The influence of pre-information on the rating of articulation.

This study evaluated whether pre-information influenced experienced and inexperienced speech clinicians' ratings of a child's articulation. All clinicans received the same written pre-information report, except that for one half of both groups the report ended with the statement that the child's articulation problem was mild-to-moderate and for the other half that is was moderate-to-severe. Each clinician completed a standard articulation inventory based on a video-tape presentation and then rated the child's articulation on a nine-point scale. Results on the rating scale were in the direction of the pre-information rating for each group, with the experienced groups' differences being statistically significant. Results on the inventory demonstrated the following : the expected shift for one experienced group, an unexplained very poor scoring of articulation errors by the other experienced group, and no significant difference between the inexperienced clinician groups. We conclude that on the more subjective task---the rating of an articulation problem--an examiner bias effect was noted, with the strongest effect being shown by the experienced clinicians. On the more specific tasks--articulation inventory--the results were equivocal.     

Predictors of future success in otolaryngology residency applicants

OBJECTIVE To evaluate the information available about otolaryngology residency applicants for factors that may predict future success as an otolaryngologist. DESIGN Retrospective review of residency applications; survey of resident graduates and otolaryngology clinical faculty. SETTING Otolaryngology residency program. PARTICIPANTS Otolaryngology program graduates from 2001 to 2010 and current clinical faculty from Barnes-Jewish Hospital/Washington University School of Medicine. MAIN OUTCOME MEASURE Overall ratings of the otolaryngology graduates by clinical faculty (on a 5-point scale) were compared with the resident application attributes that might predict success. The application factors studied are United States Medical Licensing Examination part 1 score, Alpha Omega Alpha Honor Medical Society election, medical school grades, letter of recommendation, rank of the medical school, extracurricular activities, residency interview, experience with acting intern, and extracurricular activities. RESULTS Forty-six graduates were included in the study. The overall faculty rating of the residents showed good interrater reliability. The objective factors, letters of recommendation, experience as an acting intern, and musical excellence showed no correlation with higher faculty rating. Rank of the medical school and faculty interview weakly correlated with faculty rating. Having excelled in a team sport correlated with higher faculty rating. CONCLUSIONS Many of the application factors typically used during otolaryngology residency candidate selection may not be predictive of future capabilities as a clinician. Prior excellence in a team sport may suggest continued success in the health care team.     

Effect of experience on judgments of adductor spasmodic dysphonia

OBJECTIVES: We performed a prospective, exploratory study 1) to determine differences in judgments of overall severity (OS) and vocal effort (VE) in adductor spasmodic dysphonia (ADSD) when judgments are made by experienced listeners, naive listeners, and speakers with ADSD; 2) to determine differences in judgments of listener comfort (LC) in ADSD when judgments are made by experienced and naive listeners; and 3) to determine relationships between auditory-perceptual ratings of voice and speakers' voice handicap. METHODS: Twenty speakers with ADSD provided speech recordings. They judged their own speech samples for OS and VE and completed the Voice Handicap Index (VHI). Twenty naive and 8 experienced listeners evaluated speech samples for OS, VE, and LC using rating scales. RESULTS: No differences were found for judgments of OS, VE, or LC across the groups. However, the strategies used by the speakers seemed to differ from those used by the other listeners in making OS and VE judgments. The speakers' self-judged VE correlated moderately with voice handicap; experienced and naive listeners'judgments were only weakly related to VHI scores. CONCLUSIONS: Speakers with ADSD and listeners appear to use auditory-perceptual dimensions differently. Voice handicap is best predicted by patient-perceived VE, and not by clinician or naive listeners' judgments.     

The reliability and validity of patient self‐rating of their own voice quality

Objectives: To provide preliminary data on the reliability and validity of dysphonic patients rating their own voice quality. Design: Prospective reliability/validity assessment of voice ratings in dysphonic patients. Setting: The Royal Free Hampstead NHS Primary Care Trust. Participants: Thirty‐five adult dysphonia patients recruited from ENT referrals to a speech and language therapy department. Exclusion criteria were (i) a hearing impairment which may affect auditory discrimination and (ii) a diagnosis of cognitive impairment which may affect task comprehension. Main outcome measures: Patient intra‐rater reliability was assessed by test–retest ratings, using G (Grade), R (Rough), B (Breathy), A (Asthenic), S (Strained) (GRBAS). Validity was assessed by comparing (i) patient–clinician inter‐rater reliability, (ii) patients’ GRBAS ratings with their Vocal Performance Questionnaire (VPQ) responses. Result: (i) Patients had lower intrarater reliability than clinicians (for G of GRBAS, kappa = 0.51 versus 0.74); (ii) patients consistently rated their voices more severely than clinicians (for G of GRBAS, mean rating = 1.4 versus 1.0); (iii) clinician–patient inter‐rater agreement was no better than chance (paired t‐test, all P < 0.05); (iv) patient ratings correlated significantly with vocal performance scores (r > 0.4, P < 0.05). Conclusions: Patients appear to have good validity and consistency using GRBAS as a self‐perception tool. However, validity measured in terms of agreement with clinician ratings is poor. Voice patients may rate what they perceive rather than what they hear. Disagreement between patient and clinician ratings has implications for therapy aims, prognosis, patient expectations and outcomes. Where disagreement persists, the clinician may have to determine whether therapy priorities need redesigning to reflect patients’ perceived needs, or to evaluate whether patient perceptions and expectations are unrealistic.     

