literature review on voice quality

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The Effect of Hydration on Voice Quality in Adults: A Systematic Review

Journal of Voice

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Naomi MacBean Hartley

Objectives. To examine the current state of the science regarding the role of systemic hydration in vocal function and health. Study Design. Literature review. Methods. Literature search spanning multiple disciplines, including speech-language pathology, nutrition and dietetics, medicine, sports and exercise science, physiology, and biomechanics. Results. The relationship between hydration and physical function is an area of common interest among multiple professions. Each discipline provides valuable insight into the connection between performance and water balance, as well as complimentary methods of investigation. Existing voice literature suggests a relationship between hydration and voice production; however, the underlying mechanisms are not yet defined and a treatment effect for systemic hydration remains to be demonstrated. Literature from other disciplines sheds light on methodological shortcomings and, in some cases, offers an alternative explanation for observed phenomena. Conclusions. A growing body of literature in the field of voice science is documenting a relationship between hydration and vocal function; however, greater understanding is required to guide best practice in the maintenance of vocal health and management of voice disorders. Integration of knowledge and technical expertise from multiple disciplines facilitates analysis of existing literature and provides guidance as to future research.

Naomi Eichorn

Rouxjeanne Vermeulen

Journal of Speech, Language, and Hearing Research

Four vocally untrained healthy adults, 2 men and 2 women, completed the study. A double-blind placebo-controlled approach was used to administer three treatments to each participant on separate days. Drugs treatments involved a single 60-mg dose of a diuretic, Lasix (LA), on one day, and a single 50-mg dose of an oral antihistamine, diphenhydramine hydrochloride (DH), on another day. A third day involved the administration of a placebo, sugar pills (SP). Critical posttreatment measures were weight (kg), which estimated systemic dehydration, saliva viscosity (centipoise), which estimated secretion dehydration, and phona-tion threshold pressure (PTP, in cm H 2 O), at high pitches, which indicated pulmonary drive for phonation. The central experimental question was: Does systemic dehydration, or secretory dehydration, or both, mediate increases in PTP that are known to occur following dehydration treatments? The results showed that LA induced systemic dehydration, as shown by a decreas...

International Journal of Otorhinolaryngology and Head and Neck Surgery

Sujan Ghosh

Background: Vocal loading is a phenomenon that affects the vocal folds and voice parameters. Prolonged vocal loading may cause vocal fatigue. Hydration is one of the easiest precautions to reduce the effect of vocal loading. Voice range profile is an analysis of a participant’s vocal intensity and fundamental frequency ranges. Speech range profile is a graphical display of frequency intensity interactions occurring during functional speech activity. Phonetogram software can analyse VRP and SRP.Methods: Total sixty normophonic participants (thirty male and thirty female) were included in this study. Phonetogram, version 4.40 by Tiger DRS, software used to measure the voice range profile and speech range profile. For VRP, participants were asked to produce vowel /a/ and a passage reading task was given for SRP measurement.Results: All sample recording were done at pre vocal loading task, VLT and after hydration. Parameter that were used to measure the effects were Fo-range, semitone, ...

Arden Hopkin

Collegium antropologicum

Aron Grubesic

Voice is one of the most important means of communication and as such should be taken care of. The etiology of voice disorders is diverse. Due to the development of the society we live in, way of life, environmental factors, and exposure to pharmacological agents as well as demands we make towards our voice, there is a substantial growth in the number of people with voice disorders. We tasked ourselves to find out if it is possible to enlighten people on the importance of voice, to motivate them to take care of it, to notice the changes in its quality and eventually ask for help. We assessed in which measure do we understand the importance of a healthy voice, and do we know which is the most important factor that adds to its decline. For a long number of years voice therapists and other experts in the voice disorder field have been discussing the optimal voice impostation as well as vocal exercises and methods behind voice recovery. They have all come to the same conclusion that pho...

