In Memoriam: Dr. Edmund Thile, former SLHS faculty member

Edmund Thile, Ph.D., CCC-SLP

Dr. Thile, age 85, passed away last week (August 2017) after a yearlong battle with leukemia.

Dr. Thile served on the faculty at San Diego State University from 1965 to 1998 as a Professor of Communicative Disorders, Clinical Director, Clinical Supervisor, and Project Director for numerous federally funded training grants. He was a great advocate for the students and started the diversity program in the school and the college with his Health Care Opportunities Program (HCOP) – a grant program to get minority students into health care professions.  In 1976, Dr. Thile started San Diego County Speech Pathology Services, Inc. (County Speech) serving San Diego County residents with speech, language, and communication difficulties. 

Services for Dr. Thile will be held on Friday 9/1/17 at 10:00 am at Mission Point (in south Mission Beach), 2600 Bayside Walk, San Diego, 92109.  There will be a gathering for everyone at his home following the service (2681 Ocean Front Walk) – it is walkable from the service as it’s across the street.

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In Memoriam: Dr. Edmund Thile, former SLHS faculty member

Edmund Thile, Ph.D., CCC-SLP

Dr. Thile, age 85, passed away last week (August 2017) after a yearlong battle with leukemia.

Dr. Thile served on the faculty at San Diego State University from 1965 to 1998 as a Professor of Communicative Disorders, Clinical Director, Clinical Supervisor, and Project Director for numerous federally funded training grants. He was a great advocate for the students and started the diversity program in the school and the college with his Health Care Opportunities Program (HCOP) – a grant program to get minority students into health care professions.  In 1976, Dr. Thile started San Diego County Speech Pathology Services, Inc. (County Speech) serving San Diego County residents with speech, language, and communication difficulties. 

Services for Dr. Thile will be held on Friday 9/1/17 at 10:00 am at Mission Point (in south Mission Beach), 2600 Bayside Walk, San Diego, 92109.  There will be a gathering for everyone at his home following the service (2681 Ocean Front Walk) – it is walkable from the service as it’s across the street.

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In Memoriam: Dr. Edmund Thile, former SLHS faculty member

Edmund Thile, Ph.D., CCC-SLP

Dr. Thile, age 85, passed away last week (August 2017) after a yearlong battle with leukemia.

Dr. Thile served on the faculty at San Diego State University from 1965 to 1998 as a Professor of Communicative Disorders, Clinical Director, Clinical Supervisor, and Project Director for numerous federally funded training grants. He was a great advocate for the students and started the diversity program in the school and the college with his Health Care Opportunities Program (HCOP) – a grant program to get minority students into health care professions.  In 1976, Dr. Thile started San Diego County Speech Pathology Services, Inc. (County Speech) serving San Diego County residents with speech, language, and communication difficulties. 

Services for Dr. Thile will be held on Friday 9/1/17 at 10:00 am at Mission Point (in south Mission Beach), 2600 Bayside Walk, San Diego, 92109.  There will be a gathering for everyone at his home following the service (2681 Ocean Front Walk) – it is walkable from the service as it’s across the street.

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A formal description of middle ear pressure-regulation

Publication date: Available online 24 August 2017
Source:Hearing Research
Author(s): William J. Doyle, Cuneyt M. Alper
IntroductionMiddle ear (ME) pressure-regulation (MEPR) is a homeostatic mechanism that maintains the ME-environment pressure-gradient (MEEPG) within a range optimized for “normal” hearing.ObjectiveDescribe MEPR using equations applicable to passive, inter-compartmental gas-exchange and determine if the predictions of that description include the increasing ME pressure observed under certain conditions and interpreted by some as evidencing gas-production by the ME mucosa.MethodsMEPR was modeled as the combined effect of passive gas-exchanges between the ME and: perilymph via the round window membrane, the ambient environment via the tympanic membrane, and the local blood via the ME mucosa and of gas flow between the ME and nasopharynx during Eustachian tube openings. The first 3 of these exchanges are described at the species level using the Fick's diffusion equation and the last as a bulk gas transfer governed by Poiseuille's equation. The model structure is a time-iteration of the equation: P^MEg(t=(i+1)Δt) = ∑^s(P^MEs(t=iΔt)+(1/(β^MEsV^ME)∑^P(Қ^Ps(P^Cs(t=(iΔt)-P^MEs(t=(iΔt))). There, P^MEg(t=iΔt) and P^MEs(t=iΔt) are the ME total and species-pressures at the indexed times, P^Cs(t=iΔt) is the species-pressure for each exchange-compartment, β^MEsV^ME is the product of the ME species-capacitance and volume, Қ^Ps is the pathway species-conductance, and ∑^S and ∑^P are operators for summing the expression over all species or exchange pathways.ResultsWhen calibrated to known values, the model predicts the empirically measured ME species-pressures and the observed time-trajectories for total ME pressure and the MEEPG under a wide variety of physiologic, pathologic and non-physiologic conditions.ConclusionsPassive inter-compartmental gas exchange is sole and sufficient to describe MEPR.



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A formal description of middle ear pressure-regulation

Publication date: Available online 24 August 2017
Source:Hearing Research
Author(s): William J. Doyle, Cuneyt M. Alper
IntroductionMiddle ear (ME) pressure-regulation (MEPR) is a homeostatic mechanism that maintains the ME-environment pressure-gradient (MEEPG) within a range optimized for “normal” hearing.ObjectiveDescribe MEPR using equations applicable to passive, inter-compartmental gas-exchange and determine if the predictions of that description include the increasing ME pressure observed under certain conditions and interpreted by some as evidencing gas-production by the ME mucosa.MethodsMEPR was modeled as the combined effect of passive gas-exchanges between the ME and: perilymph via the round window membrane, the ambient environment via the tympanic membrane, and the local blood via the ME mucosa and of gas flow between the ME and nasopharynx during Eustachian tube openings. The first 3 of these exchanges are described at the species level using the Fick's diffusion equation and the last as a bulk gas transfer governed by Poiseuille's equation. The model structure is a time-iteration of the equation: P^MEg(t=(i+1)Δt) = ∑^s(P^MEs(t=iΔt)+(1/(β^MEsV^ME)∑^P(Қ^Ps(P^Cs(t=(iΔt)-P^MEs(t=(iΔt))). There, P^MEg(t=iΔt) and P^MEs(t=iΔt) are the ME total and species-pressures at the indexed times, P^Cs(t=iΔt) is the species-pressure for each exchange-compartment, β^MEsV^ME is the product of the ME species-capacitance and volume, Қ^Ps is the pathway species-conductance, and ∑^S and ∑^P are operators for summing the expression over all species or exchange pathways.ResultsWhen calibrated to known values, the model predicts the empirically measured ME species-pressures and the observed time-trajectories for total ME pressure and the MEEPG under a wide variety of physiologic, pathologic and non-physiologic conditions.ConclusionsPassive inter-compartmental gas exchange is sole and sufficient to describe MEPR.