Estimating subglottal pressure via airflow redirection

Subglottal pressure (SGP) is a valuable parameter in the research and clinical assessment of laryngeal function. The lungs serve as a constant pressure source during sustained phonation, and that pressure, SGP, can be used to determine the efficiency with which the larynx converts aerodynamic power to acoustic power. As the larynx serves as an aerodynamic transducer, the vocal efficiency (Ve) coefficient, defined as acoustic power (dB) divided by aerodynamic power (SGP x glottal airflow) has been shown to reliably reflect vocal health. However, current SGP measurement techniques are hesitantly used because of either an invasive nature or the requirement of intensive patient training. This study tests a novel device that has been designed to noninvasively estimate SGP through mechanical airflow redirection, producing a numeric output on completion of the trial, which lasts only a few seconds. The novelty of this design lies in the ease of use for both the patient and the clinician. Multiple mechanical airflow redirections occlude the airway for only 135 ms, which is predicted to limit the effect of confounding laryngeal reflexes that may occur during the trials. Additionally, the airflow redirection into a retention device allows for the pneumatic in-trial comparison of the estimated SGP with the pressure achieved by the patient, providing a numeric output to the clinician on completion.     

Endoscopic surgical management of sphenoid sinus disease.

OBJECTIVES: To assess the outcome of functional endoscopic sphenoid sinus surgery, and to determine the predictors of outcome. STUDY DESIGN: Retrospective chart review of 651 consecutive endoscopic sinus procedures performed between 1992 and 1997. SETTING: USC University Hospital, University of Southern California, Los Angeles. MATERIALS AND METHODS: Seventy-four patients (11.4% of all endoscopic procedures) with sphenoid sinus disease were selected. All 74 patients were mailed a sinusitis-specific questionnaire, and 46 of them (62.2%) responded. Outcome measures derived from clinician ratings were applied to all 74 patients, and those derived from self-report were applied to 46. Outcome measures were determined from patient questionnaires at a minimum of 6-month postoperative follow-up, operative complications, and clinician perceptual ratings. Patient questionnaires addressed general patient satisfaction, symptom score, and medication usage. A statistical analysis was performed using chi2 test, linear regression, and one-way nonparametric ANOVA. RESULTS: Favorable surgical outcomes based on general patient satisfaction (84.8%, n = 39) and clinician perceptual rating (78.4%, n = 58) were noted. Minor postoperative complications were noted in 10 patients (13.5%) and 8 patients (10.8%) needed revision endoscopic procedures during follow-up. Of the complications, eight (80%) occurred in revision endoscopic procedures. The use of an expanded, sinus-specific symptom score revealed far fewer favorable outcomes (56.5%, n = 26). Seven outcome predictors were established, although none of the predictors held for more than one of the six outcome measures used. CONCLUSION: Endoscopic sphenoid sinus surgery is safe and effective. An expanded symptom score is recommended to assess the outcome of this procedure.     

Grading system for the selection of patients with congenital aural atresia.

It is generally recognized that surgery for congenital aural atresia is difficult. In an effort to select those patients who have the greatest chance of success, we have developed a grading scheme based on the preoperative temporal bone CT scan and the appearance of the external ear. Patients are graded on a possible best score of 10. The stapes is assigned the highest rating (2 points), while all other entrees on the scale are 1 point. The grade assigned preoperatively has been shown to correlate well with the patient's chance of success, herein defined as a postoperative speech reception threshold of 15 to 25 dB. A patient with a preoperative grade of 8/10 would, therefore, have a 80 percent chance of achieving this threshold. Patients with scores of 5/10, or less, are not considered surgical candidates, because the risk of the operation would outweigh the potential benefits. We have found that the grading system allows us to avoid impossible surgical cases while allowing for a reasonable prediction of the hearing outcome.     