Journal of Education, Health and Sport

Karolina Mikut

Introduction and purpose of the work: Hoarseness is a symptom of a disease characterized by a hoarse, tense or hoarse voice resulting from disturbance of the vibration of the vocal folds. It is a common symptom of the disease in patients during medical consultations in primary health care, and the causes of its occurrence can be varied. State of knowledge (brief description): Treating hoarseness depends on what causes it. For this reason, during the diagnosis, various causes that may be the cause of hoarseness should be taken into account, such as infections, structural changes caused by the use of the voice organ, psychogenic causes, autoimmune diseases, systemic diseases or neoplastic diseases. Summary: In-depth diagnosis and an interdisciplinary approach are necessary to identify the cause of chronic hoarseness and initiate effective treatment.

American Journal of Speech-Language Pathology

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QUALITY OF LIFE IN DYSPHONIC CHILDREN MEASURED ON PEDIATRIC VOICE-RELATED QUALITY OF LIFE (PVRQOL) SCALE IN SERBIA

Jasmina stojanović, branislav belić, ljiljana erdevički, svetlana jovanović, mirjana jovanović, sunčica srećković.

Hoarseness occurs in children of both genders, from the earliest age and beyond, and is caused by improper use or overuse of vocal apparatus. The study included 91 hoarse children aged 6-12 (study group) and 243 healthy children (control group) of the same age. The study group underwent detailed medical history, phoniatric examination, larynx fiber endoscopy, allergy treatment, audiologic treatment, and pulmonary treatment. Pediatric Voice-Related Quality of Life questionnaire, Serbian version (PVRQOL) was completed by parents of both groups of children. We did not find statistically significant differences in the hoarse children based on diagnosis (muscle tension disorder and vocal fold nodules) and age in physical domain, socio-emotional and global domain score (p>0.01). The results showed that parents did not recognize hoarseness as a health problem in children. There were significant gender differences in the group of children with hoarseness, i.e. parents in all three PVRQOL questionnaire domains recognized hoarseness as a significant health problem in girls, but not in boys. The presence of hoarseness impairs the quality of life in pediatric population. Social and emotional domains indicated greater impact in boys.

Introduction

Instruments that measure quality of life should be able to assess physical, social and emotional issues and contain several domains in the Pediatric Voice-Related Quality of Life (PVRQOL) protocol not only providing a total score, but also the physical and socio-emotional dimensions. Voice is essential for interpersonal relationships and good verbal communication, and any changes in its production or quality may trigger organic, social, emotional, and even academic disadvantages ( 1 ). From the earliest stages of life, the closest family members and social environment (peer groups, nurseries, kindergartens, and schools) play a major role in the formation of the child’s voice.

Hoarseness occurs in children of both genders, from the earliest age and beyond, and is caused by improper use or overuse of vocal apparatus. In their daily environment, children tend to stress vocal apparatus, speaking in raised voice without any control, yelling, screaming, which results in hoarseness ( 2 - 5 ). Children are usually treated by phoniatricians, speech therapists, due to the stress while speaking or long-term hoarseness.

Vocal fold nodules are the most common organic causes of pediatric hoarseness ( 4 , 5 ). In addition to chronic phonotrauma, which is the main etiologic factor of vocal fold nodules, specific psychological characteristics of children and their behavioral expression (dominating their environment, talking too loudly, especially in extrovert children) are usually listed ( 6 ).

Irregular phonation automatisms are difficult to dissolve, thus long-term vocal therapy is required for the installation and stabilization of new regular conditional reflexes of vocal hygiene.

Subjective parental evaluation of voice quality on the questionnaire scale is a reliable tool used to assess quality of life in adults in the sociological, emotional and physical function domains (Voice Related Quality of Life-In-RQOL) ( 2 ). Since 2001, it includes functional assessment of voice pathology by the European Laryngological Society ( 4 ). This questionnaire was further developed for use in children with a variety of disorders including voice problems and is completed by parents assessing the quality of life in hoarse children ( 3 ).

A series of surveys assessing quality of life as a parameter for the impact of disease on daily life of patients with hoarseness have emerged during the last decade. It has been indicated that voice assessment in hoarse children is a good parameter referring to the severity of hoarseness. Accordingly, pediatric and standardized questionnaires measuring the quality of life in children with hoarseness have also been designed ( 7 - 9 ).

