amplitude pertur-
bation quotient (APQ) is a measure of amplitude per-
turbation or shimmer. The NHR is a ratio of the am-
plitude of the portion of the voice signal that is pri-
marily aperiodic to that portion of the voice signal
that is primarily periodic. These measures were ob-
tained with the Multi-Dimensional Voice Program
(MDVP) model 4300B (Kay Elemetrics).
The CPPS was obtained from both the running
speech and the sustained vowel samples. The CPPS
software was designed by one of the co-authors
(J.H.).6,7 The CPPS uses larger windows for smooth-
ing of samples of sustained vowel phonation than it
does for samples of running speech." The CSL-digi-
330 Heman-Ackah et al, Cepstral Peak Prominence
60 6O~---------------,

50 50
til
.!e III
Q. Ci
E 40 ~4O
<1l
(/) (/)

e'5.~ 30
.~
.g 30
'0
Gi
.0 20 ~E 20
E
:::J :::J
Z Z
10 Std. Dey = 25.18 10 Std. Dey = 23.04
Mean=372 Mean =20.0
0 N" 281.00 . . . . . . . . . . . . . N=281.00
00 "00 ~oo U'qo '90 ~o 600 ">00 ~o "bo "'t?o "00 ~oo V'°o ~o ~o 6'00 ">00 600 "bo "'t?o
0
Mean Grade Score Mean Breathiness Score
A B
60 6O~-------------,

50 50
til til
Ql Ql
Ci Ci
E 40 E 40
<1l
(/) ~
Ql
.9
.g 30 g~ 30
'5 '0
Gi Gi
.0 20 .0 20
E E
:::J :::J
Z Z
10 Std. Dev .. 23.81 10 Std. Dey = 23.50
Mean-25.1 Mean =27.6
0 N-281.00 o N" 281.00
7. .=! Ul ..._ .~- 6J ~ 7.
"00 ~"o ~o ~o ~o 6'''0 ">"0
0'9_ .0..
00 00 «0 «0 """0 'T.:'o Po 00 q,o "0 6bo -lbo
V o V o
Mean Roughness Score Mean Strain Score
C D
Fig 7. Histograms of distribution of mean ratings of A) grade, B) breathiness, C) roughness, and D) strain for 281 voice
samples.

tized samples of running speech were inputted direct-
ly into the CPPS software for running speech; the re-
sultant value is termed the CPPS-s (CPPS for speech).
The sustained vowel samples were inputted directly
into the CPPS software for sustained vowels; the re-
sultant value is termed the CPPS-faf (CPPS for fa/).
DATA ANALYSIS
Perceptual Analysis. The inter-rater reliabilities of
the perceptual ratings of grade (overall dysphonia),
breathiness, roughness, and strain were determined
with Cronbach's coefficient ex (Table 1), which as-
sesses the correlation between each individual rater's
scores and that of the group, as well as the overall
inter-rater reliability.
The mean value of all raters for the first 145 voice
samples was considered the "gold standard" percep-
tual rating, as it represented the perceptions of sev-
eral speech-language pathologists and voice special-
ists from 2 regions of the country and was not thought
to be influenced greatly by regional bias. Because
the Philadelphia group was the only group that rated
each of the 281 samples, correlations between rat-
ings of this group and "the gold standard" (all rat-
ers) were performed to ensure that these raters' per-
ceptions were not significantly different from the
standard. Pearson's correlation coefficient was used
to determine the relationship between the mean rat-
ings of the Philadelphia group and the mean of all of
the raters for the first 145 voice samples. This corre-
lation was 0.968 for grade, 0.937 for breathiness,
0.930 for roughness, and 0.953 for strain (p < .001
for each). The correlation between the means of the
Philadelphia raters and those ofthe Minneapolis rat-
ers was 0.942 for grade, 0.879 for breathiness, 0.865
for roughness, and 0.906 for strain (p < .001 for each).
The mean perceptual rating of the Philadelphia rat-
 Heman-Ackah et al, Cepstral Peak Prominence 331

1.0,....----------------::,£;-----9---e- - 1.0,....-----------~- -,··_··& ···-(}--------8 .... •.. Q- ...-

.8 .8

sensitivity =.89 Sensitivity = .87

~ .6 Specificity = .77 >. .6 Specificity = .90
.z CPPS-fal s 10 dB :~ CPPS-ss 5.0
.~
j .4 c'3 .4

.2

O.O+-~~~~~~~~~-~,...._~~~~_t 0.0 <l!'-~~~__._~~~___,~~~~~~~__._--l

.00 .01 .02 .04 .14 .34 .71 .93 1.00 • • • ~ ro 3 ~ • 1•
~ ~ ro MD. ~ m .00 .00 .01 .01 .10 .48 .84 .99

FalsePositive Rate(1- Specificity) FalsePositive Rate(1 - Specificity)