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A formal description of middle ear pressure-regulation

Publication date: Available online 24 August 2017
Source:Hearing Research
Author(s): William J. Doyle, Cuneyt M. Alper
IntroductionMiddle ear (ME) pressure-regulation (MEPR) is a homeostatic mechanism that maintains the ME-environment pressure-gradient (MEEPG) within a range optimized for “normal” hearing.ObjectiveDescribe MEPR using equations applicable to passive, inter-compartmental gas-exchange and determine if the predictions of that description include the increasing ME pressure observed under certain conditions and interpreted by some as evidencing gas-production by the ME mucosa.MethodsMEPR was modeled as the combined effect of passive gas-exchanges between the ME and: perilymph via the round window membrane, the ambient environment via the tympanic membrane, and the local blood via the ME mucosa and of gas flow between the ME and nasopharynx during Eustachian tube openings. The first 3 of these exchanges are described at the species level using the Fick's diffusion equation and the last as a bulk gas transfer governed by Poiseuille's equation. The model structure is a time-iteration of the equation: P^MEg(t=(i+1)Δt) = ∑^s(P^MEs(t=iΔt)+(1/(β^MEsV^ME)∑^P(Қ^Ps(P^Cs(t=(iΔt)-P^MEs(t=(iΔt))). There, P^MEg(t=iΔt) and P^MEs(t=iΔt) are the ME total and species-pressures at the indexed times, P^Cs(t=iΔt) is the species-pressure for each exchange-compartment, β^MEsV^ME is the product of the ME species-capacitance and volume, Қ^Ps is the pathway species-conductance, and ∑^S and ∑^P are operators for summing the expression over all species or exchange pathways.ResultsWhen calibrated to known values, the model predicts the empirically measured ME species-pressures and the observed time-trajectories for total ME pressure and the MEEPG under a wide variety of physiologic, pathologic and non-physiologic conditions.ConclusionsPassive inter-compartmental gas exchange is sole and sufficient to describe MEPR.



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A formal description of middle ear pressure-regulation

Publication date: Available online 24 August 2017
Source:Hearing Research
Author(s): William J. Doyle, Cuneyt M. Alper
IntroductionMiddle ear (ME) pressure-regulation (MEPR) is a homeostatic mechanism that maintains the ME-environment pressure-gradient (MEEPG) within a range optimized for “normal” hearing.ObjectiveDescribe MEPR using equations applicable to passive, inter-compartmental gas-exchange and determine if the predictions of that description include the increasing ME pressure observed under certain conditions and interpreted by some as evidencing gas-production by the ME mucosa.MethodsMEPR was modeled as the combined effect of passive gas-exchanges between the ME and: perilymph via the round window membrane, the ambient environment via the tympanic membrane, and the local blood via the ME mucosa and of gas flow between the ME and nasopharynx during Eustachian tube openings. The first 3 of these exchanges are described at the species level using the Fick's diffusion equation and the last as a bulk gas transfer governed by Poiseuille's equation. The model structure is a time-iteration of the equation: P^MEg(t=(i+1)Δt) = ∑^s(P^MEs(t=iΔt)+(1/(β^MEsV^ME)∑^P(Қ^Ps(P^Cs(t=(iΔt)-P^MEs(t=(iΔt))). There, P^MEg(t=iΔt) and P^MEs(t=iΔt) are the ME total and species-pressures at the indexed times, P^Cs(t=iΔt) is the species-pressure for each exchange-compartment, β^MEsV^ME is the product of the ME species-capacitance and volume, Қ^Ps is the pathway species-conductance, and ∑^S and ∑^P are operators for summing the expression over all species or exchange pathways.ResultsWhen calibrated to known values, the model predicts the empirically measured ME species-pressures and the observed time-trajectories for total ME pressure and the MEEPG under a wide variety of physiologic, pathologic and non-physiologic conditions.ConclusionsPassive inter-compartmental gas exchange is sole and sufficient to describe MEPR.



from #Audiology via ola Kala on Inoreader http://ift.tt/2w1omk9
via IFTTT

A formal description of middle ear pressure-regulation

Publication date: Available online 24 August 2017
Source:Hearing Research
Author(s): William J. Doyle, Cuneyt M. Alper
IntroductionMiddle ear (ME) pressure-regulation (MEPR) is a homeostatic mechanism that maintains the ME-environment pressure-gradient (MEEPG) within a range optimized for “normal” hearing.ObjectiveDescribe MEPR using equations applicable to passive, inter-compartmental gas-exchange and determine if the predictions of that description include the increasing ME pressure observed under certain conditions and interpreted by some as evidencing gas-production by the ME mucosa.MethodsMEPR was modeled as the combined effect of passive gas-exchanges between the ME and: perilymph via the round window membrane, the ambient environment via the tympanic membrane, and the local blood via the ME mucosa and of gas flow between the ME and nasopharynx during Eustachian tube openings. The first 3 of these exchanges are described at the species level using the Fick's diffusion equation and the last as a bulk gas transfer governed by Poiseuille's equation. The model structure is a time-iteration of the equation: P^MEg(t=(i+1)Δt) = ∑^s(P^MEs(t=iΔt)+(1/(β^MEsV^ME)∑^P(Қ^Ps(P^Cs(t=(iΔt)-P^MEs(t=(iΔt))). There, P^MEg(t=iΔt) and P^MEs(t=iΔt) are the ME total and species-pressures at the indexed times, P^Cs(t=iΔt) is the species-pressure for each exchange-compartment, β^MEsV^ME is the product of the ME species-capacitance and volume, Қ^Ps is the pathway species-conductance, and ∑^S and ∑^P are operators for summing the expression over all species or exchange pathways.ResultsWhen calibrated to known values, the model predicts the empirically measured ME species-pressures and the observed time-trajectories for total ME pressure and the MEEPG under a wide variety of physiologic, pathologic and non-physiologic conditions.ConclusionsPassive inter-compartmental gas exchange is sole and sufficient to describe MEPR.



