OBJECTIVE: To establish a consensus protocol for telerehabilitation in speech therapy for voice disorders.
METHODS: The study was conducted according to a modified Delphi method. Twenty speech therapist or laryngologist experts of the French Society of Phoniatrics and Laryngology assessed 24 statements of voice telerehabilitation with a 10-point visual analog scale ranging from 1 (totally disagree) to 10 (totally agree). The statements were accepted if more than 80% of the experts rated the item with a score of ≥ 8/10. The statements with ≥ 8/10 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected.
RESULTS: The French Society of Phoniatrics and Laryngology experts validated 10, 6, and 2 statements after the first, second and third voting round, respectively. Seven statements did not reach agreement threshold and were rejected. The validated statements included recommendations for setting (N = 4), medical/speech history (N = 2), subjective voice evaluations (N = 3), objective voice quality measurements (N = 3), and voice rehabilitation (N = 5). The experts agreed for a follow-up consisting of combined telerehabilitation and in-office rehabilitation. The final protocol may be applied in context of pandemic but could be assessed out of pandemic period for patients located in rural regions.
CONCLUSIONS: This Delphi study established the first telerehabilitation protocol of the French Society of Phoniatrics and Laryngology for patients with voice disorders. Future controlled studies are needed to assess its feasibility, reliability, and the patient perception about telerehabilitation versus in-office rehabilitation.

BACKGROUND: Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) is a widely used perceptual evaluation scale for voice assessment. It is adapted in many regional languages worldwide. This systematic review will help critically evaluate the methodologies used to adapt and establish CAPE-V as a valid and reliable tool.
METHODS: Authors reviewed literature in search engines (Scopus, Google Scholar, PubMed) to identify studies published in English between 2002-2020. The CAPE-V translated and adapted for linguistic or cultural variations were included for the review. The studies were compiled using the Mendeley Reference Manager and screened for title/abstract before shortlisting the studies.
RESULTS: The initial database had 3459 search results and after duplicates removal, 1535 articles were analysed. Thirteen studies were narrowed based on title/abstract screening. A final of ten studies were selected for the review.
CONCLUSIONS: This review provided a comprehensive understanding of the challenges encountered during cross-cultural adaptation and will help future researchers choose a suitable adaptation method.

BACKGROUND: Since the beginning of the new pandemic, COVID-19 health services have had to face a new scenario. Voice therapy faces a double challenge, interventions using telepractice, and delivering rehabilitation services to a growing population of patients at risk of functional impairment related to the COVID-19 disease. Moreover, as COVID-19 is transmitted through droplets, it is critical to understand how to mitigate these risks during assessment and treatment.
OBJECTIVE: To promote safety, and effective clinical practice to voice assessment and rehabilitation in the pandemic COVID-19 context for speech-language pathologists.
METHODS: A group of 11 experts in voice and swallowing disorders from five different countries conducted a consensus recommendation following the American Academy of Otolaryngology-Head and Neck Surgery rules building a clinical guide for speech-language pathologists during this pandemic context.
RESULTS: The clinical guide provides 65 recommendations for clinicians in the management of voice disorders during the pandemic and includes advice from assessment, direct treatment, telepractice, and teamwork. The consensus was reached 95% for all topics.
CONCLUSIONS: This guideline should be taken only as recommendation; each clinician must attempt to mitigate the risk of infection and achieve the best therapeutic results taking into account the patient\'s particular reality.

Purpose The purpose of this document is threefold: (a) review the uses of the terms \"vocal fatigue,\" \"vocal effort,\" \"vocal load,\" and \"vocal loading\" (as found in the literature) in order to track the occurrence and the related evolution of research; (b) present a \"linguistically modeled\" definition of the same from the review of literature on the terms; and (c) propose conceptualized definitions of the concepts. Method A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scientific Electronic Library Online. Four terms (\"vocal fatigue,\" \"vocal effort,\" \"vocal load,\" and \"vocal loading\"), as well as possible variants, were included in the search, and their usages were compiled into conceptual definitions. Finally, a focus group of eight experts in the field (current authors) worked together to make conceptual connections and proposed consensus definitions. Results The occurrence and frequency of \"vocal load,\" \"vocal loading,\" \"vocal effort,\" and \"vocal fatigue\" in the literature are presented, and summary definitions are developed. The results indicate that these terms appear to be often interchanged with blurred distinctions. Therefore, the focus group proposes the use of two new terms, \"vocal demand\" and \"vocal demand response,\" in place of the terms \"vocal load\" and \"vocal loading.\" We also propose standardized definitions for all four concepts. Conclusion Through a comprehensive literature search, the terms \"vocal fatigue,\" \"vocal effort,\" \"vocal load,\" and \"vocal loading\" were explored, new terms were proposed, and standardized definitions were presented. Future work should refine these proposed definitions as research continues to address vocal health concerns.