A B
Fig 8. Receiver operating characteristic curves for A) smoothed cepstral peak prominence for sustained vowel phonation
(CPPS-fa!) and B) smoothed cepstral peak prominence for running speech (CPPS-s) as indicators of grade of dysphonia.

ers for each of the 281 voice samples was then used ber of severely dysphonic voice samples. Specific-
as the "rating" for the individual samples. For each ity was defined as the number of mildly dysphonic
of the perceptual categories, severity was divided into voice samples with values in the normal range di-
mild, moderate, and severe. Mild was defined as a vided by the total number of mildly dysphonic voice
rating between 1 and 33, moderate was defined as a samples. Positive predictive value was defined as the
rating of 34 to 67, and severe was defined as a rating ratio of the combined sum of moderately and severely
between 68 and 100. A histogram of the relative dis- dysphonic voice samples with abnormal test scores
tribution of the ratings for each of the perceptual cate- to the total number of voice samples with abnormal
gories is displayed in Fig 7. There were too few sam- values. Negative predictive value was defined as the
ples with ratings above 50 in the categories of breath- ratio of the number of mildly dysphonic voice sam-
iness, roughness, and strain for us to make inferences ples with normal test values to the total number of
about the ability of the acoustic measures to predict voice samples with normal test values. By use ofthe
any of these individual characteristics reliably. There- same definitions of sensitivity, specificity, positive
fore, only the perception of grade, which we defined predictive value, and negative predictive value, a re-
as overall dysphonia, was used as the standard against ceiver operating characteristic (ROC) curve was
which the acoustic measures were compared. drawn to determine the criteria for positivity for the
CPPS-s and CPPS-/a/.
Acoustic Analysis. Sensitivity, specificity, positive
predictive value, and negative predictive value were RESULTS
calculated for the percent jitter, RAP, sPPQ, APQ, The ROC curves for the CPPS-s and CPPS-/a/ as
and NHR by use of the values for the normal range measures of overall dysphonia (grade) are presented
given by MDVP as the defined normal values for in Fig 8. The CPPS-s and CPPS-/a/that gave the high-
these measures. Sensitivity was defined as the num- est values of both sensitivity and specificity were
ber of severely dysphonic voice samples with val- chosen as the criteria for positivity. The range of val-
ues in the abnormal range divided by the total num- ues for the CPPS-/a/ was 0 to 16.99 dB. The crite-
TABLE 2. SENSITIVITY, SPECIFICITY, AND PREDICTIVE VALUE OF ACOUSTIC MEASURES
Positive Negative
Predictive Predictive
Measure Sensitivity Specificity Value Value
Smoothed cepstral peak prominence for running speech 0.87 0.90 0.81 0.77
Smoothed cepstral peak prominence for sustained vowel phonation 0.89 0.77 0.69 0.80
Amplitude perturbation quotient 0.87 0.55 0.54 0.82
Percent jitter 0.70 0.87 0.74 0.76
Noise-to-harmonic ratio 0.50 0.96 0.83 0.69
Relative average perturbation 0.82 0.79 0.66 0.78
Smoothed pitch perturbation quotient 0.91 0.67 0.59 0.81
332 Heman-Ackah et at, Cepstrat Peak Prominence
rion for positivity for the CPPS-faf was 10 dB or low-
er, with values above 10 dB falling within the nor-
mal range. This criterion resulted in a sensitivity for
the CPPS-faf of 89% and a specificity of 77%. The
positive predictive value of the CPPS-faf was 69%,
and the negative predictive value was 80%. For the
CPPS-s, the criterion for positivity was 5.0 dB or
lower. The range of CPPS-s values was 0.76 to 8.13
dB. All values above 5.0 dB were deemed to be within
the normal range. By these criteria, the sensitivity of
the CPPS-s in detecting overall dysphonia was 87%,
and the specificity was 90%. The corresponding posi-
tive predictive value was 81 %, and the negative pre-
dictive value was 77%. The sensitivity, specificity,
and positive predictive and negative predictive val-
ues of the percent jitter, RAP, sPPQ, APQ, and NHR <
are presented in Table 2.
DISCUSSION
The assessment of a new diagnostic test must
" ...begin with the identification of a group of patients
known to have the disorder of interest, using an ac-
cepted reference test known as the gold stan-
dard."12(p34) The assessment of dysphonia relies on
perceptual judgments. There is no other reliable stan-
dard to measure dysphonia; thus, perceptual judg-
ments must be considered the gold standard. Because
there is an inherent bias in a rater's perceptions of
dysphonia based on an individual sense of aesthet-
ics, it is somewhat risky to use individual assess-
ments of dysphonia as the gold standard. This risk
was lessened in this study by using the perceptions
of 10 speech-language pathologists and voice spe-
cialists with extensive knowledge and experience in
the diagnosis of voice disorders. Although there is
some debate about the reliability of perceptual judg-
ments, the raters in this study were found to have a
remarkable degree of inter-rater reliability in the as-
sessment of overall dysphonia, with a mean correla-
tion of 0.91 (Cronbach's coefficient a, p < .00l).
Thus, the use of their perceptual ratings as the gold
staridard against which the other measures are evalu-
ated seems reasonable. Currently, there is no other
method of assessing the voice that has this degree of
reliability.
a
If diagnostic measure is to be clinically useful,
it should be able to distinguish reliably the diseased
state from the nondiseased state. The ability of the
ACKNOWLEDGMENTS - We thank Leslie Glaze, Nancy Solomon. Miriam van Mersbergen, Carol Rue. Lynne Conley. and Robert Grider for
their contributions to this study.
REFERENCES
1. Nichols AC. Jitter and shimmer related to vocal rough-
ness: a comment on the Deal and Emanuel study. J Speech Hear
Res 1979;22:670-1.
measure to do so is reflected in its sensitivity, speci-
ficity, and predictive values. If dysphonia is the dis-
ease of interest, the sensitivity of a measure of dys-
phonia is the percentage of patients with dysphonia
who have a positive test result. The specificity is the
proportion of normal patients who have a negative
test result. The sensitivity and specificity are not af-
fected by the prevalence of the disease in the popu-
lation of interest. 12 The predictive values of the test
give information regarding the interpretation of a
negative or positive test result. The positive predic-
tive value is the proportion of individuals with a posi-
tive test result who have dysphonia; the negative pre-
dictive value is the proportion of patients with a nega-
tive test result who are normal.
A comparison of the sensitivity, specificity, and
predictive values of the CPPS-s and CPPS-faf to those
of the APQ, percent jitter, NHR, RAP, and sPPQ re-
veals several interesting findings. The sensitivity of
the CPPS-s and CPPS-faf is similar to the sensitivity
of the APQ and sPPQ; that is, the proportion of pa-
tients with dysphonia who test positive on these 4
measures is on the order of 87% to 91%. However,
when one compares the predictive values of positive
tests using these measures, the CPPS-s and CPPS-faf
are better measures, with predictive values that are
81 % and 69%, respectively (versus 54% and 59%
for the APQ and sPPQ, respectively). Although the
positive predictive value of the NHR is similar to
that of the CPPS-s, the sensitivity of the NHR is con-
siderably lower than that of the CPPS-s or the CPPS-
lal (50% versus 87% and 89%), as is reflected in a
lower negative predictive value for the NHR. Al-
though the percent jitter and RAP have predictive
values that are similar to those of the CPPS-faf, both
of these measures lack the sensitivity and positive
predictive value of the CPPS-s.
CONCLUSIONS
The CPPS-s and CPPS-/a/ are good predictors of
dysphonia. Overall, the CPPS-s has better sensitiv-
ity, specificity, and positive and negative predictive
values than do measures ofjitter, shimmer, and NHR.
The software that measures the CPPS-s and CPPS-
[al is fast and relatively easy to use, and relies merely
on the transfer into the CPP program of acoustic sig-
nals captured by the CSL. The CPPS-s and CPPS-
fa/ are reliable measures that should become routine
in objective voice analysis.
2. Yumoto E. Sasaki Y. Okamura H. Harmonics-to-noise
ratio and psychophysical measurement of the degree of hoarse-
ness. J Speech Hear Res 1984;27:2-6.
 Heman-Ackah et al, Cepstrai Peak Prominence 333