The PVRQOL questionnaire is a valid instrument evaluating the quality of life in hoarse children and relies on the parent report as a source of information. The questionnaire includes physical, socio-emotional and functional aspects of hoarseness ( 3 ).

In Serbia, hoarseness in children has not been sufficiently recognized as a health problem that needs to be treated, which if not treated, leads to numerous consequences in the population of preschool and schoolchildren. Therefore, the objective of our study was to determine the quality of life in hoarse children aged 6-12 years by using PVRQOL questionnaire completed by parents.

Subjects and Methods

Cohort studies that involved pediatric hoarse patients were performed at the Phoniatric Division, Otorhinolaryngology Department (tertiary institution), Kragujevac Clinical Center in Kragujevac, during a 3-year period (2011-2014). The study included 91 hoarse children (study group) aged 6-12 and control group of 243 age-matched healthy children from two elementary schools in two Serbian towns. All subjects gave their informed consent for participation in the study and ethical guidelines of the Declaration of Helsinki were followed during the study. Healthy children were chosen by the method of randomized sample in two elementary schools. Study group underwent detailed medical history, phoniatric examination, larynx fiber endoscopy, allergy treatment, audiologic treatment, pulmonary treatment, and multidimensional computer software voice analysis (jitter, shimmer and standard deviation). The study applied PVRQOL questionnaire as a valid instrument for assessing life quality, which was filled-out by the parents of hoarse children and parents of healthy children. The questionnaire was translated from English in Serbian language and culturally adapted for each item. To ensure accuracy of the translated questionnaire, back translation to English was done by another translator who was unfamiliar with the original version. The questionnaire was administered by the first author through face-to-face interviews. The PVRQOL is a 10-item instrument designed to measure Voice-Related Quality-of Life (VRQOL) adapted from the adult VRQOL instrument. The scores of the instrument have been normalized to a scale of 100 for ease of interpretation. A score of 100 represents the highest QOL, meaning that the parents perceived no problems with their child’s voice, no limitations on voice function, and no adverse social or emotional effects attributable to their child’s voice quality. In the hoarse children, diagnosis had already been made during initial examination and appropriate therapy determination. However, the study did not include treatment results, as the goal of the study was assessment of the quality of life in hoarse children at first examination.

Complete statistical analysis was performed using IBM SPSS Statistics 19.0 computer program. All continuous variables (age, scores of scales) were expressed as mean ± standard deviation, and categorical variables (gender, marital status) as percentage of particular category frequency. For categorical variables, statistical significance of differences was assessed by χ 2 -test, while differences in continuous variables were tested by Student’s t -test for independent causes or Mann-Whitney U test. Correlation between two continuous variables was examined by Pearson linear correlation or Spearman rank correlation.