A randomized controlled trial: is water better than a standard lubricant in nasendoscopy?

Objectives: Previous studies have shown that nasendoscopy is made easier with the use of lubrication at the expense of the quality of the view obtained, but had no effect on the discomfort or pain experienced by the patient. We set out to determine whether the advantages of lubrication with a standard lubricant (KY Jelly) could be achieved by using water, without incurring the same disadvantages. Design: Single blind randomized controlled trial. Setting: Outpatient Departments at two District General Hospitals. Participants: One hundred and fifty participants selected sequentially from patients requiring a nasendoscopy where the endoscope would be passed far enough to view the larynx. Patients requiring topical anaesthetic were excluded. Methods: Patients were randomly assigned to have either water or standard lubricant applied to the nasendosope prior to nasendoscopy. Levels of pain experienced by the patient were recorded on a visual analogue score as well as visual analogue scores from the clinician for the levels of difficulty in passing the endoscope. All participants who were entered the study completed the study. Endoscopy was performed by all grades of medical staff. Main outcome measures: Levels of pain experienced by the participants were assessed by a visual analogue scale. Difficulty of passing the scope was indicated by the endoscopist using a visual analogue scale, as was the quality of image obtained. Results: Endoscopists found the insertion of the endoscope was easier and the image better when water was used rather than KY Jelly. There was no significant difference in reported in levels of pain experienced by the patient. Conclusion: Although the use of water as a lubricant during nasendoscopy confers no additional benefit in term of the levels of pain suffered by patients during the procedure, it makes the insertion of the endoscope easier and provides a better quality image than standard lubrication.     

Success and predictability of provox prosthesis voice rehabilitation

OBJECTIVES: To determine the success rate and relating clinical factors of voice prosthesis rehabilitation and to analyze the discrimination ability of the multidimensional Harrison-Robillard-Shultz Tracheoesophageal Puncture Rating Scale (HRS Rating Scale). DESIGN: Prospective clinical study. SETTING: University Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Inselspital, Bern, Switzerland. SUBJECTS AND METHODS: From 1992 through 1998, 87 patients with advanced squamous cell carcinoma of the larynx and/or hypopharynx underwent primary tracheoesophageal puncture after total laryngectomy. Clinician otolaryngologists and speech/language pathologists independently used the HRS Rating Scale for success assessment of voice prosthesis rehabilitation. RESULTS: Age, sex, tumor localization, tumor stage, and radiation therapy had no influence on the success of voice prosthesis rehabilitation. Overall, voice rehabilitation success rates between 40% and 62% were achieved. Speech/language pathologists and clinician otolaryngologists evaluated the same patient group without significant statistical differences. The HRS Rating Scale analysis showed an equal distribution of the subscale parameter care in functional and nonfunctional speakers and a strong correlation between the subscale parameters quality and use. CONCLUSIONS: Because of its safety and simplicity, tracheoesophageal puncture has become a state of the art method for voice rehabilitation after total laryngectomy. The short-term superiority of voice prosthesis in voice rehabilitation over esophageal speech rehabilitation must be seen in light of comparable long-term success rates of the 2 methods.     

Evaluation of poorly differentiated head and neck neoplasms. Immunocytochemistry techniques

Despite the use of strict morphologic criteria, some head and neck neoplasms remain classified as "poorly differentiated" or "undifferentiated." To circumvent this diagnostic quandary, newer techniques primarily based on immunocytochemistry are being utilized to study tumor specimens. These methods rely on the binding of specific antibodies to cellular antigens in order to better define the tumor according to cell type. We treated six patients in whom a definitive pathologic diagnosis could not be obtained without the use of immunohistologic stains. In each case, the definition of a specific tumor category altered patient management. The approach to the evaluation of patients with undifferentiated head and neck neoplasms is important. Close cooperation between the clinician and pathologist is necessary in such cases; this is assisted by a knowledge of the uses and limitations of the current diagnostic modalities being used, as well as proper tissue handling and processing.     

Development and validation of an individual supervisory conference rating scale for use in speech-language pathology

An Individual Supervisory Conference Rating Scale (ISCRS) was developed and validated to provide a conference rating instrument for researchers, supervisors, and supervisees in speech-language pathology. Procedures to determine both reliability and validity of the scale were implemented throughout the development process. Direct and indirect supervisory behaviors were identified as factors indicative of effective individual supervisory conferences by experts, trained raters, supervisors, and supervisees. Though these two major factors perceived as indicators of effectiveness remained consistent across groups rating the conferences, perceptions of those factors varied depending on the group rating the conference interactions. Ratings of the factors were strongly related for experts and trained raters; however, ratings for supervisees showed little or no relationship to the ratings of any of the other three groups. The Individual Supervisory Conference Rating Scale is suggested for use in research, supervisor self-analysis, and supervisor/supervisee joint analyses to measure perceptions of conference interactions and to determine perceived effectiveness.     