3. Wolfe V,Fitch J, Cornell R. Acoustic prediction of sever-
ity in commonly occurring voice problems. J Speech Hear Res
1995;38:273-9.
4. Noll AM. Short-time spectrum and "cepstrum" tech-
niques for vocal-pitch detection. J Acoust Soc Am 1964;36:296-
302.
5. Noll AM. Cepstrum pitch determination. J Acoust Soc
Am 1967;41:293-309.
6. Hillenbrand J, Cleveland RA, Erickson RL. Acoustic cor-
relates of breathy vocal quality. J Speech Hear Res 1994;37:769-
78.
7. Hillenbrand J, Houde RA. Acoustic correlates of breathy
vocal quality: dysphonic voices and continuous speech. J Speech
Hear Res 1996;39:311-21.
8. Kersta LG. Amplitude cross-section representation with
the sound spectrograph. J Acoust Soc Am 1948;20:796-801.
9. Baken RJ, Orlikoff RF. Clinical measurement of speech
and voice. 2nd ed. San Diego, Calif: Singular Publishing Group,
2000:227-33.
10. Hernan-Ackah YD, Michael DO, Goding GS Jr. The re-
lationship between cepstral peak prominence and selected pa-
rameters of dysphonia. J Voice 2002; 16:20-7.
II. Price DB, Sataloff RT. Technical note. A simple tech-
nique for consistent microphone placement in voice recording.
J Voice 1988;2:206-7.
12. Knapp RG, Miller Me. Clinical epidemiology and bio-
statistics. Malvern, Pa: Harwal Publishing Company, 1992:31-
60.

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