The study involved 91 hoarse children (study group) aged 6-12 and control group of 243 age-matched healthy children. None of the study group children were born from multiple pregnancies and only five children were delivered by cesarean section. Children were of regular psychomotor development according to gender and age. All children had normal audiology findings. Study group mostly included families with two children (n=50; 54.9%). There were 60 (65.9%) male and 31 (34.1%) female children, mean age 8.64±1.79 years. Table 1 shows distribution of disorders diagnosed in the study group. Muscle tension disorder was present in 63 (69.2%) and vocal fold nodules were detected in 28 (30.8%) children. Clinical examination and fiber laryngoscopy revealed that all children had pronounced outward signs of hyperkinesia and insufficient glottic occlusion with sound in the speech voice. Allergic rhinitis as comorbidity was found in 13 (14.3%) and bronchial asthma in seven (7.7%) children. There was no statistically significant age difference between the two groups (p<0.01) but there was a statistically significant gender difference ( Table 2 ). We analyzed computerized voice parameters in relation to age and gender in the study group that included patients divided by age into two subgroups of 6-8 and 9-12 years. There were no statistically significant differences between study subgroups in jitter and shimmer according to gender and age (p>0.01). Our results of PVRQOL questionnaire suggested that parents did not recognize hoarseness as a health problem in children, nor that a raised tone of voice, yelling and vocal fold strain was related to hoarseness. Hoarseness in children was associated with significantly high parental response to item 01 (“My child has trouble speaking loudly or being heard in noisy situations”), item 07 (“My child has trouble doing his or her job or schoolwork because of his or her voice”) and item 09 (“My child has to repeat himself or herself to be understood) of PVRQOL questionnaire ( Table 3 ). In the study group (hoarse children) we found that allergic rhinitis in children affected the significantly high parental response to item 01 (“My child has trouble speaking loudly or being heard in noisy situations”), item 07 (“My child has trouble doing his or her job or schoolwork because of his or her voice”) and item 08 (“My child avoids going out socially because of his or her voice”) of PVRQOL questionnaire (χ 2 -test; p<0.01). On the other hand, asthma in children was associated with the significantly high parental response to item 01 (“My child has trouble speaking loudly or being heard in noisy situations”), item 05 (“My child sometimes gets depressed because of his or her voice”) and item 07 (“My child has trouble doing his or her job or schoolwork because of his or her voice”) of PVRQOL questionnaire (χ 2 -test; p<0.01). Using the same test, we established that gender did not affect only item 08, while the number of children in the family did not affect only item 09 (“My child has to repeat himself or herself to be understood”) of PVRQOL questionnaire (χ 2 -test; p<0.01). Analysis of gender differences in scale scores between the two groups showed that there was a statistically significant gender difference when looking at the group of hoarse children, i.e. parents in all three domains recognized hoarseness as a significant health disorder in girls. On average, the scores were significantly higher in girls ( Table 4 ). We did not find statistically significant difference in hoarse children according to diagnosis (muscle tension disorder and vocal fold nodules) and age in the physical, socio-emotional and global domain scores (p>0.01). Based on the distribution of frequencies and absolute numbers, hoarse children had the highest frequency rate with score 20, that is fair to good, whereas in the control group the highest frequency rate had score 10, i.e. excellent, which means that the questionnaire is good and that it showed lower values in the group of hoarse children than in control group. On the other hand, there were children with a score of 30 and 40 in the control group, indicating that parents failed to recognize that these children had a voice problem ( Table 5 ).

*χ 2 -test; **Mann-Whitney test; ***statistically significant

*statistically significant (χ 2 -test); PVRQOL = Pediatric Voice-Related Quality of Life questionnaire

*Statistically significant; **Mann-Whitney test; PVRQOL = Pediatric Voice-Related Quality of Life questionnaire

*χ 2 -test

Pediatric dysphonia is characterized as any difficulty that hinders or prevents children from producing their natural voice. Vocal changes during childhood negatively interfere with the social, affective, and emotional development of children. The impact of vocal problem on the life of children may be underestimated, considering that they do not present more comprehensive symptoms involving other systems ( 10 - 12 ).

In order to assess the quality of life in hoarse children, hetero history, clinical and otorhinolaryngologic examinations, as well as acoustic perception are not sufficient. There is only one instrument that measures the voice-related quality of life in pediatric population, and it is a questionnaire for parents. The reference literature data confirm the relevance of this research ( 3 , 13 ).

Our research included children aged 6-12, mean age 8.64 years. Boseley et al . included children aged 2-18 years in their research; there were more boys than girls ( 3 ). Our study results are consistent with the literature suggesting more frequent occurrence of vocal changes in the 5- to 10-year age groups, more present in boys than in girls. The prevalence of pediatric dysphonia in schools varies from 6% to 23.4%, reaching its peak in children aged 5-10 ( 1 , 3 , 6 , 9 , 14 ).

The questionnaire used in our study was adapted in accordance with Boseley et al . PVRQOL validation, taking into account the fact that each society exists in the context of different cultures, beliefs, habits, attitudes and behavior patterns, which influence the perception of vocal changes, as well as the search for appropriate research and treatment ( 3 ).

