Monitoring treatment of vocal fold paralysis by biomechanical analysis of voice
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(2) and respiratory organs, and a periodic or quasi-periodic inspection of voice quality improvements. Sometimes other interventions as minor surgery are required. The inspection purpose is to evaluate the patient and the process. The surgical and physical interventions have a corrective character. The inspection process in itself has been based mainly on the ability of the speech therapist to subjectively evaluate certain aspects of patient’s voicing, as (timbre, loudness, mucosal wave presence, glottal closure, roughness, breathiness, grade of dysphonia, etc.), and produce a graduation on a specific scale [1] for further use in comparing subsequent inspections of patient’s voice production separated some weeks or even months. This methodology is prone to statistical dispersion due to its strong dependency on the specific circumstances affecting the speech therapist in the precise evaluation process (stress, rush, awareness, etc.). The work presented here is an exploratory study conducted to show the possibilities of using advanced signal processing tools to extract important biomechanical information from the patient’s voicing, which may provide objective indices to judge on the quality of voice and on the progress or regress of corrective treatment and complementary rehabilitation techniques. A longitudinal case of a patient having lost the phonation function as a collateral effect following a cardio-vascular major surgery has been studied using biomechanical indices to objectively evaluate voice restoration. Indices estimated using the tool BioMet®Phon [2] as pitch, jitter, shimmer, noise-to-harmonic or mucosal wave ratios, as well as vocal fold biomechanics and glottal closure during vowel phonation allow depicting a colourful and highly semantic diagram of the rehabilitative process. The paper is organized as follows: A brief overview of the technique fundamentals is given in section 2. A description of the treatment methodology is given in section 3. In section 4 results obtained from the study case are presented, and their potential use discussed. Conclusions are presented in section 5.. 2 Study Background The signal processing methodology of voice quality analysis used in the present study is adaptive vocal tract inversion to produce an estimate of the glottal source. Accurate spectral domain techniques [3] allow the estimation of a set of biomechanical parameters associated to a 2-mass model of the vocal folds [4]. More details of the study may be found in a twin paper in these same proceedings [5]. The template (a) shows the physiological structure of the vocal folds as a body composed by the musculis vocalis, and a cover or lamina propria and the visco-elastic tissues in Reinke’s space and the ligaments. The biomechanical model in (b) shows that the masses of the cover and Reinke’s space have been included in the cover masses Mcl and Mcr for the left (l) and right (r) vocal folds. Masses Mbl and Mbr account for the body and ligaments. It must be kept in mind that these masses are not distributed, but dynamic point-like ones. Visco-elastic parameters Kcl and Kcr explain the relations between tissue compression and acting forces on the cover and Reinke’s space. Parameters Kbl and Kbr are the same regarding the body and ligaments. Although the tool in itself produces a wide range of parameters (jitter, shimmer, NHR, mucosal/aaw, glottal source cepstral, spectral profile, biomechanical, OQ, CQ, RQ,. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