OBJECTIVE: To develop a summary of the first version of the Clinical Practice Guideline of Voice Disorders for Diagnosis, Management, and Treatment in Japan by the Clinical Practice Guideline Committee of the Japan Society of Logopedics and Phoniatrics and The Japan Laryngological Association. The 2018 recommendations, based on a review of the scientific literature, are intended to serve as clinical practice guidelines for the diagnosis, management, and treatment of voice disorders in Japan.
METHODS: A summary of the original version of the Clinical Practice Guideline of Voice Disorders for Diagnosis, Management, and Treatment in Japan was described. Recommendations for the diagnosis, management, and treatment of voice disorders were prepared. Twelve clinical questions (CQs) regarding the diagnosis, management, treatment, and effectiveness of therapy for voice disorders were also prepared.
RESULTS: A summary of the first version of the clinical practice guidelines for the diagnosis, management, and therapy of voice disorders was prepared and is presented. Additionally, answers to the 12 CQs on the diagnosis, management, treatment, and effectiveness of voice disorder therapy were prepared, and include evidence-based recommendations.
CONCLUSIONS: These guidelines present a summary of the standard approaches for the diagnosis and treatment of voice disorders and relevant CQs that consider the medical environments in Japan. We hope that the guidelines will assist physicians in clinical settings for patients with voice disorders.

OBJECTIVE: The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was developed to assess voice quality. The aim of this study was to develop a Turkish adaptation of CAPE-V and to evaluate the reliability and validity of the Turkish version.
METHODS: To adapt the CAPE-V protocol to Turkish, six sentences were constructed to meet the phonetic requirements. The validity of the Turkish version of the CAPE-V was tested with inter-rater reliability, intrarater reliability, and GRBAS versus the CAPE-V judgments. Ninety-nine dysphonic and 83 healthy subjects were enrolled.
RESULTS: High inter-rater and intrarater reliability (ICC > 0.88, r > 0.81, respectively) were obtained for all vocal parameters. The differences in the six CAPE-V parameters between healthy and dysphonic subjects were statistically significant (P < 0.0001). The correlations between CAPE-V and GRBAS scales were high in overall severity-grade and roughness parameters (r = 0.85, r = 0.82, respectively), the lowest correlation was the strain parameter (r = 0.66).
CONCLUSIONS: The Turkish version of CAPE-V is a reliable and valid instrument for auditory-perceptual evaluation of the Turkish speaking population.