Given the aforementioned, the research included translation and back-translation of PVRQOL as to confirm whether the subjects had difficulties in understanding the segments of the instrument used, as well as to test the questions which are not applicable in the context of Serbian culture. The translated version was thus applied to the group of 20 subjects, enabling the option ‘unclear’ for all of the questions that were not clear enough and applicable for the domain being evaluated. Only appropriately adjusted questionnaire could be applied to a wider sample as ours ( 9 ).

Vocal assessment in children has characteristics different from those in adults, such as little cooperation in tests, small-sized laryngeal structures, and vocal similarities between genders in preschool and schoolchildren, change of vocal parameters near the time of voice change, and difficulties in defining normative parameters for vocal samples in different age ranges. Our study group was divided into two age groups of 6-8 and 9-12 years according to the intensity of hoarseness. We noticed that the latter age group (9-12 years) involved children with more intense phonation automatism.

Results of multidimensional computer software voice analysis (jitter, shimmer and standard deviation) yielded no statistically significant difference in the homogeneous population. In the older group (9-12 years), the values were higher for each of the three parameters but without statistically significant difference (p>0.01). These findings were expected, as children of that age are already on the verge of puberty, when differences between the genders are becoming more prominent ( 15 ).

On a large sample of 312 children, Angelillo et al . demonstrated that hoarseness is most common between the age of 2 and 16, with a large prevalence among boys as compared to girls ( 16 ). Similar were our findings that indicated a higher prevalence in male children (n=60; 65.9%) than in female children (n=31; 34.1%). In our study, significant gender differences were also found when observing the group of hoarse voice children, i.e. hoarseness was more frequently recognized in girls as a significant health problem in all three domains by parent reports. Families with two children predominated in our study (n=50; 54.9%). In the study conducted by Angelillo et al ., families with more than two children were dominant, which can be explained by the size of the test sample. It has been noticed that vocal abuse in children occurs when extrovert children want to dominate their environment. In this study, there were 79% of extrovert children, while the study conducted by Italian authors included 83% of such children ( 16 ).

Walz et al . carried out a study to determine the risk factors for hoarseness in premature infants. Literature data suggest that prolonged intubation is associated with poorer long-term parent-perceived voice quality in these patients ( 17 ). In our study group, most children were born without complications. Only five deliveries were completed by cesarean section. There were no premature infants.

In a large retrospective study of pediatric hoarse voice patients, Shah et al . ( 18 ) found that muscle tension disorder correlated with vocal fold nodules, which was confirmed by our research. Muscle tension disorder was found in 63 (69.2%) and vocal fold nodules in 28 (30.8%) children. We also detected comorbidities of allergic rhinitis in 14.3% and asthma in 7.7% of the study group of children. Allergic rhinitis affected the function of voice resonator, referring to the parental statistically significant responses to items 01, 07 and 08 in PVRQOL questionnaire. All children with allergic rhinitis were of the extrovert type. Jitter values and shimmer vocal assessments in this group were slightly higher than the normal range. In our study group, seven (7.7%) patients had bronchial asthma, which influenced statistically significantly responses to items 01, 05 and 07 in PVRQOL questionnaire. This finding is expected especially in children with a longer period of inhalation therapy (pump) ( 19 ).

The extrovert quality in these children was established by using hetero history records provided by the parents or custodians. Bronchial asthma and use of inhaled medications additionally disrupt vocal function voice activator, which was confirmed by vocal assessment. PVRQOL as an instrument directly leaning on parent responses is used to determine how hoarseness affects the quality of life in their children ( 3 , 10 , 19 ).

Connor et al . conducted a study on dysphonic children aged 5-18 years, which showed a discrepancy between the children’s and their parents’ reports on their voices, with a conclusion that children at an early age were able to comment their vocal disorders. Their study also suggested that chronic hoarseness in children negatively affected the quality of their life ( 12 ).