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How Stuttering Develops: The Multifactorial Dynamic Pathways Theory

Purpose

We advanced a multifactorial, dynamic account of the complex, nonlinear interactions of motor, linguistic, and emotional factors contributing to the development of stuttering. Our purpose here is to update our account as the multifactorial dynamic pathways theory.

Method

We review evidence related to how stuttering develops, including genetic/epigenetic factors; motor, linguistic, and emotional features; and advances in neuroimaging studies. We update evidence for our earlier claim: Although stuttering ultimately reflects impairment in speech sensorimotor processes, its course over the life span is strongly conditioned by linguistic and emotional factors.

Results

Our current account places primary emphasis on the dynamic developmental context in which stuttering emerges and follows its course during the preschool years. Rapid changes in many neurobehavioral systems are ongoing, and critical interactions among these systems likely play a major role in determining persistence of or recovery from stuttering.

Conclusion

Stuttering, or childhood onset fluency disorder (Diagnostic and Statistical Manual of Mental Disorders, 5th edition; American Psychiatric Association [APA], 2013), is a neurodevelopmental disorder that begins when neural networks supporting speech, language, and emotional functions are rapidly developing. The multifactorial dynamic pathways theory motivates experimental and clinical work to determine the specific factors that contribute to each child's pathway to the diagnosis of stuttering and those most likely to promote recovery.

from #Audiology via ola Kala on Inoreader http://article/doi/10.1044/2017_JSLHR-S-16-0343/2652602/How-Stuttering-Develops-The-Multifactorial-Dynamic
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Respiratory and Laryngeal Changes With Vocal Loading in Younger and Older Individuals

Purpose

The objective of the current study was to investigate the effects of age and vocal loading on the respiratory and laryngeal systems.

Method

Fourteen younger (M = 20 years) and 13 older (M = 75 years) healthy individuals participated in a 40-min vocal loading challenge in the presence of 70-dB background noise. Respiratory kinematic and laryngeal measurements were obtained before and after the challenge.

Results

Following the loading challenge, participants in both groups reported greater speaking effort. Sound pressure level increased in the older group and decreased in the younger group after loading. Younger adults, but not older adults, used lower lung volume initiations and higher lung volume terminations after loading. Cepstral peak prominence increased with loading in both groups, but this change was of small magnitude and not clinically significant.

Conclusions

The negative effects of loading were observed in respiratory and laryngeal measures, although the pattern of changes differed across the groups. These data increase our knowledge of underlying respiratory and laryngeal physiological changes following a loading challenge and may reflect some of the physiologic mechanisms underlying vocal fatigue.

from #Audiology via ola Kala on Inoreader http://article/doi/10.1044/2017_JSLHR-S-17-0106/2652564/Respiratory-and-Laryngeal-Changes-With-Vocal
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Modeling the Pathophysiology of Phonotraumatic Vocal Hyperfunction With a Triangular Glottal Model of the Vocal Folds

Purpose

Our goal was to test prevailing assumptions about the underlying biomechanical and aeroacoustic mechanisms associated with phonotraumatic lesions of the vocal folds using a numerical lumped-element model of voice production.

Method

A numerical model with a triangular glottis, posterior glottal opening, and arytenoid posturing is proposed. Normal voice is altered by introducing various prephonatory configurations. Potential compensatory mechanisms (increased subglottal pressure, muscle activation, and supraglottal constriction) are adjusted to restore an acoustic target output through a control loop that mimics a simplified version of auditory feedback.

Results

The degree of incomplete glottal closure in both the membranous and posterior portions of the folds consistently leads to a reduction in sound pressure level, fundamental frequency, harmonic richness, and harmonics-to-noise ratio. The compensatory mechanisms lead to significantly increased vocal-fold collision forces, maximum flow-declination rate, and amplitude of unsteady flow, without significantly altering the acoustic output.

Conclusion

Modeling provided potentially important insights into the pathophysiology of phonotraumatic vocal hyperfunction by demonstrating that compensatory mechanisms can counteract deterioration in the voice acoustic signal due to incomplete glottal closure, but this also leads to high vocal-fold collision forces (reflected in aerodynamic measures), which significantly increases the risk of developing phonotrauma.

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Short-Term Effect of Two Semi-Occluded Vocal Tract Training Programs on the Vocal Quality of Future Occupational Voice Users: “Resonant Voice Training Using Nasal Consonants” Versus “Straw Phonation”

Purpose

The purpose of this study was to determine the short-term effect of 2 semi-occluded vocal tract training programs, “resonant voice training using nasal consonants” versus “straw phonation,” on the vocal quality of vocally healthy future occupational voice users.

Method

A multigroup pretest–posttest randomized control group design was used. Thirty healthy speech-language pathology students with a mean age of 19 years (range: 17–22 years) were randomly assigned into a resonant voice training group (practicing resonant exercises across 6 weeks, n = 10), a straw phonation group (practicing straw phonation across 6 weeks, n = 10), or a control group (receiving no voice training, n = 10). A voice assessment protocol consisting of both subjective (questionnaire, participant's self-report, auditory–perceptual evaluation) and objective (maximum performance task, aerodynamic assessment, voice range profile, acoustic analysis, acoustic voice quality index, dysphonia severity index) measurements and determinations was used to evaluate the participants' voice pre- and posttraining. Groups were compared over time using linear mixed models and generalized linear mixed models. Within-group effects of time were determined using post hoc pairwise comparisons.

Results

No significant time × group interactions were found for any of the outcome measures, indicating no differences in evolution over time among the 3 groups. Within-group effects of time showed a significant improvement in dysphonia severity index in the resonant voice training group, and a significant improvement in the intensity range in the straw phonation group.

Conclusions

Results suggest that the semi-occluded vocal tract training programs using resonant voice training and straw phonation may have a positive impact on the vocal quality and vocal capacities of future occupational voice users. The resonant voice training caused an improved dysphonia severity index, and the straw phonation training caused an expansion of the intensity range in this population.

from #Audiology via ola Kala on Inoreader http://article/doi/10.1044/2017_JSLHR-S-17-0017/2652563/ShortTerm-Effect-of-Two-SemiOccluded-Vocal-Tract
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How Stuttering Develops: The Multifactorial Dynamic Pathways Theory

Purpose

We advanced a multifactorial, dynamic account of the complex, nonlinear interactions of motor, linguistic, and emotional factors contributing to the development of stuttering. Our purpose here is to update our account as the multifactorial dynamic pathways theory.