(3) glottal gap defects [3], tremor) the biomechanical parameters are by far the most interesting set to assess the dysphonic conditions both in modal voice as well as in singing voice. Having such description in mind, the subset of parameters used in the study is composed of the following correlates: • • • • • • • • • • • • • •. Parameter 1: Absolute Pitch evaluated by cycle clipping. Parameter 2: Relative jitter evaluated as the pitch difference between neighbor phonation cycles divided by their arithmetic average. Parameter 3: Relative shimmer evaluated as the area difference between neighbor glottal source cycles divided by their arithmetic average. Parameter 5: Noise to harmonic ratio evaluated as the ratio between the turbulent and harmonic contents of the glottal source cepstrum. Parameter 6: Ratio between the energy of the Mucosal to the average acoustic wave as defined by Titze [7], and described in [6]. Parameter 38: Unbalance of dynamic body mass per each two neighbor cycles. Parameter 40: Unbalance of body stiffness per each two neighbor cycles. Parameter 41: Dynamic mass associated to the cover averaged on the left and right folds (Mcl and Mcr). Parameter 43: Stiffness parameter associated to the cover averaged on the left and right folds (Kcl and Kcr). Parameter 44: Unbalance of dynamic cover masses per each two neighbor cycles. Parameter 46: Unbalance of cover stiffness per each two neighbor cycles. Parameter 60: Contact gap defect. Parameter 61: Adduction gap defect. Parameter 62: Permanent gap defect.. The estimation of the above parameters is carried out by inverting a 2-mass model the spectral domain as described in [6]. Examples of estimates from biomechanical parameters from a balanced database of 50 male and 50 female normative speakers collected and evaluated by endoscopy at Hospital Universitario Gregorio Marañón are given [5]. The irregular behavior of biomechanical or gap defect parameters bears a clear semantics on the presence of dysphonia in modal as well as in singing voice.. 3 Study Case: Materials and Methods The study case selected for analysis corresponds to a 40 years old female subject who suffered a work accident with cardiac and lung compromises requiring a transplant of aortic arch. She required 8-day intubation and posterior tracheotomy which was maintained during 2 weeks under sedative care. When she started talking after her stay in the ICU her voice was very airy and asthenic. Another associate symptom was dysphagia to liquid which improved shortly after. The rehabilitative process required a series of inspections and actions to be carried out being described in Table 1.. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
(4) Date 2010.09.14 (pre). Inspection Videostroboscopy, spirometry, vowel utterance recording.. 2010.11.02 (post1). Videostroboscopy, spirometry, vowel utterance recording.. 2011.02.22 (post2). Videostroboscopy, spirometry, vowel utterance recording.. 2011.05.03 (post3). Videostroboscopy, spirometry, vowel utterance recording.. 2011.06.21 (post4). Videostroboscopy, spirometry, vowel utterance recording.. Table 1. Study case treatment description Treatment Observations Rehabilitation: Convex left vocal fold ridge; strong 8 sessions of longitudinal hiatus; motionless left postural, waist, arytenoid; small mucosal wave; estimated shoulder and pitch: C2 (138 Hz); frequency span C2-G3 neck exercises, (138-392 Hz); loudness span: 55-90 dB; blow control, GRBAS: voiceless, rough (1), breathy (3), muscle toning. strain (1); impression: voiceless, hypophonic, no glottal clap; air capacity: 1800 cm3; espiration time: 34 s; phonation time: 3 s; airflow: 600 cm3/s. Rehabilitation: Slightly convex left vocal fold ridge; 8 sessions of important but reduced longitudinal hiatus; postural, waist, motionless left arytenoid; little more shoulder and mucosal wave; estimated pitch: E2 (165 Hz); neck exercises, frequency span: E2-E4 (165-659 Hz); blow control, loudness span: 55-100 dB; GRBAS: rough muscle toning. (1), breathy (2), strain; impression: voiceless, monotonous, no glottal clap; air capacity: 2400 cm3; espiration time: 25 s; phonation time: 3 s; airflow: 800 cm3/s. Rehabilitation: Slightly convex left vocal fold ridge; 4 sessions of reduced longitudinal hiatus; motionless left postural, waist, arytenoid; asymmetric and arrhythmic shoulder and mucosal wave; estimated pitch: F2 (175 Hz); neck exercises, frequency span: C2-E4 (138-659 Hz); blow control, loudness span: 55-100 dB; GRBAS: grade muscle toning. (3-4); rough (2); breathy (2); strain; no glottal clap; air capacity: 2700 cm3; espiration time: 35 s; phonation time: 5 s; airflow: 625 cm3/s. Treatment: Sligthly convex left vocal fold ridge; further intra-cord shot reduced longitudinal hiatus; motionless left of Radiesse