Verduyckt et al . have indicated that subjective evaluation of voice is routinely used in adults, but is not appropriate for children. Therefore, they used a questionnaire for children and their mothers in voice self-assessment. They concluded that children could express voice disorders, although they defined them differently than their parents or custodians ( 15 ).

Tavares et al . examined hoarse voice children with nodules and made comparisons with the control group of children without vocal disorders by employing vocal self-assessment methods and multi-dimensional computerized voice analysis. It was observed that some parents often overestimated hoarseness in children, while others did not consider hoarseness as an important symptom, giving biased answers to the questions assessing the quality of life, thus potentially causing delay in reaching an accurate diagnosis ( 20 , 21 ).

Timely identification of improper voice use and voice misuse can lead to significant reduction in the prevalence of voice disorders in children, i.e. improvement in the children’s quality of life.

So far research has shown that younger children are not mature enough, nor do they possess cognitive abilities for self-assessment, and therefore questionnaires for parents or custodians are necessary to assess the child’s vocal status ( 4 , 7 - 10 ).

However, older children are capable of self-assessment using adapted questionnaires. By applying different assessment instruments, in our study the PVRQOL scale, clinicians and researchers can monitor progression of the disorder, as well as efficiency of the treatment.

In conclusion, taking all this in consideration, it is necessary to educate parents and teachers in order to attain proper vocal hygiene and appropriate voice production. Likewise, it is of great importance that healthcare professionals such as general practitioners and pediatricians, who come first in contact with the hoarse voice child, be acquainted with the issue. The PVRQOL questionnaire demonstrated that hoarseness did not affect the quality of life in the children, as indicated by the global domain score of the study children.

Quality of Literature Reviews

• First Online: 11 August 2022

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• Rob Dekkers 4 ,
• Lindsey Carey 5 &
• Peter Langhorne 6  

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Whereas the starting point of a literature review is presented in Chapter 2 —finding out more about what is written about a specific topic by evaluating it from a critical objective—, it leaves open what constitutes a good quality literature review, whether as review of scholarly knowledge before an empirical study or as stand-alone study. Keeping in mind that there are different archetypes of literature reviews, see Section  2.5 , also the way of looking at quality will vary across these types and with the objective of the literature review. Thus, it deserves a closer look at how quality of literature reviews can be assured.

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Interestingly, the publication by Webster and Watson ( 2002 ) does not dwell on the implication of the title, even though it captures the essence of a literature review.

Note that this proposition by Yin et al. ( 1976 ) is related to the formalisation of the case survey method in Yin and Heald (1975); the case survey method appears in this book as method associated with qualitative synthesis in Section  10.3 . Also note that the latter publication is a precursor to what is known now as the case study methodology.

The topical survey is also addressed by Elisabeth Bergdahl in Section  11.1 .

There is some discussion about whom introduced or modified the concepts of nomothetic and idiographic forms of generating knowledge in its early stages. On this matter, Hurlburt and Knapp ( 2006 , pp. 287–9), and Salvatore and Valsiner ( 2010 , pp. 818–20) produce slightly different accounts.

Such is found by Steenhuis & de Bruijn ( 2006 ), too, in the case which journals gravitate toward nomothetic or ideographic research.

The common term ‘craftsmanship’ has been replaced with ‘academic mastery’ to avoid any unintended connotations.

Note that Boell and Cecez-Kecmanovic ( 2010 , p. 134 ff.) introduce a search strategy that is reminiscent of the iterative search strategy, presented in Section  5.3 , rather than representative of the hermeneutic approach as detailed in the current section. In their next writing (Boell and Cecez-Kecmanovic 2014 , p. 264), the search strategy is expanded with a cycle of analysis and interpretation, closer to the analysis stages in the systematic quantitative literature review (Section  9.5 ) and content analysis (see Section  10.3 ) than to hermeneutics.

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Dekkers, R., Carey, L., Langhorne, P. (2022). Quality of Literature Reviews. In: Making Literature Reviews Work: A Multidisciplinary Guide to Systematic Approaches. Springer, Cham. https://doi.org/10.1007/978-3-030-90025-0_3

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