ORIGINAL ARTICLE

Computer-Assisted Voice Analysis

Establishing a Pediatric Database
Paolo Campisi, MD, MSc; Ted L. Tewfik, MD, FRCSC; John J. Manoukian, MD, FRCSC;
Melvin D. Schloss, MD, FRCSC; Elaine Pelland-Blais, MOA, SLP(C); Nader Sadeghi, MD, FRCSC

Objectives: To establish and characterize the first pe-
diatric normative database for the Multi-Dimensional
Voice Program, a computerized voice analysis system, and
to compare the normative data with the vocal profiles of
patients with vocal fold nodules.
Design: A cross-sectional, observational design was used
to establish the normative database. The comparative study
was completed using a case-control design.
Setting: University-based outpatient pediatric otolar-
yngology clinic.
Participants: One hundred control subjects (50 boys and
50 girls) aged 4 to 18 years contributed to the normative
database. The voices of 26 patients (19 boys and 7 girls)
with bilateral vocal fold nodules were also analyzed.
Main Outcome Measures: Demographic data, in-
cluding sex, age, height, weight, body mass index, and
cigarette smoke exposure, were obtained. The Multi-
Dimensional Voice Program extracted up to 33 acoustic
variables from each voice analysis.
Results: The mean (SEM) values of each of the acous-
tic variables are presented. At age 12 years, boys expe-
rience a dramatic decrease in fundamental frequency mea-
surements. The voices of patients with vocal fold nodules
had significantly elevated frequency perturbation mea-
surements compared with control subjects (P⬍.001).
Conclusions: The vocal profile of children is uniform
across all girls and prepubescent boys. Patients with vo-
cal fold nodules demonstrated a consistent acoustic pro-
file characterized by an elevation in frequency perturba-
tion measurements. Normal acoustic reference ranges may
be used to detect various vocal fold pathologic abnor-
malities and to monitor the effects of voice therapy.
Arch Otolaryngol Head Neck Surg. 2002;128:156-160

From the Departments of
Otolaryngology (Drs Campisi,
Tewfik, Manoukian, Schloss,
and Sadeghi) and
Speech-Language Pathology
(Ms Pelland-Blais), The
Montreal Children’s Hospital,
McGill University Health
Centre, Montreal, Quebec.
A
SSESSMENT OF pediatric
dysphonia has proven to
be problematic for speech
pathologists, pediatri-
cians, and otolaryngolo-
gists. Clinical judgments of vocal quality
have been commonly derived from sub-
jective grading systems rather than from
objective measures,1,2 which has resulted
in the development of inconsistent de-
scriptive terminology and severity classi-
fications. Furthermore, standard adult di-
agnostic modalities have demonstrated
limited usefulness in the assessment of pe-
diatric voice disorders.3,4 Fiberoptic en-
doscopy, for example, is often difficult and
rushed in the uncooperative child, and
stroboscopic examination is technically
challenging in any young patient.5
Computer-assisted voice analysis
represents an important diagnostic
advancement because it provides objec-
tive acoustic measurements, and it is
well tolerated by children.6,7 The Multi-
Dimensional Voice Program (MDVP), in
conjunction with the Computerized
Speech Lab (Kay Elemetrics Corp, Lin-
coln Park, NJ), is a highly versatile voice-
processing and spectrographic analysis
software package ideally suited for use in
the pediatric population.8 It provides an
objective, reproducible, and noninvasive
measure of vocal fold function. The
MDVP extracts up to 33 acoustic vari-
ables from each voice analysis and com-
pares them graphically or numerically
with a built-in normative database. The
normative data, however, were derived
solely from adults. It is apparent that a
pediatric database must be developed if
acoustic measures are to be applied to
the identification of pediatric vocal
pathologic abnormalities.
The main objective of this study,
therefore, was to establish and character-
ize the first pediatric normative database
for the MDVP. To our knowledge, a pe-
diatric normative database has not been