Method

We review evidence related to how stuttering develops, including genetic/epigenetic factors; motor, linguistic, and emotional features; and advances in neuroimaging studies. We update evidence for our earlier claim: Although stuttering ultimately reflects impairment in speech sensorimotor processes, its course over the life span is strongly conditioned by linguistic and emotional factors.

Results

Our current account places primary emphasis on the dynamic developmental context in which stuttering emerges and follows its course during the preschool years. Rapid changes in many neurobehavioral systems are ongoing, and critical interactions among these systems likely play a major role in determining persistence of or recovery from stuttering.

Conclusion

Stuttering, or childhood onset fluency disorder (Diagnostic and Statistical Manual of Mental Disorders, 5th edition; American Psychiatric Association [APA], 2013), is a neurodevelopmental disorder that begins when neural networks supporting speech, language, and emotional functions are rapidly developing. The multifactorial dynamic pathways theory motivates experimental and clinical work to determine the specific factors that contribute to each child's pathway to the diagnosis of stuttering and those most likely to promote recovery.

from #Audiology via xlomafota13 on Inoreader http://article/doi/10.1044/2017_JSLHR-S-16-0343/2652602/How-Stuttering-Develops-The-Multifactorial-Dynamic
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Respiratory and Laryngeal Changes With Vocal Loading in Younger and Older Individuals

Purpose

The objective of the current study was to investigate the effects of age and vocal loading on the respiratory and laryngeal systems.

Method

Fourteen younger (M = 20 years) and 13 older (M = 75 years) healthy individuals participated in a 40-min vocal loading challenge in the presence of 70-dB background noise. Respiratory kinematic and laryngeal measurements were obtained before and after the challenge.

Results

Following the loading challenge, participants in both groups reported greater speaking effort. Sound pressure level increased in the older group and decreased in the younger group after loading. Younger adults, but not older adults, used lower lung volume initiations and higher lung volume terminations after loading. Cepstral peak prominence increased with loading in both groups, but this change was of small magnitude and not clinically significant.

Conclusions

The negative effects of loading were observed in respiratory and laryngeal measures, although the pattern of changes differed across the groups. These data increase our knowledge of underlying respiratory and laryngeal physiological changes following a loading challenge and may reflect some of the physiologic mechanisms underlying vocal fatigue.

from #Audiology via xlomafota13 on Inoreader http://article/doi/10.1044/2017_JSLHR-S-17-0106/2652564/Respiratory-and-Laryngeal-Changes-With-Vocal
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Modeling the Pathophysiology of Phonotraumatic Vocal Hyperfunction With a Triangular Glottal Model of the Vocal Folds

Purpose

Our goal was to test prevailing assumptions about the underlying biomechanical and aeroacoustic mechanisms associated with phonotraumatic lesions of the vocal folds using a numerical lumped-element model of voice production.

Method

A numerical model with a triangular glottis, posterior glottal opening, and arytenoid posturing is proposed. Normal voice is altered by introducing various prephonatory configurations. Potential compensatory mechanisms (increased subglottal pressure, muscle activation, and supraglottal constriction) are adjusted to restore an acoustic target output through a control loop that mimics a simplified version of auditory feedback.

Results

The degree of incomplete glottal closure in both the membranous and posterior portions of the folds consistently leads to a reduction in sound pressure level, fundamental frequency, harmonic richness, and harmonics-to-noise ratio. The compensatory mechanisms lead to significantly increased vocal-fold collision forces, maximum flow-declination rate, and amplitude of unsteady flow, without significantly altering the acoustic output.

Conclusion

Modeling provided potentially important insights into the pathophysiology of phonotraumatic vocal hyperfunction by demonstrating that compensatory mechanisms can counteract deterioration in the voice acoustic signal due to incomplete glottal closure, but this also leads to high vocal-fold collision forces (reflected in aerodynamic measures), which significantly increases the risk of developing phonotrauma.

from #Audiology via xlomafota13 on Inoreader http://article/doi/10.1044/2017_JSLHR-S-16-0412/2652562/Modeling-the-Pathophysiology-of-Phonotraumatic
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Short-Term Effect of Two Semi-Occluded Vocal Tract Training Programs on the Vocal Quality of Future Occupational Voice Users: “Resonant Voice Training Using Nasal Consonants” Versus “Straw Phonation”

Purpose

The purpose of this study was to determine the short-term effect of 2 semi-occluded vocal tract training programs, “resonant voice training using nasal consonants” versus “straw phonation,” on the vocal quality of vocally healthy future occupational voice users.

Method

A multigroup pretest–posttest randomized control group design was used. Thirty healthy speech-language pathology students with a mean age of 19 years (range: 17–22 years) were randomly assigned into a resonant voice training group (practicing resonant exercises across 6 weeks, n = 10), a straw phonation group (practicing straw phonation across 6 weeks, n = 10), or a control group (receiving no voice training, n = 10). A voice assessment protocol consisting of both subjective (questionnaire, participant's self-report, auditory–perceptual evaluation) and objective (maximum performance task, aerodynamic assessment, voice range profile, acoustic analysis, acoustic voice quality index, dysphonia severity index) measurements and determinations was used to evaluate the participants' voice pre- and posttraining. Groups were compared over time using linear mixed models and generalized linear mixed models. Within-group effects of time were determined using post hoc pairwise comparisons.

Results

No significant time × group interactions were found for any of the outcome measures, indicating no differences in evolution over time among the 3 groups. Within-group effects of time showed a significant improvement in dysphonia severity index in the resonant voice training group, and a significant improvement in the intensity range in the straw phonation group.

Conclusions

Results suggest that the semi-occluded vocal tract training programs using resonant voice training and straw phonation may have a positive impact on the vocal quality and vocal capacities of future occupational voice users. The resonant voice training caused an improved dysphonia severity index, and the straw phonation training caused an expansion of the intensity range in this population.

from #Audiology via xlomafota13 on Inoreader http://article/doi/10.1044/2017_JSLHR-S-17-0017/2652563/ShortTerm-Effect-of-Two-SemiOccluded-Vocal-Tract
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How Stuttering Develops: The Multifactorial Dynamic Pathways Theory

Purpose

We advanced a multifactorial, dynamic account of the complex, nonlinear interactions of motor, linguistic, and emotional factors contributing to the development of stuttering. Our purpose here is to update our account as the multifactorial dynamic pathways theory.

Method

We review evidence related to how stuttering develops, including genetic/epigenetic factors; motor, linguistic, and emotional features; and advances in neuroimaging studies. We update evidence for our earlier claim: Although stuttering ultimately reflects impairment in speech sensorimotor processes, its course over the life span is strongly conditioned by linguistic and emotional factors.

Results

Our current account places primary emphasis on the dynamic developmental context in which stuttering emerges and follows its course during the preschool years. Rapid changes in many neurobehavioral systems are ongoing, and critical interactions among these systems likely play a major role in determining persistence of or recovery from stuttering.

Conclusion

Stuttering, or childhood onset fluency disorder (Diagnostic and Statistical Manual of Mental Disorders, 5th edition; American Psychiatric Association [APA], 2013), is a neurodevelopmental disorder that begins when neural networks supporting speech, language, and emotional functions are rapidly developing. The multifactorial dynamic pathways theory motivates experimental and clinical work to determine the specific factors that contribute to each child's pathway to the diagnosis of stuttering and those most likely to promote recovery.

from #Audiology via ola Kala on Inoreader http://article/doi/10.1044/2017_JSLHR-S-16-0343/2652602/How-Stuttering-Develops-The-Multifactorial-Dynamic
via IFTTT

Respiratory and Laryngeal Changes With Vocal Loading in Younger and Older Individuals

Purpose

The objective of the current study was to investigate the effects of age and vocal loading on the respiratory and laryngeal systems.

Method

Fourteen younger (M = 20 years) and 13 older (M = 75 years) healthy individuals participated in a 40-min vocal loading challenge in the presence of 70-dB background noise. Respiratory kinematic and laryngeal measurements were obtained before and after the challenge.

Results

Following the loading challenge, participants in both groups reported greater speaking effort. Sound pressure level increased in the older group and decreased in the younger group after loading. Younger adults, but not older adults, used lower lung volume initiations and higher lung volume terminations after loading. Cepstral peak prominence increased with loading in both groups, but this change was of small magnitude and not clinically significant.

Conclusions

The negative effects of loading were observed in respiratory and laryngeal measures, although the pattern of changes differed across the groups. These data increase our knowledge of underlying respiratory and laryngeal physiological changes following a loading challenge and may reflect some of the physiologic mechanisms underlying vocal fatigue.

from #Audiology via ola Kala on Inoreader http://article/doi/10.1044/2017_JSLHR-S-17-0106/2652564/Respiratory-and-Laryngeal-Changes-With-Vocal
via IFTTT

Modeling the Pathophysiology of Phonotraumatic Vocal Hyperfunction With a Triangular Glottal Model of the Vocal Folds

Purpose

Our goal was to test prevailing assumptions about the underlying biomechanical and aeroacoustic mechanisms associated with phonotraumatic lesions of the vocal folds using a numerical lumped-element model of voice production.

Method

A numerical model with a triangular glottis, posterior glottal opening, and arytenoid posturing is proposed. Normal voice is altered by introducing various prephonatory configurations. Potential compensatory mechanisms (increased subglottal pressure, muscle activation, and supraglottal constriction) are adjusted to restore an acoustic target output through a control loop that mimics a simplified version of auditory feedback.

Results

The degree of incomplete glottal closure in both the membranous and posterior portions of the folds consistently leads to a reduction in sound pressure level, fundamental frequency, harmonic richness, and harmonics-to-noise ratio. The compensatory mechanisms lead to significantly increased vocal-fold collision forces, maximum flow-declination rate, and amplitude of unsteady flow, without significantly altering the acoustic output.

Conclusion

Modeling provided potentially important insights into the pathophysiology of phonotraumatic vocal hyperfunction by demonstrating that compensatory mechanisms can counteract deterioration in the voice acoustic signal due to incomplete glottal closure, but this also leads to high vocal-fold collision forces (reflected in aerodynamic measures), which significantly increases the risk of developing phonotrauma.

from #Audiology via ola Kala on Inoreader http://article/doi/10.1044/2017_JSLHR-S-16-0412/2652562/Modeling-the-Pathophysiology-of-Phonotraumatic
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Short-Term Effect of Two Semi-Occluded Vocal Tract Training Programs on the Vocal Quality of Future Occupational Voice Users: “Resonant Voice Training Using Nasal Consonants” Versus “Straw Phonation”

Purpose

The purpose of this study was to determine the short-term effect of 2 semi-occluded vocal tract training programs, “resonant voice training using nasal consonants” versus “straw phonation,” on the vocal quality of vocally healthy future occupational voice users.

Method

A multigroup pretest–posttest randomized control group design was used. Thirty healthy speech-language pathology students with a mean age of 19 years (range: 17–22 years) were randomly assigned into a resonant voice training group (practicing resonant exercises across 6 weeks, n = 10), a straw phonation group (practicing straw phonation across 6 weeks, n = 10), or a control group (receiving no voice training, n = 10). A voice assessment protocol consisting of both subjective (questionnaire, participant's self-report, auditory–perceptual evaluation) and objective (maximum performance task, aerodynamic assessment, voice range profile, acoustic analysis, acoustic voice quality index, dysphonia severity index) measurements and determinations was used to evaluate the participants' voice pre- and posttraining. Groups were compared over time using linear mixed models and generalized linear mixed models. Within-group effects of time were determined using post hoc pairwise comparisons.

Results

No significant time × group interactions were found for any of the outcome measures, indicating no differences in evolution over time among the 3 groups. Within-group effects of time showed a significant improvement in dysphonia severity index in the resonant voice training group, and a significant improvement in the intensity range in the straw phonation group.

Conclusions

Results suggest that the semi-occluded vocal tract training programs using resonant voice training and straw phonation may have a positive impact on the vocal quality and vocal capacities of future occupational voice users. The resonant voice training caused an improved dysphonia severity index, and the straw phonation training caused an expansion of the intensity range in this population.

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Clinical Characteristics of Benign Recurrent Vestibulopathy: Clearly Distinctive From Vestibular Migraine and Ménière's Disease?

Clinical Characteristics of Benign Recurrent Vestibulopathy: Clearly Distinctive From Vestibular Migraine and Ménière's Disease?