Cerclage sphincter pharyngoplasty: a new technique for velopharyngeal insufficiency

OBJECTIVES: Several surgical techniques are available for the treatment of velopharyngeal insufficiency (VFI). Each method has its own complications and non-dynamic roles. So the aim of this study was to present a novel physiological surgical technique designed by the author for reconstruction of the velopharyngeal sphincter in VFI. METHODS: This prospective study included six patients with VFI (two males and four females) with ages from 5 to 20 years (mean: 12.50 years). Speeches, nasopharyngeal and oral endoscopies for velopharyngeal valve closure were measured according to a 5-point scale where 0 was equivalent to normal and 4 meant a severe (constant) deviation. They were scheduled for cerclage sphincter pharyngoplasty after failure of appropriate speech therapy. Under general anaesthesia and the patient in semiflower's position; two level cerclages (1-0 polypropylene suture materials) were inserted behind the muscles of the velopharynx. The first at the level of junction of posterior and middle one-thirds of the soft palate passing through soft palate, left lateral pharyngeal wall, posterior pharyngeal wall, right lateral pharyngeal wall and the soft palate. The second was at 3mm in front of the latter. The surgical technique was described in details. RESULTS: Before surgery five patients (83.3%) had sever hypernasality (rating scale 3). After the cerclage operation and speech therapy four patients (66.6%) significantly improved to normal nasality (rating scale 0) and the remaining two patients improved to mild and moderate hypernasality (rating scale 1 and 2), respectively (p<0.05). By endoscopy the closing activity was (rating scale 3) in five patients (83.3%) and (rating scale 2) in one patient (18%). After the cerclage operation and speech therapy five patients (83.3%) changed significantly to complete closure (rating scale 0) and to (rating scale 1) in one patient (p<0.05). CONCLUSIONS: Cerclage sphincter pharyngoplasty is a new procedure designed by the author in VFI. It helps the velopharynx to function physiologically in three-dimensional patterns without dependency on the type of closure. Also it is an easy technique; without tissue flaps transfer, upper airway obstruction or hyponasality.     

Pain assessment of the intratympanic injections: a prospective comparative study

The objective of the study is to compare the pain level of three methods of intratympanic (IT) injections using prospective, randomized clinical study in a tertiary care center. 39 patients with Ménière’s disease and 30 patients with sudden sensorineural hearing loss are included. Excluded were patients treated for a chronic pain or those who took any pain killer for the last 24?h. Each patient received one IT injection a week, for three consecutive weeks. Three methods of IT injections were compared, with the application of EMLA cream on the tympanic membrane filling the external auditory canal 60?min before the procedure, with subcutaneous injection of lidocaine 1% with 1:100,000 epinephrine in the external auditory canal, and finally with an IT injection without any previous anesthesia. The pain intensity was immediately measured at 5?min, and then 45?min after the procedure, each time using four pain rating scales (visual analogue scale, numerical rating scale, verbal rating scale and categorical rating scale). No difference in pain intensity between the three methods of IT injections was detected by the visual analogue scale and numerical rating scale (p?>?0.05). 45.8% of patients preferred the IT injection without previous anesthesia. However, methylprednisolone has been associated with pain intensity greater than that of gentamicin 45?min after the injection (p?<?0.05). The IT injection performed without any previous anesthesia is an interesting option since it has not been shown to be more painful than the other methods of injections, and spares the patient from disadvantages associated with the anesthesia.     

Effects of clinician behaviors on acceptability of patients' responses in aphasia treatment sessions.

Records of the content of 40 videotaped samples of aphasia treatment sessions were prepared. These records were analyzed to determine (a) whether certain clinician behaviors and task characteristics are related to the occurrence of patient error responses in speech and language treatment sessions for aphasic individuals, and (b) whether "errors generate errors"; that is, whether error responses tend to occur in clusters rather than being distributed uniformly throughout the treatment session. The results of these analyses indicated that a number of event categories were significantly related to the occurrence of unacceptable patient responses. These results suggest that certain clinician behaviors generate patient error responses and also that clinicians tend to response to patient errors in characteristic ways. An analysis of these results also confirmed that unacceptable patient responses tended to occur in clusters.     