arytenoid; asymmetric and arrhythmic mucosal wave; estimated pitch: E2 (165 Hz); frequency span: C2-E4 (138-659 Hz); loudness span: 55-100 dB; GRBAS: rough (2); breathy (2); strain; no glottal clap; air capacity: 2700 cm3; espiration time: 40 s; phonation time: 5 s; airflow: 625 cm3/s. Rehabilitation: Reports dyspnea during physical exercise; 6 sessions of straight reddish left vocal fold rigde; full postural, waist, glottal closure; motionless left arytenoid; no shoulder and mucosal wave in left fold; estimated pitch: neck exercises, E2 (165 Hz); C2-C4 (138-523 Hz); loudness blow control, span: 55-100 dB; GRBAS: grade (2); rough muscle toning. (1), breathy (1), strain; no glottal clap; air capacity: 2700 cm3; espiration time: 34 s; phonation time: 10 s; airflow: 270 cm3/s.. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
(5) Date 2011.09.05 (post5). Inspection Videostroboscopy, spirometry, vowel utterance recording.. Treatment. Observations Reports less dyspnea during physical exercise; full glottal closure although short contact phase, minimal longitudinal hiatus; motionless left arytenoid; small mucosal wave in left fold; estimated pitch: F2 (175 Hz); frequency span: D2-E4 (147-659 Hz); loudness span: 53-104 dB; GRBAS: grade (2), rough (1), breathy (2); no glottal clap; air capacity: 2800 cm3; espiration time: 34 s; phonation time: 10 s; airflow: 280 cm3/s.. Voice recordings were maintained vowel /a/ for as long as the patient could sustain phonation at 44100 Hz and 16 bits using a condenser table-supported Shure microphone and a SoundBlaster external sound card in the practitioner’s office. Results of the longitudinal analysis of the recordings using BioMet®Phon are given in the next section.. 4 Results and Discussion The analysis consisted in estimating the glottal source from voice after vocal tract inversion. The power spectral density of the voice signal and the glottal source were estimated subsequently. The results are shown in the set of templates in Fig. 1 to Fig. 6. In general it may be seen that the process of rehabilitation is able by itself of restoring the glottal source, from a very irregular asymmetric cycle (Fig. 1) to a more stable phonation although showing a large amount of inter-harmonics (Fig. 4). The shot of Radiesse directly in the left vocal fold is responsible of an almost complete restoration of the glottal source Liljencrants-Fant pattern [9], visible in Fig. 5, and especially in Fig. 6, these last figures showing a better display of the harmonic structure of voice, which is the last guarantee of timbre restoration.. Fig. 1 Evaluation dated 14.09.2010 (pre). Rough, asthenic and airy voicing. Top left: prototype glottal cycle, showing strong irregular openings and closings. Bottom left: neighbor irregular patterns showing strong asymmetric vibration. Top right: Power spectral density of voice. Formants signaled by turbulent noise. Bottom right: Power spectral density of the glottal source. Poor harmonic structure.. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
(6) Fig. 2 Evaluation dated 02.11.2010 (post1). Asthenic and airy voicing. Top left: prototype glottal cycle, showing turbulent glottal source. Bottom left: more regular neighbor patterns showing airy but less asymmetric vibration. Top right: Power spectral density of voice. Formants signaled by turbulent noise. Bottom right: Power spectral density of the glottal source. A very incipient harmonic structure is present.. Fig. 3 Evaluation dated 22.02.2011 (post2). Irregular cyclical voice pattern. Top left: prototype glottal cycle, showing reverted glottal L-F cycle. Bottom left: neighbor patterns showing low cyclical reverted patterns. Top right: Power spectral density of voice. Formants signaled by harmonic structure. Bottom right: Power spectral density of the glottal source. A well established harmonic structure is found up to 1800 Hz. Harmonic phonation is restored.. Fig. 4 Evaluation dated 03.05.2011 (post3). L-F cycle is restored. Top left: prototype glottal cycle, showing an adduction gap defect and short open phase compatible with vocal fold edema. Bottom left: more regular neighbor patterns. Top right: Power spectral density of voice.. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