Otol Neurotol. 2017 Aug 22;:

Authors: van Esch BF, van Wensen E, van der Zaag-Loonen HJ, van Benthem PPG, van Leeuwen RB

Abstract
OBJECTIVE: We aimed to systematically investigate the clinical characteristics of benign recurrent vestibulopathy (BRV), vestibular migraine (VM), and Ménière's disease (MD) and to assess whether clinical symptoms exist that are unique to BRV.
STUDY DESIGN: Prospective cohort study.
SETTING: Tertiary referral center.
METHODS: Between January 2015 and November 2016, patients were prospectively recruited at a specialized dizziness clinic. Patients were included if they met the diagnostic criteria for BRV, VM, or MD which was evaluated by simultaneous consultation of an otorhinolaryngologist and neurologist. All patients received a comprehensive clinical examination that included vestibular tests and pure-tone audiometry. A questionnaire was designed to systematically document symptoms of the three vestibular disorders.
RESULTS: A total of 122 patients were included in our study, 65 (53%) were females in whom 29 (24%) were postmenopausal. The mean age was 55.5 ± 13.7 years and the mean age of onset of vertigo attacks was 49.2 ± 14.8 years (n = 119). Forty-five (37%) patients had a clinical diagnosis of BRV, 34 (28%) of VM, and 43 (35%) of MD. No symptom could be identified which was specifically linked to BRV. In patients with BRV, similar to those with VM, we found a female preponderance (p = 0.05 in BRV, p = 0.001 in VM). Patients with VM reported significantly more often a positive history of motion sickness (p = 0.01). In addition, canal paresis was most profound in patients with MD (p = 0.001).
CONCLUSION: We found no clinical characteristics that were distinctive for BRV. However, we did find several distinctive clinical features for VM and MD which may assist the physician in their history taking.

PMID: 28834943 [PubMed - as supplied by publisher]

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Normative data for diagnosing auditory processing disorder in Norwegian children aged 7–12 years

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Relational quality, illness interference, and partner support in Ménière’s disease

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Book review

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Normative data for diagnosing auditory processing disorder in Norwegian children aged 7–12 years

.


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Relational quality, illness interference, and partner support in Ménière’s disease

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Book review

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Gender Perception After Raising Vowel Fundamental and Formant Frequencies: Considerations for Oral Resonance Research

Publication date: Available online 24 August 2017
Source:Journal of Voice
Author(s): Sally J.K. Gallena, Betsy Stickels, Emily Stickels
ObjectivesVoice feminization therapy for male-to-female transgender women typically targets increasing fundamental frequency (F0). Increasing vowel formant frequencies (FFs) has also been proposed. To better understand formant conditions that shift listeners' perception of gender from male to “not-male,” individual and combined vowel FFs were incrementally raised, whereas F0 was held constant at a gender-ambiguous level.MethodsThe study used a prospective, experimental group design. Using a customized MATLAB program, vowels (/i/, /æ/, /ɑ/, and /u/) spoken by an adult were manipulated by isolating and increasing FF1–3 until they matched those of a woman. Listeners heard randomized samples and perceptually categorized each as male, female, or gender neutral. The latter two choices were combined and labeled not-male.ResultsChi-square analyses revealed that listeners rated samples as not-male for /ɑ/ and /æ/ with all three formants shifted or individual formants shifted at >60%. Individual analysis of vowels, formants, and shifted FF using Kruskal-Wallis revealed a statistical significance for vowels only.ConclusionsResults suggest that voice was convincingly perceived as not-male, for vowels characterized by a high F1 frequency, and that raising FFs for all four vowels increased (in varying amounts) the perception of voice femininity beyond that of raising F0 alone.



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Buckled Thyroid Cartilage: An Anatomic Variant

Publication date: Available online 24 August 2017
Source:Journal of Voice
Author(s): Brent A. Chang, Kimberly Luu, Ethan K. Newton, Murray D. Morrison
ObjectiveAnatomic abnormalities in the larynx can cause significant and bothersome symptoms. Identified here is an anatomical variant of the thyroid cartilage.Study DesignThis study is a retrospective case series of 11 subjects diagnosed with an anatomic variant of the thyroid cartilage.MethodsPatients with an anatomic inward buckling of the thyroid cartilage, termed here as buckled thyroid cartilage, were identified through a 20-year retrospective chart review of a tertiary care laryngology practice.ResultsWe describe 11 patients with fullness or asymmetry in the area of the false vocal fold and an associated inward buckling of the thyroid cartilage on computed tomography scan. All patients presented with a bothersome voice-related complaint. The most common presenting complaints were hoarseness (54%), globus sensation (45%), or vocal fatigue (27%). One patient was found to have a history of known laryngeal trauma. Surgical correction through an external approach on one patient was successfully performed with subsequent resolution of symptoms.ConclusionWe postulate that deformity and protrusion of the false vocal fold can result in a dampening effect on the vibratory capacity of the vocal fold that can lead to symptomatic hoarseness and vocal fatigue. Buckled thyroid cartilage is, therefore, an important anatomical variant to be aware of and be able to recognize.



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Normative data for diagnosing auditory processing disorder in Norwegian children aged 7–12 years

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Relational quality, illness interference, and partner support in Ménière’s disease

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Book review

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Normative data for diagnosing auditory processing disorder in Norwegian children aged 7–12 years

.


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Relational quality, illness interference, and partner support in Ménière’s disease

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Book review

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Normative data for diagnosing auditory processing disorder in Norwegian children aged 7–12 years

.


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Relational quality, illness interference, and partner support in Ménière’s disease

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Book review

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Marfanoid habitus is a nonspecific feature of Perrault syndrome.

Marfanoid habitus is a nonspecific feature of Perrault syndrome.

Clin Dysmorphol. 2017 Aug 21;:

Authors: Zerkaoui M, Demain LAM, Cherkaoui Jaouad I, Ratbi I, Amjoud K, Urquhart JE, O'Sullivan J, Newman WG, Sefiani A

Abstract
The objective of this study was to report the clinical and biological characteristics of two Perrault syndrome cases in a Moroccan family with homozygous variant c.1565C>A in the LARS2 gene and to establish genotype-phenotype correlation of patients with the same mutation by review of the literature. Whole-exome sequencing was performed. Data analysis was carried out and confirmed by Sanger sequencing and segregation. The affected siblings were diagnosed as having Perrault syndrome with sensorineural hearing loss at low frequencies; the female proband had primary amenorrhea and ovarian dysgenesis. Both affected individuals had a marfanoid habitus and no neurological features. Both patients carried the homozygous variant c.1565C>A; p.Thr522Asn in exon 13 of the LARS2 gene. This variant has already been reported as a homozygous variant in three other Perrault syndrome families. Both affected siblings of a Moroccan consanguineous family with LARS2 variants had low-frequency sensorineural hearing loss, marfanoid habitus, and primary ovarian insufficiency in the affected girl. According to the literature, this variant, c.1565C>A; p.Thr522Asn, can be correlated with low-frequency hearing loss. However, marfanoid habitus was been considered a nonspecific feature in Perrault syndrome, but we believe that it may be more specific than considered previously. This diagnosis allowed us to provide appropriate management to the patients and to provide more accurate genetic counseling to this family.

PMID: 28832386 [PubMed - as supplied by publisher]

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A homozygous missense variant in HSD17B4 identified in a consanguineous Chinese Han family with type II Perrault syndrome.

Related Articles

A homozygous missense variant in HSD17B4 identified in a consanguineous Chinese Han family with type II Perrault syndrome.

BMC Med Genet. 2017 Aug 23;18(1):91

Authors: Chen K, Yang K, Luo SS, Chen C, Wang Y, Wang YX, Li DK, Yang YJ, Tang YL, Liu FT, Wang J, Wu JJ, Sun YM

Abstract
BACKGROUND: Perrault syndrome is a rare multisystem disorder that manifests with sensorineural hearing loss in both sexes, primary ovarian insufficiency in females and neurological features. The syndrome is heterogeneous both genetically and phenotypically.
CASE PRESENTATION: We reported a consanguineous family (two affected sisters) with Perrault syndrome. The proband had the characteristics of Perrault syndrome: ovarian dysgenesis, bilateral hearing loss and obvious neurological signs. Target genetic sequencing and triplet repeat primed PCR (TP-PCR) plus capillary electrophoresis was conducted to detect causative mutations in the proband. The detected variant was further confirmed in the proband and tested in other family members by Sanger sequencing. Both the proband and her sister were found homozygous for the novel variant HSD17B4 c.298G > T (p.A100S) with their parents heterozygous. Detected by western blot, the protein expression of HSD17B4 mutant was much lower than that of the wild type in SH-SY5Y cells transfected by HSD17B4 wild type or mutant plasmid, which indicated the pathogenicity of the HSD17B4 mutation.
CONCLUSIONS: Our findings supported that HSD17B4 was one of the genes contributing to Perrault syndrome with the likely pathogenic variant c.298G > T (p.A100S). Special manifestations of cerebellar impairment were found in cases caused by HSD17B4 mutations. Besides, attention should be paid to distinguish Perrault syndrome from D-bifunctional protein deficiency and hereditary ataxia.

PMID: 28830375 [PubMed - in process]

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A novel splice site mutation of myosin VI in mice leads to stereociliary fusion caused by disruption of actin networks in the apical region of inner ear hair cells.

A novel splice site mutation of myosin VI in mice leads to stereociliary fusion caused by disruption of actin networks in the apical region of inner ear hair cells.

PLoS One. 2017;12(8):e0183477

Authors: Seki Y, Miyasaka Y, Suzuki S, Wada K, Yasuda SP, Matsuoka K, Ohshiba Y, Endo K, Ishii R, Shitara H, Kitajiri SI, Nakagata N, Takebayashi H, Kikkawa Y

Abstract
An unconventional myosin encoded by the myosin VI gene (MYO6) contributes to hearing loss in humans. Homozygous mutations of MYO6 result in nonsyndromic profound congenital hearing loss, DFNB37. Kumamoto shaker/waltzer (ksv) mice harbor spontaneous mutations, and homozygous mutants exhibit congenital defects in balance and hearing caused by fusion of the stereocilia. We identified a Myo6c.1381G>A mutation that was found to be a p.E461K mutation leading to alternative splicing errors in Myo6 mRNA in ksv mutants. An analysis of the mRNA and protein expression in animals harboring this mutation suggested that most of the abnormal alternatively spliced isoforms of MYO6 are degraded in ksv mice. In the hair cells of ksv/ksv homozygotes, the MYO6 protein levels were significantly decreased in the cytoplasm, including in the cuticular plates. MYO6 and stereociliary taper-specific proteins were mislocalized along the entire length of the stereocilia of ksv/ksv mice, thus suggesting that MYO6 attached to taper-specific proteins at the stereociliary base. Histological analysis of the cochlear hair cells showed that the stereociliary fusion in the ksv/ksv mutants, developed through fusion between stereociliary bundles, raised cuticular plate membranes in the cochlear hair cells and resulted in incorporation of the bundles into the sheaths of the cuticular plates. Interestingly, the expression of the stereociliary rootlet-specific TRIO and F-actin binding protein (TRIOBP) was altered in ksv/ksv mice. The abnormal expression of TRIOBP suggested that the rootlets in the hair cells of ksv/ksv mice had excessive growth. Hence, these data indicated that decreased MYO6 levels in ksv/ksv mutants disrupt actin networks in the apical region of hair cells, thereby maintaining the normal structure of the cuticular plates and rootlets, and additionally provided a cellular basis for stereociliary fusion in Myo6 mutants.

PMID: 28832620 [PubMed - in process]

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A novel splice site mutation of myosin VI in mice leads to stereociliary fusion caused by disruption of actin networks in the apical region of inner ear hair cells.

A novel splice site mutation of myosin VI in mice leads to stereociliary fusion caused by disruption of actin networks in the apical region of inner ear hair cells.

PLoS One. 2017;12(8):e0183477

Authors: Seki Y, Miyasaka Y, Suzuki S, Wada K, Yasuda SP, Matsuoka K, Ohshiba Y, Endo K, Ishii R, Shitara H, Kitajiri SI, Nakagata N, Takebayashi H, Kikkawa Y

Abstract
An unconventional myosin encoded by the myosin VI gene (MYO6) contributes to hearing loss in humans. Homozygous mutations of MYO6 result in nonsyndromic profound congenital hearing loss, DFNB37. Kumamoto shaker/waltzer (ksv) mice harbor spontaneous mutations, and homozygous mutants exhibit congenital defects in balance and hearing caused by fusion of the stereocilia. We identified a Myo6c.1381G>A mutation that was found to be a p.E461K mutation leading to alternative splicing errors in Myo6 mRNA in ksv mutants. An analysis of the mRNA and protein expression in animals harboring this mutation suggested that most of the abnormal alternatively spliced isoforms of MYO6 are degraded in ksv mice. In the hair cells of ksv/ksv homozygotes, the MYO6 protein levels were significantly decreased in the cytoplasm, including in the cuticular plates. MYO6 and stereociliary taper-specific proteins were mislocalized along the entire length of the stereocilia of ksv/ksv mice, thus suggesting that MYO6 attached to taper-specific proteins at the stereociliary base. Histological analysis of the cochlear hair cells showed that the stereociliary fusion in the ksv/ksv mutants, developed through fusion between stereociliary bundles, raised cuticular plate membranes in the cochlear hair cells and resulted in incorporation of the bundles into the sheaths of the cuticular plates. Interestingly, the expression of the stereociliary rootlet-specific TRIO and F-actin binding protein (TRIOBP) was altered in ksv/ksv mice. The abnormal expression of TRIOBP suggested that the rootlets in the hair cells of ksv/ksv mice had excessive growth. Hence, these data indicated that decreased MYO6 levels in ksv/ksv mutants disrupt actin networks in the apical region of hair cells, thereby maintaining the normal structure of the cuticular plates and rootlets, and additionally provided a cellular basis for stereociliary fusion in Myo6 mutants.

PMID: 28832620 [PubMed - in process]

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Using Electrically-evoked Compound Action Potentials to Estimate Perceptive Levels in Experienced Adult Cochlear Implant Users.

Hypothesis: The cochlear implant (CI) fitting level prediction accuracy of electrically-evoked compound action potential (ECAP) should be enhanced by the addition of demographic data in models. Introduction: No accurate automated fitting of CI based on ECAP has yet been proposed. Methods: We recorded ECAP in 45 adults who had been using MED-EL CIs for more than 11 months and collected the most comfortable loudness level (MCL) used for CI fitting (prog-MCL), perception thresholds (meas-THR), and MCL (meas-MCL) measured with the stimulation used for ECAP recording. Linear mixed models taking into account cochlear site factors were computed to explain prog-MCL, meas-MCL, and meas-THR. Results: Cochlear region and ECAP threshold were predictors of the three levels. In addition, significant predictors were the ECAP amplitude for the prog-MCL and the duration of deafness for the prog-MCL and the meas-THR. Estimations were more accurate for the meas-THR, then the meas-MCL, and finally the prog-MCL. Conclusion: These results show that 1) ECAP thresholds are more closely related to perception threshold than to comfort level, 2) predictions are more accurate when the inter-subject and cochlear regions variations are considered, and 3) differences between the stimulations used for ECAP recording and for CI fitting make it difficult to accurately predict the prog-MCL from the ECAP recording. Predicted prog-MCL could be used as bases for fitting but should be used with care to avoid any uncomfortable or painful stimulation. Copyright (C) 2017 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Clinical Characteristics of Benign Recurrent Vestibulopathy: Clearly Distinctive From Vestibular Migraine and Meniere's Disease?.

Objective: We aimed to systematically investigate the clinical characteristics of benign recurrent vestibulopathy (BRV), vestibular migraine (VM), and Meniere's disease (MD) and to assess whether clinical symptoms exist that are unique to BRV. Study Design: Prospective cohort study. Setting: Tertiary referral center. Methods: Between January 2015 and November 2016, patients were prospectively recruited at a specialized dizziness clinic. Patients were included if they met the diagnostic criteria for BRV, VM, or MD which was evaluated by simultaneous consultation of an otorhinolaryngologist and neurologist. All patients received a comprehensive clinical examination that included vestibular tests and pure-tone audiometry. A questionnaire was designed to systematically document symptoms of the three vestibular disorders. Results: A total of 122 patients were included in our study, 65 (53%) were females in whom 29 (24%) were postmenopausal. The mean age was 55.5 +/- 13.7 years and the mean age of onset of vertigo attacks was 49.2 +/- 14.8 years (n = 119). Forty-five (37%) patients had a clinical diagnosis of BRV, 34 (28%) of VM, and 43 (35%) of MD. No symptom could be identified which was specifically linked to BRV. In patients with BRV, similar to those with VM, we found a female preponderance (p = 0.05 in BRV, p = 0.001 in VM). Patients with VM reported significantly more often a positive history of motion sickness (p = 0.01). In addition, canal paresis was most profound in patients with MD (p = 0.001). Conclusion: We found no clinical characteristics that were distinctive for BRV. However, we did find several distinctive clinical features for VM and MD which may assist the physician in their history taking. Copyright (C) 2017 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Selective Stimulation of Facial Muscles Following Chronic Intraneural Electrode Array Implantation and Facial Nerve Injury in the Feline Model.

Background: Our group has previously shown that activation of specific facial nerve (FN) fiber populations and selective activation of facial musculature can be achieved through acute intraneural multichannel microelectrode array (MEA) implantation in the feline model. Hypothesis: Selective stimulation of facial muscles will be maintained in the setting of 1) chronic and 2) acute MEA implantation after FN injury and subsequent recovery. Methods: This study included seven cats. In three cats with normal facial function, 4-channel penetrating MEAs were implanted chronically in the FN and tested biweekly for 6 months. Electrical current pulses were delivered to each channel individually, and elicited electromyographic (EMG) voltage outputs were recorded for each of several facial muscles. For FN injury experiments, two cats received a standardized hemostat-crush injury, and two cats received a transection-reapproximation injury to the FN main trunk. These four underwent acute implantation of MEA and EMG recording in terminal experiments 4 months postinjury. Results: Stimulation through individual channels selectively activated restricted nerve populations, resulting in activation of individual muscles in cats with chronic MEA implantation and after nerve injury. Increasing stimulation current levels resulted in increasing EMG voltage responses in all patients. Nerve histology showed only minor neural tissue reaction to the implant. Conclusion: We have established in the animal model the ability of a chronically implanted MEA to selectively stimulate restricted FN fiber populations and elicit activations in specific facial muscles. Likewise, after FN injury, selective stimulation of restricted FN fiber populations and subsequent activation of discrete facial muscles can be achieved after acute MEA implantation. Copyright (C) 2017 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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