OBJECTIVE: The purpose of this study was to assure a reliable and valid European Portuguese (EP) version of Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). This resulted in the second EP version of CAPE-V (II EP CAPE-V), with permission granted by American Speech-Language-Hearing Association.
METHODS: This is a transversal, observational, descriptive, and comparative study.
METHODS: Retranslation of CAPE-V into EP was reviewed by an EP linguistic expert for content validity. A total of 20 subjects: 10 male individuals (mean age = 45) and 10 female individuals (mean age = 43) formed a control group (n = 10) and a dysphonic group (n = 10) were matched by age and gender. All subjects\' CAPE-V phonatory tasks were captured with PEYLE PMENI (China) microphone and recorded with TASCAM DR-05 (Tokyo, Japan). Fourteen speech-language pathologists voice experts (>5 years of clinical practice) rated 26 voice samples with 6 repeated samples added for intrarater reliability. All voice samples were heard using AKG K101 (Europe) headphones and were rated in two sessions with a 1-week interval: one with the II EP CAPE-V; and the second with the GRBAS scale to establish for inter-rater reliability and construct and concurrent validity. Statistical analysis for inter-rater reliability was obtained with the intraclass correlation coefficient. Intrarater reliability was obtained with Pearson correlation. Construct and concurrent validity were performed with Student t test and multiserial correlation coefficient, respectively. SPSS 22.0 (IBM Corp, Armonk, NY) and LISREL 8.8 (Scientific Software International, Inc, Chicago, IL) were used with significance level cut-off points: r > 0.70 and α = 0.05.
RESULTS: High inter-rater reliability was obtained for all vocal parameters (intraclass correlation coefficient  > 0.84) revealing good equivalence. Intrarater reliability was high (r > 0.87) for overall severity, breathiness, and pitch; good (r = 0.73) for strain; and moderate (r > 0.61) for roughness and loudness. These results revealed good reproducibility and stability of the II EP CAPE-V over time. Content validity was assured by an EP linguistic expert. Construct validity was obtained for all vocal parameters (P < 0.05), except for strain (P = 0.52), revealing these were the salient parameters for rating normal and dysphonic voices samples. Concurrent validity between the II EP CAPE-V and the GRBAS scales had strong correlations (r > 0.89) for overall severity/grade, roughness, and breathiness parameters, suggesting both instruments measure the same construct.
CONCLUSIONS: The II EP CAPE-V is a reliable and valid instrument for auditory-perceptual evaluation of the EP population, with all psychometric measures assured.

A roadblock for research on adductor spasmodic dysphonia (ADSD), abductor SD (ABSD), voice tremor (VT), and muscular tension dysphonia (MTD) is the lack of criteria for selecting patients with these disorders.
To determine the agreement among experts not using standard guidelines to classify patients with ABSD, ADSD, VT, and MTD, and develop expert consensus attributes for classifying patients for research.
From 2011 to 2016, a multicenter observational study examined agreement among blinded experts when classifying patients with ADSD, ABSD, VT or MTD (first study). Subsequently, a 4-stage Delphi method study used reiterative stages of review by an expert panel and 46 community experts to develop consensus on attributes to be used for classifying patients with the 4 disorders (second study). The study used a convenience sample of 178 patients clinically diagnosed with ADSD, ABSD, VT MTD, vocal fold paresis/paralysis, psychogenic voice disorders, or hypophonia secondary to Parkinson disease. Participants were aged 18 years or older, without laryngeal structural disease or surgery for ADSD and underwent speech and nasolaryngoscopy video recordings following a standard protocol.
Speech and nasolaryngoscopy video recordings following a standard protocol.
Specialists at 4 sites classified 178 patients into 11 categories. Four international experts independently classified 75 patients using the same categories without guidelines after viewing speech and nasolaryngoscopy video recordings. Each member from the 4 sites also classified 50 patients from other sites after viewing video clips of voice/laryngeal tasks. Interrater κ less than 0.40 indicated poor classification agreement among rater pairs and across recruiting sites. Consequently, a Delphi panel of 13 experts identified and ranked speech and laryngeal movement attributes for classifying ADSD, ABSD, VT, and MTD, which were reviewed by 46 community specialists. Based on the median attribute rankings, a final attribute list was created for each disorder.
When classifying patients without guidelines, raters differed in their classification distributions (likelihood ratio, χ2 = 107.66), had poor interrater agreement, and poor agreement with site categories. For 11 categories, the highest agreement was 34%, with no κ values greater than 0.26. In external rater pairs, the highest κ was 0.23 and the highest agreement was 38.5%. Using 6 categories, the highest percent agreement was 73.3% and the highest κ was 0.40. The Delphi method yielded 18 attributes for classifying disorders from speech and nasolaryngoscopic examinations.
Specialists without guidelines had poor agreement when classifying patients for research, leading to a Delphi-based development of the Spasmodic Dysphonia Attributes Inventory for classifying patients with ADSD, ABSD, VT, and MTD for research.

Objective This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia. Purpose The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology-head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology. Action Statements The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia. Disclaimer This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia.

Objective This guideline provides evidence-based recommendations on treating patients presenting with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia. Purpose The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology-head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology. Action Statements The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include but are not limited to recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids in patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia. Differences from Prior Guideline (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia.