The thyroid gland is positioned directly below the larynx in the anterior portion of the neck (Kumrow & Dahlen, 2002). The nerves and arteries of the thyroid and larynx are intertwined thus damage to one structure could easily affect the other structure. Thyroid dysfunction may also affect the histology of the larynx thus changing vocal quality (Stemple, 2010). This study measured vocal quality of patients with thyroid disease using the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V). Voice samples from 16 subjects with thyroid disease were compared to an age-matched group of 18 control subjects with no reported history of thyroid dysfunction. An experienced voice clinician rated each sample on the six parameters of the CAPE-V: overall severity, roughness, breathiness, strain, pitch and loudness. Statistical analysis of the results revealed a significant difference between the thyroid disease group and the control group for overall severity of vocal quality and vocal roughness. These results further strengthen the connection between thyroid disease and vocal dysfunction. Further research is warranted to explore the specific thyroid diagnoses that relate to vocal dysfunction, as well as to strengthen the findings on a larger population of participants. / Lori Lombard, Ph.D., CCC-SLP David Stein, Ph. D., CCC-SLP Jill Brady, Ph.D., CCC-SLP

Abstract There is a need in medicine and research for noninvasive, painless, safe and simple bed-side techniques to measure physiological processes associated with muscle function and activity. Bioelectrical Impedance Analysis (BIA) is a widely used, noninvasive, painless, safe and simple procedure for the measurement of body composition. However, although capable of producing accurate and reproducible data, it is known to be prone to movement artifacts. This poses the interesting question “Could impedance changes be used to monitor movement and, consequently, be related to muscle function or activity?” This project investigated the utility of impedance change as a monitoring technique for physiological processes that involve movement such as muscular contraction, the calf muscle pump, and swallowing. The impedance of leg muscle segments during locomotion, whilst riding a stationary exercise cycle, was measured at discrete frequencies and by bioimpedance spectroscopy to monitor muscle function or activity. Impedance traces were compared to information obtained by electromyography (EMG). Impedance, at a discrete frequency, was able to measure the cadence of cycling and its magnitude was related to the position of the pedal during the pedal cycle. When the cycling action was measured by bioimpedance spectroscopy, R0 and Zc showed a statistically significant difference, (p<0.05), between all angles of the pedal crank cycle while R∞ showed a statistically significant difference between angles in the lower hemisphere of the pedal crank cycle. The cyclical changes in impedance during cycling may be attributed to changes in shape and volume of the muscle during contraction as well as a volume change due to blood and lymph being pumped from the limb by the action of the calf muscle pump. Based on procedures used in the cycling studies, an impedance-based method for the measurement of calf muscle pump function during an exercise protocol, originally designed for use with air plethysmography, was developed. It was shown that impedance measured at 5 kHz provides a simple, non-invasive method for the measurement of the ejection fraction and ejection volume of the calf muscle pump as well as other haemodynamic variables. The impedance-based method was less technically challenging than accepted volumetric methods, such as air plethysmography and strain gauge plethysmography, and non-invasive c.f. ambulatory venous pressure, enabling it to be used repeatedly. Muscle function and activity is not confined to the legs so impedance changes in the arm and forearm during exercise were measured. Impedance measurements, at discrete frequencies and using bioimpedance spectroscopy, of the forearm during contractions of the hand were able to distinguish the difference between a ramp and a pulse contraction. When the impedance of the arm and forearm were plotted against the angle of the forearm to the horizontal during a bicep curl, there was an hysteresis effect. Impedance traces of a bicep curl were compared to an EMG trace of the same action. The larynx is a hollow muscular organ situated in the front of the neck above the trachea consisting of a framework of cartilages bound together by muscles and ligaments. The two major functions of the larynx are deglutition and phonation. Dysphagia, which is becoming more prevalent as the population ages, is defined as difficulty in swallowing thin liquids such as water or juices which splash into the trachea because the patient is unable to control the thin liquid bolus. Aspiration pneumonia and dehydration can be prevented by using thickened liquids which allow patients to achieve a safer swallowing response, but it is difficult to assess this response without interfering with the swallowing process. Impedance pharynography (IPG) is a technique using BIA to monitor an impedance waveform of the swallowing process that presents no radiation hazard to the patient, is non-invasive and does not require specialist trained personnel to operate it. Resistance changes across the neck were measured while subjects swallowed solutions of different viscosities. The resistance changes were distinctive and reproducible for each of the solutions of different viscosities which were swallowed. Measuring the function of the larynx by this method could be useful in the diagnosis and treatment of dysphagia. In conclusion, the studies described in this thesis demonstrate the potential usefulness of the measurement of change in impedance as a measure of muscle activity. Impedance-based methods can measure volume changes associated with changes in cross-sectional area of the muscles involved in contraction as well as compartmental fluid changes caused by the force of the contraction on the surrounding tissues including the vasculature. In particular, measuring the ejection fraction and other haemodynamic variables of the calf muscle pump by impedance has the potential to become the method of choice in the future because it is easy to use, inexpensive, non-invasive, safe, and hygenic. Measuring resistance changes across the neck during swallowing yields distinctive waveforms with features corresponding to the physiological phases of the swallowing process as well as identifying distinctive swallowing patterns associated with the different viscosities of liquids swallowed. Function of the larynx and the associated diseases of the larynx will potentially be easier to diagnose and treat with a safe, non-invasive, inexpensive, portable bed-side method of assessment such as BIA.

Abstract There is a need in medicine and research for noninvasive, painless, safe and simple bed-side techniques to measure physiological processes associated with muscle function and activity. Bioelectrical Impedance Analysis (BIA) is a widely used, noninvasive, painless, safe and simple procedure for the measurement of body composition. However, although capable of producing accurate and reproducible data, it is known to be prone to movement artifacts. This poses the interesting question “Could impedance changes be used to monitor movement and, consequently, be related to muscle function or activity?” This project investigated the utility of impedance change as a monitoring technique for physiological processes that involve movement such as muscular contraction, the calf muscle pump, and swallowing. The impedance of leg muscle segments during locomotion, whilst riding a stationary exercise cycle, was measured at discrete frequencies and by bioimpedance spectroscopy to monitor muscle function or activity. Impedance traces were compared to information obtained by electromyography (EMG). Impedance, at a discrete frequency, was able to measure the cadence of cycling and its magnitude was related to the position of the pedal during the pedal cycle. When the cycling action was measured by bioimpedance spectroscopy, R0 and Zc showed a statistically significant difference, (p<0.05), between all angles of the pedal crank cycle while R∞ showed a statistically significant difference between angles in the lower hemisphere of the pedal crank cycle. The cyclical changes in impedance during cycling may be attributed to changes in shape and volume of the muscle during contraction as well as a volume change due to blood and lymph being pumped from the limb by the action of the calf muscle pump. Based on procedures used in the cycling studies, an impedance-based method for the measurement of calf muscle pump function during an exercise protocol, originally designed for use with air plethysmography, was developed. It was shown that impedance measured at 5 kHz provides a simple, non-invasive method for the measurement of the ejection fraction and ejection volume of the calf muscle pump as well as other haemodynamic variables. The impedance-based method was less technically challenging than accepted volumetric methods, such as air plethysmography and strain gauge plethysmography, and non-invasive c.f. ambulatory venous pressure, enabling it to be used repeatedly. Muscle function and activity is not confined to the legs so impedance changes in the arm and forearm during exercise were measured. Impedance measurements, at discrete frequencies and using bioimpedance spectroscopy, of the forearm during contractions of the hand were able to distinguish the difference between a ramp and a pulse contraction. When the impedance of the arm and forearm were plotted against the angle of the forearm to the horizontal during a bicep curl, there was an hysteresis effect. Impedance traces of a bicep curl were compared to an EMG trace of the same action. The larynx is a hollow muscular organ situated in the front of the neck above the trachea consisting of a framework of cartilages bound together by muscles and ligaments. The two major functions of the larynx are deglutition and phonation. Dysphagia, which is becoming more prevalent as the population ages, is defined as difficulty in swallowing thin liquids such as water or juices which splash into the trachea because the patient is unable to control the thin liquid bolus. Aspiration pneumonia and dehydration can be prevented by using thickened liquids which allow patients to achieve a safer swallowing response, but it is difficult to assess this response without interfering with the swallowing process. Impedance pharynography (IPG) is a technique using BIA to monitor an impedance waveform of the swallowing process that presents no radiation hazard to the patient, is non-invasive and does not require specialist trained personnel to operate it. Resistance changes across the neck were measured while subjects swallowed solutions of different viscosities. The resistance changes were distinctive and reproducible for each of the solutions of different viscosities which were swallowed. Measuring the function of the larynx by this method could be useful in the diagnosis and treatment of dysphagia. In conclusion, the studies described in this thesis demonstrate the potential usefulness of the measurement of change in impedance as a measure of muscle activity. Impedance-based methods can measure volume changes associated with changes in cross-sectional area of the muscles involved in contraction as well as compartmental fluid changes caused by the force of the contraction on the surrounding tissues including the vasculature. In particular, measuring the ejection fraction and other haemodynamic variables of the calf muscle pump by impedance has the potential to become the method of choice in the future because it is easy to use, inexpensive, non-invasive, safe, and hygenic. Measuring resistance changes across the neck during swallowing yields distinctive waveforms with features corresponding to the physiological phases of the swallowing process as well as identifying distinctive swallowing patterns associated with the different viscosities of liquids swallowed. Function of the larynx and the associated diseases of the larynx will potentially be easier to diagnose and treat with a safe, non-invasive, inexpensive, portable bed-side method of assessment such as BIA.

Abstract There is a need in medicine and research for noninvasive, painless, safe and simple bed-side techniques to measure physiological processes associated with muscle function and activity. Bioelectrical Impedance Analysis (BIA) is a widely used, noninvasive, painless, safe and simple procedure for the measurement of body composition. However, although capable of producing accurate and reproducible data, it is known to be prone to movement artifacts. This poses the interesting question “Could impedance changes be used to monitor movement and, consequently, be related to muscle function or activity?” This project investigated the utility of impedance change as a monitoring technique for physiological processes that involve movement such as muscular contraction, the calf muscle pump, and swallowing. The impedance of leg muscle segments during locomotion, whilst riding a stationary exercise cycle, was measured at discrete frequencies and by bioimpedance spectroscopy to monitor muscle function or activity. Impedance traces were compared to information obtained by electromyography (EMG). Impedance, at a discrete frequency, was able to measure the cadence of cycling and its magnitude was related to the position of the pedal during the pedal cycle. When the cycling action was measured by bioimpedance spectroscopy, R0 and Zc showed a statistically significant difference, (p<0.05), between all angles of the pedal crank cycle while R∞ showed a statistically significant difference between angles in the lower hemisphere of the pedal crank cycle. The cyclical changes in impedance during cycling may be attributed to changes in shape and volume of the muscle during contraction as well as a volume change due to blood and lymph being pumped from the limb by the action of the calf muscle pump. Based on procedures used in the cycling studies, an impedance-based method for the measurement of calf muscle pump function during an exercise protocol, originally designed for use with air plethysmography, was developed. It was shown that impedance measured at 5 kHz provides a simple, non-invasive method for the measurement of the ejection fraction and ejection volume of the calf muscle pump as well as other haemodynamic variables. The impedance-based method was less technically challenging than accepted volumetric methods, such as air plethysmography and strain gauge plethysmography, and non-invasive c.f. ambulatory venous pressure, enabling it to be used repeatedly. Muscle function and activity is not confined to the legs so impedance changes in the arm and forearm during exercise were measured. Impedance measurements, at discrete frequencies and using bioimpedance spectroscopy, of the forearm during contractions of the hand were able to distinguish the difference between a ramp and a pulse contraction. When the impedance of the arm and forearm were plotted against the angle of the forearm to the horizontal during a bicep curl, there was an hysteresis effect. Impedance traces of a bicep curl were compared to an EMG trace of the same action. The larynx is a hollow muscular organ situated in the front of the neck above the trachea consisting of a framework of cartilages bound together by muscles and ligaments. The two major functions of the larynx are deglutition and phonation. Dysphagia, which is becoming more prevalent as the population ages, is defined as difficulty in swallowing thin liquids such as water or juices which splash into the trachea because the patient is unable to control the thin liquid bolus. Aspiration pneumonia and dehydration can be prevented by using thickened liquids which allow patients to achieve a safer swallowing response, but it is difficult to assess this response without interfering with the swallowing process. Impedance pharynography (IPG) is a technique using BIA to monitor an impedance waveform of the swallowing process that presents no radiation hazard to the patient, is non-invasive and does not require specialist trained personnel to operate it. Resistance changes across the neck were measured while subjects swallowed solutions of different viscosities. The resistance changes were distinctive and reproducible for each of the solutions of different viscosities which were swallowed. Measuring the function of the larynx by this method could be useful in the diagnosis and treatment of dysphagia. In conclusion, the studies described in this thesis demonstrate the potential usefulness of the measurement of change in impedance as a measure of muscle activity. Impedance-based methods can measure volume changes associated with changes in cross-sectional area of the muscles involved in contraction as well as compartmental fluid changes caused by the force of the contraction on the surrounding tissues including the vasculature. In particular, measuring the ejection fraction and other haemodynamic variables of the calf muscle pump by impedance has the potential to become the method of choice in the future because it is easy to use, inexpensive, non-invasive, safe, and hygenic. Measuring resistance changes across the neck during swallowing yields distinctive waveforms with features corresponding to the physiological phases of the swallowing process as well as identifying distinctive swallowing patterns associated with the different viscosities of liquids swallowed. Function of the larynx and the associated diseases of the larynx will potentially be easier to diagnose and treat with a safe, non-invasive, inexpensive, portable bed-side method of assessment such as BIA.

Submitted by Dândara Bernado Siqueira (dada_bs@yahoo.com.br) on 2018-03-13T14:31:53Z No. of bitstreams: 1 Dandara_Tese final.pdf: 9857869 bytes, checksum: 40f75a2d5e16a50c2c64d0caf112e97b (MD5) / Approved for entry into archive by Luciana Pizzani null (luciana@btu.unesp.br) on 2018-03-13T19:01:24Z (GMT) No. of bitstreams: 1 siqueira_db_me_bot.pdf: 9857869 bytes, checksum: 40f75a2d5e16a50c2c64d0caf112e97b (MD5) / Made available in DSpace on 2018-03-13T19:01:24Z (GMT). No. of bitstreams: 1 siqueira_db_me_bot.pdf: 9857869 bytes, checksum: 40f75a2d5e16a50c2c64d0caf112e97b (MD5) Previous issue date: 2018-02-27 / Introdução: A disfonia afeta 10% da população infantil, com pico de incidência entre cinco e dez anos, especialmente os meninos. Após essa faixa etária, observa-se uma mudança no comportamento com predomínio no sexo feminino. Os nódulos vocais são as lesões mais frequentes, seguidas pelos cistos. Além dessas, as alterações estruturais mínimas são alterações congênitas da laringe que também provocam disfonia, como por exemplo: sulco vocal, microweb, ponte de mucosa e cisto epidérmico. Não há consenso na literatura entre os autores quanto às indicações de microcirurgia de laringe em crianças, exceto nos casos de dispnéia e/ou estridor. Objetivos: Descrever nossa experiência com microcirurgia de laringe na infância e propor um protocolo de conduta terapêutica para as lesões mais prevalentes. Material e métodos: Estudo do tipo transversal que incluiu crianças de quatro a 18 anos atendidas em um hospital universitário nos últimos cinco anos com indicação de microcirurgia de laringe após um período de tratamento fonoterápico regular. Os critérios de exclusão foram: crianças que não permitiram videolaringoscopia, que perderam seguimento ou que realizaram fonoterapia irregular ou inconstante. Os resultados do tratamento foram avaliados após seis meses da cirurgia e classificados didaticamente em três tipos: melhora total (sem sintomas vocais e videolaringoscopia normal), melhora parcial (com algum grau de sintomas vocais e/ou lesões remanescentes ao exame videolaringoscópico) ou sem melhora (persistência de sintomas vocais na mesma intensidade e/ou lesão ao exame videolaringoscópico). Resultados: Foram selecionadas 119 crianças no estudo, com predomínio no sexo masculino até os 12 anos e do sexo feminino após essa idade. Destes, 29 pacientes foram submetidos à microcirurgia (M-14; F-15) com as seguintes indicações: cistos epidérmicos (n-12), nódulos vocais (n-12), sulco vocal (n-3), ponte de mucosa bilateral (n-1) e microweb (n-1). Todas as crianças foram previamente submetidas à fonoterapia de forma regular e a indicação cirúrgica se deu após o insucesso da mesma. Das crianças com nódulos vocais, houve indicação de microcirurgia em 15,38% dos casos com desfecho favorável em 75,00% deles. Dentre as crianças com cisto vocal, todas apresentavam o tipo epidérmico e nos casos cirúrgicos foi utilizada a técnica de microflap lateral. O sucesso da cirurgia nesses pacientes foi de 83,34%. Os casos de sulco vocal e ponte de mucosa realizaram microcirurgia somente após a puberdade e em nenhum caso foi observado resultado completamente satisfatório. Um único caso de microweb teve indicação cirúrgica com melhora apenas parcial. Conclusão: Apresentamos as principais indicações e os resultados da microcirurgia de laringe adotadas em nosso serviço em crianças disfônicas. Os resultados mais favoráveis foram observados nos casos de cistos e nódulos vocais e a partir deles elaboramos um fluxograma de condutas terapêuticas, que resultou em um protocolo que poderá ser compartilhado por outros autores, a fim de se determinar o melhor tratamento para as disfonias da infância. / Introduction: Dysphonia affects 10% of children, with a peak incidence of five to ten years, especially in boys. After this age group, there is a change in behaviour with predominance in females. Vocal nodules are the most frequent lesions, followed by cysts. In addition, minimal structural alterations are congenital alterations of the larynx that also causes dysphonia, such as: vocal sulcus, microweb, mucosal bridge and epidermal cyst. There is no consensus in the literature among the authors regarding indications for laryngeal microsurgery in children. Propose: To describe our experience with childhood laryngeal microsurgery and propound a protocol of therapeutic management for the most prevalent lesions. Material and methods: A cross-sectional study including children aged four to 18 years who were attended at a hospital university in the last five years with indication of laryngeal microsurgery after a period of regular voice therapy. The exclusion criteria were: children who did not allow videolaringoscopy, who lost follow-up or who performed irregular or inconstant voice therapy. The results for the treatment were evaluated after six months of surgery and didactically classified into three types: total improvement (without vocal symptoms and normal videolaryngoscopy), partial improvement (with some degree of vocal symptoms and/or remaining lesions at the videolaryngoscopyexam) or no improvement (persistence of vocal symptoms in the same intensity and/or lesion to the videolaringocopy exam). Results: 119 children were selected inthe study, with predominance in males up to 12 years and females after that age. Of these, 29 patients underwent microsurgery (M-14; F15) due to: epidermal cysts (n-12), vocal nodules (n-12), vocal sulcus (n-3), bilateral mucosal bridge (n-1) and microweb (n-1). All children were previously submitted to regular voice therapy and the surgical indication was given after their failure. Of the children with vocal nodules, microsurgery was indicated in 15.38% of the cases with a favorable outcome in 75.00% of them. Of the children with vocal cyst, all of them presented with an epidermal cyst and in the surgical cases the lateral microflap technique was used. The success of the surgery in these patients was 83.34%. The cases of vocal sulcus and mucosal bridge performed microsurgery only after puberty and in no case was observed completely satisfactory result. A single case of microweb had surgical indication with only partial improvement. Conclusion: We presented the main indications and results of laryngeal microsurgery adopted in our service in dysphonic children. The most favorable results were observed in cases of cysts and vocal nodules, and from them we developed a flowchart of therapeutic conducts, wich resulted in a protocol that could be shared by other authors in order to determine the best treatment for childhood dysphonia.