Measurement of hearing aid benefit in the elderly

Providing amplification is at the heart of most rehabilitation programs for the elderly. Given the importance of quality assurance, methods of quantifying hearing aid fitting success are needed. This study was designed to assess the adequacy of a self-assessment scale at measuring hearing aid benefit following a 3 week interval of hearing aid use. Forty-five new hearing aid users completed the Hearing Handicap Inventory for the Elderly (HHIE) prior to and following 3 weeks of hearing aid use. Results of the study showed a significant reduction in handicap following 3 weeks of hearing aid use, suggesting the feasibility of using the HHIE as an outcome measure for hearing aid success after a brief interval of hearing aid use. Subjects will be followed longitudinally to determine the best time frame in which to administer this scale.     

Evaluation of Nasal Patency: Comparison of Patient and Clinician Assessments with Rhinomanometry

The correlation between the objective measurement of nasal resistance and nasal airflow sensation is usually regarded as poor. The aim of the study was to assess the relation between objective indices of nasal patency, as assessed by the occlusion method (RN) and the Youlten peak nasal inspiratory flow meter (PNIF), with subjective sensations of nasal blockade by either the patient or the clinician in groups of patients with rhinitis, asthma, rhinitis and asthma, nasal septal deformity and in normal controls. We studied nasal airway patency in 254 subjects (37 women, 217 men), mean age 21 years (range 14-78) by RN and PNIF. Nasal resistance was also measured by the application of Ohm's law for parallel resistors (NRO) by estimating the unilateral resistance separately. Subjective sensation of nasal blockade was assessed either by the patient on a 10-point Borg scale (SUB), or the clinician (CLN) on a 6-point scale (3 for each side of the nose). The latter was done in a controlled fashion with the aid of reference sensations. Adjusting for age, height, smoking status and airway calibre, we found good correlation between RN and CLN (r=0.57, p=10     

The effect of visible speech in the perceptual rating of pathological voices

OBJECTIVE: To test a simple method for improving consistency among raters for the perceptual evaluation of pathological voice quality by providing visible speech (spectrogram) as additional information because, to date, the interrater variability still limits the widespread clinical use of the best available rating system. DESIGN: Experimental comparison between 2 different ways (with and without the addition of visible speech) of perceptual rating by trained professionals of recorded pathological voices. Furthermore, the correlation between acoustical (jitter, shimmer, and noise-harmonic ratio) and perceptual parameters was investigated in both rating conditions. SUBJECTS: Six experts evaluated 70 recorded pathological voices using the GIRBAS (grade, instability, roughness, breathiness, asthenicity, and strain) scale in 2 separate sessions: first, conventionally, without visible speech as additional information, and several months later, with visible speech as additional information. MAIN OUTCOME MEASURES: The kappa interrater agreement and the correlation coefficient between GIRBAS scores and acoustic measures. RESULTS: We found a significant effect of visible speech on the agreement between the raters. The interrater agreement according to kappa statistics was significantly stronger with the addition of visible speech than without for rating grade, roughness, and breathiness. The correlation between acoustical and perceptual parameters showed no significant effect of visible speech. CONCLUSIONS: The addition of visible speech to the perceptual evaluation of pathological voices is an interesting clinical asset to enhance its reliability. The addition of visible speech to the clinical setting is feasible, since affordable computer programs are currently available that can provide the spectrogram in quasi-real time while conversing with the patient. The acoustical analysis might be applied in addition to perceptual rating in a multidimensional approach to assess voice quality.     

Reliability of a rating scale used to distinguish direction of eye movement using infrared/video ENG recordings during repositioning maneuvers

The purpose of this study was to determine the validity of the nystagmus rating scale (NRS) and to assess inter- and intra-rater reliability of audiologists and experts using the scale. Face and content validity was established by eliciting feedback from two neurotologists and one neurologist. A training tape was developed to describe the rating scale and provide practice with patterns of nystagmus in benign paroxysmal positional vertigo (BPPV). Eye movements of 34 patients, ages 33 to 82 years, were videotaped using infrared/video ENG during repositioning maneuvers. Six randomly paired audiologists and six experts viewed the videotape recordings and completed the NRS for each pattern. Cohen's kappa coefficients were calculated to determine inter-rater reliability. The kappa values were 0.31 with 41% agreement for audiologists, and 0.48 with 59% agreement for experts. Intra-rater reliability for a subgroup of audiologists was 0.55 with 64% agreement, and for experts was 0.75 with 81% agreement. In summary, even in this experienced population, additional training in viewing nystagmus patterns is needed to improve reliability among clinicians during diagnosis and treatment.