(7) Spectrum indicates the presence of strong inter-harmonics. Bottom right: Power spectral density of the glottal source. The harmonic structure is instable showing inter-harmonics.. Fig. 5 Evaluation dated 08.06.2011 (post4). L-F cycle shows unbalance to the return phase. Top left: prototype glottal cycle, showing a better and fast return phase, but a contact gap defect. Bottom left: regular neighbor patterns. Top right: Power spectral density of voice. Spectrum indicates a clear expansion of the harmonic spectrum to 2500 Hz. Bottom right: Power spectral density of the glottal source. The harmonic structure is well established.. Fig. 6 Evaluation dated 05.09.2011 (post5). Better contact phase with some turbulence. Top left: prototype glottal cycle, showing a good return phase, the contact defect has been corrected. Bottom left: very regular neighbor patterns. Top right: Power spectral density of voice. Spectrum indicates an expansion of the harmonic spectrum to 3000 Hz but with a defect around 2200 Hz. Bottom right: Power spectral density of the glottal source. The harmonic structure is well established but there is still presence of turbulent noise.. The restoration process may also be observed in the behaviour of glottal source correlates: four perturbation parameters (jitter, shimmer, NHR, mucosal/aaw), four biomechanical ones, their unbalances, the contact, adduction and permanent gap defects, and pitch (totaling 16 estimates) evaluated for each recording taken at the 6 inspection sections given in Fig. 4. The parameters have been normalized to their respective means from the general normative database of 50 female subjects already mentioned [5]. It may be noticed that some parameters show almost no influence with the tone change, as the Cover Mass (41), Cover Stiffness (43), Contact Gap Defect (60) or Permanent Gap Defect (62) whereas others as the Body Mass Unbalance (38) or Body Stiffness Unbalance (40) reflect important changes.. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
(8) Fig. 7 Estimates of pitch and 12 perturbation and biomechanical parameters on the tonal span.. Some of these parameters are summarized as well in Table 2. As it may be seen Absolute Pitch (1) values follow the estimation of the practitioner given in Table 1, except in the pre and post3 cases. The pre estimation of pitch by BioMet®Phon may not be very accurate as the irregularity of the phonation pattern suggests that different estimates for pitch could be produced, the strongest peak in the power spectral density being possibly in better agreement with the practitioner’s estimate. The post3 disagreement may be attributed to a subjective estimation by the practitioner. Table 2. Comparing voice quality parameters from successive inspections Shimmer Body Mass Unb. Body Stiff. Unb. Add. Inspection Pitch (Hz) Jitter (%) (%) (mean, %) (mean, %) Gap (%) pre 74.08 34.50 35.20 88.12 113.05 54.21 post1 157.63 4.75 12.74 8.50 17.57 28.34 post2 177.10 3.13 7.93 6.87 13.08 45.95 post3 193.29 8.19 12.34 51.56 67.00 15.29 post4 157.08 4.82 3.77 12.19 21.13 24.34 post5 177.41 0.86 2.52 0.21 1.89 2.18. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
(9) Important facts to be stressed are the sensitivity of Body Mass Unbalance and Body Stiffness Unbalance to assess the dysphonic condition of the patient, relative to traditional perturbation parameters as jitter or shimmer. It may be seen that these parameters are highly correlated among themselves but Body Mass Unbalance amplifies much better the dysphonic condition, and attributes a semantic nature to the etiology of dysphonia, as when large it expresses that one of the vocal folds is much more involved in phonation than the other, and when lower it means that both vocal folds contribute similarly in the phonation cycle. The adduction gap has also a very important meaning, as it attributes dysphonic behaviour to the imperfections in the closing phase resulting from asymmetric vocal fold dynamics, therefore defects are not to be found during the contact phase or by a permanent air escape.. 5 Conclusions The results of the study unveil some of the reasons for deficient vocal fold behaviour in the recovery process, tracking quite carefully the rehabilitation process in producing objective measurements of the restoration of the phonation function performance based on the biomechanical description of the vocal folds. Due to the limitations of the present study based in the description of a single patient, statistical significance cannot be claimed. Nevertheless some interesting important findings may be remarked: • • •. •. Specific unbalance parameters as those associated to the vocal fold body mass and stiffness are of a crucial role in monitoring vocal fold paralysis. The sensitivity of these parameters to monitor the subjective observations of the laryngologist seems to be larger than classical perturbation parameters. The semantic value of these parameters is much larger than traditional perturbation parameters, as they not only monitor the phonation restoration process better, they but contribute as well to identifying possible causes of explanatory nature, associating asymmetry to vocal fold body or cover. Specific relevance should be attributed to glottal gap defects, with special emphasis in the adduction defect in this case.. Many other estimates can be obtained and included in a biomechanical study of singing voice, such as the distribution of the harmonic/noise factors, the open, close and return quotients, or the parameters of tremor and vibrato [8]. These would be especially relevant to investigate and characterize neurological disease leaving correlates in phonation. The next steps to be covered are to extend the methodology to a large database of organic pathologies to produce and test etiologic assessment and validation. Acknowledgments. This work is being funded by grants TEC2009-14123-C04-03 and TEC2012-38630-C04-04 from Plan Nacional de I+D+i, Ministry of Economic Affairs and Competitiveness of Spain.. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
(10) References 1. Yamauchi, E. J., Imaizumi, S., Maruyama, H., & Haji, T. (2010). Perceptual evaluation of pathological voice quality: A comparative analysis between the RASATI and GRBASI scales. Logopedics Phoniatrics Vocology, 35(3), 121-128. 2. Gómez, P., Rodellar, V., Nieto, V., Martínez, R., Álvarez, A., Scola, B., Ramírez, C., Poletti, D., and Fernández, M.: BioMet®Phon: A System to Monitor Phonation Quality in the Clinics. Proc. eTELEMED 2013: The Fifth Int. Conf. on e-Health, Telemedicine and Social Medicine, Nice, France, 2013, 253-258. 3. Gómez, P., Nieto, V., Rodellar, V., Martínez, R., Muñoz, C., Álvarez, A., Mazaira, L. M., Scola, B., Ramírez, C. and Poletti, D.: Wavelet Description of the Glottal Gap. Proc. of the 18th DSP Int. Conf., Santorini, July 1-3, 2013 (to appear). 4. Berry, D. A., “Modal and nonmodal phonation”, J. Phonetics, (29) 2001, pp. 431-450. 5. Gómez, P., Belmonte, E., Nieto, V., Rodellar, V.: Vocal Fold Biomechanical Analysis of the Singing Voice. Proc. of the 1st Multidisciplinary Conference of Users of Voice, Speech and Singing (JVHV 2013). Las Palmas de Gran Canaria, 27-28 June, 2013. 6. Gómez, P., Fernández, R., Rodellar, V., Nieto, V., Álvarez, A., Mazaira, L. M., Martínez, R, and Godino, J. I., “Glottal Source Biometrical Signature for Voice Pathology Detection”, Speech Comm., (51) 2009, pp. 759-781. 7. Titze, I. R. Summary Statement. Workshop on Acoustic Voice Analysis, National Center for Voice and Speech (1994). 8. Gómez-Vilda, P., Rodellar-Biarge, V., Nieto-Lluis, V., Muñoz-Mulas, C., MazairaFernández, L. M., Ramírez-Calvo, C., Fernández-Fernández, M. and Toribio-Díaz, E.: Neurological Disease Detection and Monotoring from Voice Production. LNAI 7015 (2011) 1-8. 9. Fant, G., Liljencrants, J. and Lin, Q.: A four-parameter model of glottal flow, STL-QSPR 4 (1985) 1-13. Reprinted in: Speech Acoustics and Phonetics: Selected Writings, G. Fant, Kluwer Academic Publishers, Dordrecht (2004) 95-108.. Disclaimer: This is a draft copy (restricted to non-commercial personal use) of the paper published in the Proceedings of the JVHC 2013, I Jornadas Multidisciplinares de Usuarios de la Voz, el Habla y el Canto, Las Palmas de Gran Canaria - 27-28 de junio 2013, pp. 13-22, ISBN: 84-695-8101-5 © GIAPSI-UPM.
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