Introdução: Para o tratamento das disfonias comportamentais associadas à tensão muscular são recomendadas técnicas de relaxamento cervical e laríngeo, concomitantemente à estimulação da onda de mucosa das pregas vocais, bem como adequação do fechamento glótico e suavização da emissão. Nesse sentido, o recurso da Estimulação Elétrica Nervosa Transcutânea (TENS), corrente elétrica aplicada por meio de eletrodos de superfície, tem sido utilizada no tratamento vocal de mulheres com nódulos vocais. Esta prática tem demonstrado bons resultados na qualidade vocal e na redução da dor muscular, porém, verifica-se escassez de comprovação científica dos seus efeitos somados à terapia vocal. Objetivo: verificar a efetividade da TENS de baixa frequência associada à terapia vocal no tratamento de voz em mulheres disfônicas. Método: Este estudo foi aprovado pelo Comitê de Ética em Pesquisa em Seres Humanos, número 556.273. Participaram 27 mulheres com nódulos vocais, de 18 a 45 anos de idade (média de 33 anos de idade), divididas, de forma randomizada, em: Grupo Experimental (GE) 13 mulheres que receberam 12 sessões de aplicação de TENS (pulso: 200 &#x3BC;s, frequência: 10 Hz, no limiar motor), com eletrodos posicionados no músculo trapézio - fibras descendentes e na região submandibular, bilateralmente, por 20 minutos, associada a 30 minutos de terapia vocal; e Grupo Controle (GC) 14 mulheres que receberam 12 sessões de aplicação de TENS placebo (mesmas condições do GE, incluindo posicionamento dos eletrodos, porém sem receber o estímulo em forma de corrente elétrica) por 20 minutos, associada a 30 minutos de terapia vocal. Todas foram submetidas à avaliação da qualidade vocal por meio das análises perceptivo-auditiva e acústica da voz; da laringe por meio de análise perceptivo-visual; autopercepção sobre a voz, qualidade de vida por meio do protocolo de Qualidade de Vida em Voz (QVV); queixas e sintomas vocais/laríngeos e dor musculoesquelética, antes, imediatamente após o tratamento e um mês após. Resultados: Observou-se, após análise estatística, que não houve modificação da qualidade vocal em ambos os grupos tratados. Verificou-se na análise acústica diminuição do parâmetro acústico Índice de Fonação Suave (SPI) imediatamente após tratamento e um mês após, em ambos os grupos. Em relação à laringe, observou-se melhora do tamanho da lesão nas pregas vocais apenas no GE, imediatamente após tratamento e um mês após.Não houve diferença significativa quanto à qualidade de vida em voz, em ambos os grupos. Houve melhora na autopercepção da voz em ambos os grupos, após o tratamento, assim como os sintomas vocais/laríngeos e de dor musculoesquelética se apresentaram em menor ocorrência após tratamento e um mês após. Conclusão: A TENS de baixa frequência associada à terapia vocal foi efetiva em relação à diminuição da lesão das pregas vocais em mulheres disfônicas. A associação da TENS com a terapia vocal produziu resultados semelhantes à terapia vocal, em relação à qualidade da voz, autopercepção e qualidade de vida em voz, sintomas vocais e dor musculoesquelética. / Introduction: For the treatment of the behavior dysphonia associated muscle tension are recommended techniques of cervical and laryngeal relaxation, concurrently with stimulation of the mucosa wave of the vocal folds, such as adequacy of glottal closure and smoothing the emission. Thereby, the use of Transcutaneous Electrical Nerve Stimulation (TENS), electrical current applied through surface electrodes, have been used in the vocal treatment of women with vocal nodules. This practice has shown good results in vocal quality and in reducing muscle pain, however, there are few scientific evidence about their effects added to voice therapy. Proposal: to verify the effectiveness of low frequency TENS associated with voice therapy on vocal quality and laryngeal dysphonic women. Methods: This study was approved by the Research Ethics Committee, number 556.273. Twenty seven women with vocal nodules participated, 18-45 years of age (mean 33 years), divided, randomly into: experimental group (EG) - 13 women who received 12 sessions of application TENS (pulse: 200 &#x3BC;s, frequency 10 Hz, motor threshold), with electrodes placed on the trapezius muscle descending fibers and submandibular area, bilaterally, for 20 minutes, associated with 30 minutes of vocal therapy; and Control Group (CG) - 14 women who received 12 sessions of application TENS placebo (same conditions as EG, including the placed of the electrodes, but without receiving the stimulus in the form of electrical current) for 20 minutes, associated with 30 minutes of vocal therapy. All were submitted to vocal quality through auditory perceptual and acoustic voice analyzes; ENT evaluation through visual perceptual analysis; vocal self-perception; voice-related quality of life through the Voice-Related Quality of Life Protocol (V-RQOL); complaints and vocal/laryngeal and musculoskeletal pain symptoms, before, immediately after treatment and one month after. Results: It was observed, after statistical analysis, that there was no change vocal quality in both treated groups. In the acoustic analysis, there was decrease of the Soft Phonation Index (SPI) parameter, immediately after treatment and one month after, in both groups. In relation to larynx, there was improvement in the size of the lesion on the vocal folds only GE, immediately after treatment and one month after. There was no significant difference in the voice related quality of life, in both groups. There was improvement in the vocal self-perception in both groups after treatment, as well as lower frequency of the voice/laryngeal and musculoskeletal pain symptoms present immediately after treatment and one month after. Conclusion: The low frequency TENS associated with vocal therapy was effective in the reduction of the size of the lesion on the vocal folds in dysphonic women. The association of the TENS with vocal therapy produced similar results to vocal therapy, in relation to vocal quality, self-perception and voice-related quality of life, vocal and musculoskeletal pain symptoms.

Orientadores: Lúcia Figueiredo Mourão, Helenice Yemi Nakamura / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-27T08:32:37Z (GMT). No. of bitstreams: 1 Nalesso_KarineSandalo_M.pdf: 1565659 bytes, checksum: f4ab75ad116aa663c627129c14198ae9 (MD5) Previous issue date: 2015 / Resumo: Disfonias funcionais são alterações de voz decorrentes do comportamento vocal e o uso impróprio da voz torna-se o principal desencadeador das disfonias. O tubo de ressonância flexível, considerado integrante dos Exercícios de Trato Vocal Semiocluído, é um dos possíveis tratamentos para alterações vocais, dentre elas as disfonias funcionais, por permite uma fonação de menor impacto, com economia vocal. O objetivo do presente estudo foi analisar o efeito do uso contínuo e exclusivo do tubo de ressonância flexível nos parâmetros acústicos da região glótica e nas medidas do trato vocal supraglótico em sujeitos com disfonia funcional, pré e pós-intervenção. Participaram adultos entre 20 e 50 anos, 10 mulheres e 2 homens, em oito sessões de terapia com frequência semanal. Os seguintes parâmetros acústicos foram analisados: média da frequência fundamental, jitter, shimmer, proporção harmônico-ruído, H1-H2 e ênfase espectral. Para análise dos frames de imagem do trato vocal, obtidos por videofluoroscopia, oito medidas foram analisadas: a medida de abertura de lábio absoluta, abertura de mandíbula, ápice do dorso de língua ao palato duro, raíz da língua á faringe, comprimento horizontal e vertical do trato vocal, nível glótico, medida entre epiglote e a terceira vértebra, pré e pós-terapia. A tarefa utilizada para as gravações da análise acústica e na videofluoroscopia foi a vogal /a/. Para análise acústica, cada parâmetro foi medido em três pontos distintos da vogal e para a análise dos dados de imagem cada parâmetro foi extraído cinco vezes de cada frame para garantir a confiabilidade dos dados obtidos. A análise comparativa dos parâmetros acústicos mostrou aumento na F0 para o grupo masculino (p<0,01) e diminuição de jitter após terapia exclusiva com tubo (p=0.04). Os demais parâmetros mostraram pequenas mudanças e estão próximos aos valores padrão para sujeitos sem alteração vocal. As medidas do trato vocal mostraram aumento após a terapia, porém, sem significância estatística. As vozes dos sujeitos estudados apresentam pouca alteração nos parâmetros mesmo durante a pré-avaliação. O método estatístico LDA apontou para um alto índice de previsão dos resultados nos dois momentos estudados, considerando o conjunto de dados analisados. O efeito do uso exclusivo e contínuo do tubo flexível de látex em sujeitos com disfonia funcional parece se relacionar, neste experimento, com a melhora da estabilidade da frequência dos ciclos glóticos e com o aumento do número de ciclos glóticos por segundo. Os resultados demonstram que o efeito é mais expressivo nos homens do que nas mulheres disfônicas, porém estudos com maior número de homens são recomendados. Observou-se que os efeitos acústicos e de imagem do uso prolongado e exclusivo do tubo de ressonância flexível podem ser diferentes dos resultados em estudos imediatos. Em relação aos parâmetros acústicos analisados o jitter e a F0 mostraram melhoras dos valores obtidos no momento pós-terapia. Quanto ao trato vocal o uso do Lax Vox, sugere expansão principalmente da cavidade oral. Assim, pode-se sugerir que a intervenção terapêutica exclusiva do tubo de látex melhora globalmente a atividade glótica e a supraglótica de pacientes com disfonia funcional / Abstract: Functional dysphonia is a voice disorder generated by an inappropriate vocal use. One of the semioccluded vocal tract exercises, the flexible resonance tube, is one of the exercises that can be used in the management of functional dysphonia. Using the flexible resonance tube in water generates a low impact between the vocal folds during phonation and it is known to induce the concept of vocal economy. The goal of this study was to analyze acoustical parameters and vocal tract images pre and post prolonged and exclusive use of flexible resonance tube therapy in adults with functional dysphonia. Method: Participated 8 women and 2 men with functional dysphonia who received eight voice therapy sessions using exclusively flexible resonance tube. The following acoustic parameters were analyzed: fundamental frequency mean, jitter, shimmer, harmonic-to-noise ratio, H1-H2 and spectral emphasis. The vocal tract images were analyzed with eight distance measurements: the absolute lip opening measures, opening jaw, tongue back from the apex to the hard palate, the tongue will pharynx root, horizontal and vertical length of the vocal tract, glottal level measured between the epiglottis and the third vertebra, were taken from the images recorded before and after voice therapy. The task used for the analysis was a sustained /a/ vowel and measurements were taken from three distinct points of the vowel. Voice recordings were taken for pre (at the first session) and post-test (at the end of the eighth session) purpose. Paired t-test (p <0.05) was used to compare the means of the parameters pre and post-treatment. A comparative analysis of the acoustic parameters showed increase in F0 for the male group (p <0.001). Jitter decreased after the vocal therapy process (p = 0.04). The other parameters presented results close to the typical range for subjects without voice disorders. The statistics method Linear Discriminant Analysis (LDA) showed a high level of prediction in characterizing the two studied moments. The effect of exclusive and prolonged use of the flexible resonance tube in subjects with functional dysphonia seems to be related, with improved stability of the frequency of glottal cycles and increased number of glottic cycle per second (higher F0). The results demonstrated a more significant effect on the men than women, but further studies with a larger number of men in the subject group are recommended. The effect of prolonged and exclusive use of flexible tube in patients with functional dysphonia seems to be related to the stabilization of glottal cycles of vocal fold vibration and the LDA results revealed that the use of Lax Vox can provide a global improvement, considering the acoustic and image parameters / Mestrado / Interdisciplinaridade e Reabilitação / Mestra em Saúde, Interdisciplinaridade e Reabilitação

The purpose of this study was to determine if speech language pathologists could reliably identify different perceptual variants of adductor spasmodic dysphonia (ADSD) using a classification system proposed by Bastian (2009). Audio samples of sustained vowel phonation, sentence production, passage reading, and conversation were pre-recorded from 16 patients with a primary diagnosis of spasmodic dysphonia. Four speech language pathologists specializing in voice disorders listened to the audio samples and identified the ADSD variant, the presence of co-occurring tremor, and overall severity of the voice disorder. Re-rating of half of the audio samples was conducted two weeks later. Inter-judge reliability for the diagnosis of ADSD variants was fair (©§ = 0.25). All four judges agreed on variant 19% (3/16) of the time, three judges agreed 62% (10/16) of the time, and two judges 19% (3/16) of the time. Inter-judge reliability agreement for identifying co-occurring tremor was fair (©§ = 0.35). All four judges agreed on the presence of co-occurring tremor 44% (7/16) of the time. Three judges agreed 50% (8/16) of the time. Inter-judge reliability for assessing overall severity was moderate (©§ = 0.41). Four judges agreed on overall severity 38% (6/16) of the time. Three judges agreed 19% (3/16) of the time. Two judges agreed 38% (6/16) of the time. Judges disagreed on overall severity 6% of the time (1/16). Further analysis revealed three sources of diagnostic discrepancies: 1) the co-occurrence of multiple perceptual characteristics that correspond to multiple variants, 2) the ambiguity in identifying co-occurring tremor, 3) misidentification of perceptually similar characteristics. Relevant spectrographic evidence was presented. Clustering and categorizing perceptual characteristics were proposed as a more reasonable approach to capture perceptual variation of ADSD to optimize clinical diagnosis and acoustic research.

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Introdução: A terapia vocal indireta pode ser dividida em direta e indireta. A Terapia Vocal Indireta (TVI) é composta por orientações a respeito de higiene vocal e mecanismos fisiológicos da produção da voz, orientando o indivíduo sobre hábitos inadequados para a voz. Já a terapia direta é constituída pela prática de exercícios vocais para aprimorar a qualidade vocal. A terapia direta, pode ser composta por diversos exercícios, dentre as diversas abordagens terapêuticas encontram-se os exercícios de função vocal (EFV), um grupo de exercícios que visa a melhora dos três subsistemas para a produção da voz: respiração, ressonância e fonação. Há ainda outros exercícios de trato vocal semiocluído (ETVSO), em que ocorre a semioclusão do trato vocal, possibilitando interação fonte/filtro por meio de mudanças na impedância do trato vocal. Estudos que comprovem a eficiência dos ETVSO em processo terapêutico são escassos. Acredita-se que uma proposta como essa poderá contribuir para a prática clínica. Proposição: Analisar os efeitos da aplicação de um protocolo de Exercícios de Trato Vocal Semiocluído (ETVSO) na qualidade vocal e autopercepção de indivíduos com queixa de fadiga vocal e diagnóstico de disfonia funcional, e comparar seus efeitos com os EFV e com TVI. Metodologia: Estudo clínico randomizado e cego. Participaram 27 voluntários (12 homens e 15 mulheres), com idades entre 18 e 50 anos, com queixas de fadiga vocal e disfonia funcional, divididos igualmente em três grupos: grupo experimental, com aplicação de ETVSO (GE), grupo de exercícios de função vocal (GEFV) e grupo de terapia indireta (GTVI). Após assinarem o termo de consentimento livre e esclarecido, os voluntários realizaram três avaliações nos seguintes momentos: antes da intervenção (M1), imediatamente após o término da intervenção (M2) e um mês após o término (M3). Foram avaliados o Índice de Fadiga Vocal (IFV), sensação de economia vocal, Índice de Desvantagem Vocal (IDV) e a qualidade vocal (análise perceptivo-auditiva e acústica). Para os três grupos, o protocolo de terapia foi composto por oito sessões, duas vezes/semana com duração de 35 minutos. Aplicou-se o teste ANOVA de medidas repetidas (p<0,05) e Tukey para comparação dos dados antes e após as intervenções e entre grupos. Resultados: Os resultados foram estatisticamente significantes para o fator momento para as seguintes variáveis: IFV (p<0,001), economia vocal (p=0,007), IDV (p<0,001). Para IFV e IDV houve redução dos escores em M2 que mantiveram-se em M3, porém, para economia vocal em M2 há aumento e M3 os valores tendem a aproximar-se de M1. A análise perceptivo-auditiva para Grau Geral e Rugosidade na vogal (p=0,015 e p=0,029) e na contagem (p=0,036 e p=0,039), mostraram que os grupos são diferentes entre si. Por fim, a análise acústica para frequência fundamental (p<0,001) demonstrou que mulheres possuem valores mais elevados que homens e que a Proeminência do Pico Cepstral-suavizada na emissão da vogal (p=0,019) em mulheres é menor que em homens. Conclusão: Em indivíduos com disfonia funcional e queixa de fadiga vocal, os ETVSO são tão efetivos em relação à autopercepção de fadiga vocal, economia vocal e desvantagem vocal quanto aos EFV e TVI. Da mesma forma que os EFV e a TVI, o protocolo de ETVSO apresentara nenhuma mudança na qualidade vocal na população estudada. / Introducion: The voice therapy can be divided into direct and indirect. The indirect vocal therapy (IVT) are vocal hygiene orientations and voice physiologic production orientations, making the subject aware of harmful vocal habits. The direct therapy can be composed by voice exercises, such as Vocal Function Exercises (VFE) that improve the voice production subsystems: breathing, resonance, and phonation. Another way of direct therapy is using the semi-occluded vocal exercises (SOVTE), these exercises enable better filter and source interaction by the means of acoustic impedance changes. Studies that use a SOVTE protocol are almost zero. Therefore it is believed that a SOVTE protocol can contribute to voice clinic. Objective: Verify the effect of the treatment with SOVTE protocol at self-assessment and voice quality in dysphonic subjects. Compare it with VFE and Vocal Hygiene Approach. Methodology: Randomized and blind clinical trial. Twenty-seven volunteers (12 men and 15 women) were included in this study. They aged between 18 to 50 years old, with vocal complaints about vocal fatigue, and they received the functional dysphonia diagnose. The volunteers were equally divided into three groups: Experimental Group (EG), Vocal Function Exercises Group (VFEG), and Indirect Vocal Therapy Group (IVTG). After they filled the consent form, they were assessed by the researcher at three moments: before the intervention (M1), immediately after it (M2), and one month after it (M3). The researcher used the Vocal Fatigue Index (VFI), selfassessment of the vocal economy, Vocal Handicap Index (VHI), perceptual, and acoustic analysis. For the three groups, the interventions happened twice per week (four weeks) and last 35 minutes. It was used Repeated measures ANOVA test (p<0,05) and Tukey Test. Results: There were statistically significant results in the moment factor for IFV (p<0,001), vocal economy (p=0,007), and VHI (p<0,001). In M2 there was a decrease in the IFV and VHI scores keeping to M3. The vocal economy improved in M2, whereas in M3 it decreases, tending to M1 values. Regarding perceptual analysis, for general degree and roughness in the sustained vowel (p=0,015 e p=0,029) and counting numbers (p=0,036 e p=0,039), they only show that the groups are different. In the acoustic parameter of the fundamental frequency (p<0,001), women show greater values than men and the Cepstral Peak Prominence-smoothed (p=0,019) women show a smaller value than men. Conclusion: The subjects with functional dysphonia e vocal fatigue complaints, the SOVTE protocol is effective as VFE and IVT, regarding vocal fatigue, vocal economy, and vocal impairment. All interventions groups did not have changes at voice quality in this population.