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 PARTICIPANTS AND METHODS
MDVP ANALYSIS
Apparatus
An IBM-compatible personal computer is used to operate
MDVP model 4305. The MDVP is used in combination with
Computerized Speech Lab model 4300. The Computer-
ized Speech Lab consists of a hardware and software sys-
tem that uses an MS-DOS–based computer as host. The
Computerized Speech Lab includes signal conditioning ca-
pability, 16-bit analog/digital converters, and dual digital
signal processors. The MDVP uses the signal conditioning
and analog/digital hardware to sample speech at 50 kHz
for sustained voicing.
The MDVP extracted up to 33 acoustic voice vari-
ables from each voice analysis. These variables were dis-
played numerically and graphically and were classified into
1 of 6 groups: (1) fundamental frequency information; (2)
frequency perturbation; (3) amplitude perturbation; (4)
noise and tremor evaluation; (5) voice break, subhar-
monic, and voice irregularity; or (6) miscellaneous. Defi-
nitions of the individual variables listed in Table 1 are avail-
able from the authors.
Technique
A consistent technique was used for each MDVP analysis.
Seated in a quiet room, the subject held a microphone at a
fixed distance (8 cm) and at a 45° off-axis position to re-
duce aerodynamic noise from the mouth. The subject was
then instructed to vocalize and sustain the vowel a 3 times
in a flat tone, at a comfortable pitch and a constant ampli-
tude. To standardize the input amplitude, the input signal
was adjusted to a predetermined level. This adjustment pre-
vented signal loss and system overloading. Each subject’s
third production of a was recorded. A 3-second voice sample
was captured and incorporated into the MDVP using a mi-
crophone (Visi-Pitch; Kay Elemetrics Corp). The voice
sample was not trimmed. The MDVP analysis was then per-
formed, and the acoustic voice variables were displayed.
ESTABLISHING THE NORMATIVE DATABASE
Control Subjects
One hundred control subjects (50 boys and 50 girls) aged
4 to 18 years contributed to the normative database. Sub-
jects were recruited from a pediatric otolaryngology out-
patient clinic (Montreal Children’s Hospital, Montreal,
Quebec). All subjects were healthy and had no history of
laryngeal or voice pathologic abnormalities. Patients with
moderate to severe conductive hearing loss or any degree
of sensorineural hearing loss were excluded from the study.
previously developed for this or any other computer-
assisted voice analysis system. Another objective of this
study was to evaluate the ability of the MDVP to iden-
tify vocal pathologic abnormalities. To achieve the lat-
ter objective, the normative data were compared with the
acoustic profiles of patients with vocal fold nodules us-
ing a case-control study design.
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Demographic data, including sex, age, height, weight, body
mass index, and cigarette smoke exposure, were obtained
for each subject. The absence of pathologic abnormalities
of the vocal fold was verified in each subject using indi-
rect mirror laryngoscopy or flexible nasolaryngoscopy. An
MDVP analysis was then performed, as described in the
“Technique” subsection. All laryngoscopies and voice analy-
ses were performed by a single observer (P.C.) to elimi-
nate interobserver variability.
Statistical Analysis
The normative data were analyzed using a statistical soft-
ware program (SPSS/PC+; SPSS Inc, Chicago, Ill). Back-
ward stepwise multiple linear regression was used to iden-
tify statistically significant associations between the acoustic
voice variables and the independent variables of sex, age,
height, weight, and body mass index. A 2-tailed P⬍.05 was
considered statistically significant. The mean (SEM) of each
acoustic variable was calculated.
CASE-CONTROL STUDY
Patients
Twenty-six patients (19 boys and 7 girls) with vocal fold
nodules, diagnosed using flexible nasolaryngoscopy, were
recruited into the study. All the patients had bilateral vo-
cal fold nodules at the junction of the anterior one third
and posterior two thirds of the vocal folds. The presence
of hemorrhagic nodules or other laryngeal pathologic ab-
normalities resulted in exclusion from the study. Re-
cruited patients were evaluated by a speech language pa-
thologist (E.P.-B.) and underwent a perceptual evaluation
of the voice. An MDVP analysis was then performed as de-
scribed in the “Technique” subsection.
Statistical Analysis
Determination of a statistically significant difference in voice
variable values between the control group and the vocal
fold nodule group was achieved using 1-way analysis of vari-
ance. Again, a 2-tailed P⬍.05 was considered statistically
significant.
If a statistically significant difference in a voice vari-
able was detected, a threshold value was assigned as the
upper limit of the 95% confidence interval (mean +
1.96⫻SD) of the control group value. Based on the thresh-
old value, data for the control and nodule groups were di-
chotomized, and a 2⫻2 table was constructed. A ␹2 test
was then used to assess the statistical significance of the
distribution of the dichotomized data. An odds ratio was
also calculated to quantify the association between the pres-
ence of vocal fold nodules and a voice variable value greater
than the assigned threshold value.
RESULTS
NORMATIVE DATABASE
Voice samples from 100 control subjects were used to
develop the normative database. Backward stepwise mul-
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 310
Table 1. Multidimensional Voice Program
Acoustic Variables in 94 Patients* 300

290 P = .23

Frequency, Hz
Variable Value,
280 P = .02
Acoustic Variable Symbol Mean (SEM)
270
Fundamental Frequency Information Measurements
Average fundamental frequency, Hz Fo 279.05 (5.79) 260
Average pitch period, ms To 3.71 (0.07) 250
Highest fundamental frequency, Hz Fhi 299.41 (6.38)
240
Lowest fundamental frequency, Hz Flo 260.73 (5.40) All Boys All Girls Boys <12 y
Standard deviation of the fundamental STD 4.86 (0.24)
frequency, Hz Figure 1. Fundamental frequency in all boys, all girls, and boys younger than
Phonatory fundamental frequency range, PFR 3.32 (0.13) 12 years. Values are expressed as mean ± 1.96 ⫻ SEM.
semitones
Fo tremor frequency, Hz Fftr 2.29 (0.15)
Amplitude tremor frequency, Hz Fatr 2.14 (0.15) Table 2. Demographic Characteristics of the Control
Frequency Perturbation Measurements and Vocal Fold Nodule Groups
Absolute jitter, µs Jita 45.67 (2.62)
Jitter, % Jitt 1.24 (0.07) Vocal Fold
Relative average perturbation, % RAP 0.75 (0.04) Control Group Nodule Group
Pitch period perturbation quotient, % PPQ 0.71 (0.04) Characteristic (n = 94) (n = 23)
Smoothed pitch period perturbation sPPQ 0.84 (0.04) Sex, M:F, No. 44:50 16:7
quotient, %
Age, mean (SD), y 8.1 (2.9) 9.1 (2.2)
Fundamental frequency variation, % vFO 1.75 (0.08)
Height, mean (SD), cm 127.7 (14.0) 130.4 (12.4)
Amplitude Perturbation Measurements Weight, mean (SD), kg 29.8 (11.3) 31.2 (12.6)
Shimmer, dB ShdB 0.29 (0.01) Body mass index, mean (SD), kg/m2 17.7 (3.2) 15.8 (4.1)
Shimmer, % Shim 3.35 (0.12) Cigarette smoke exposure, % 18.3 17.9
Amplitude perturbation quotient, % APQ 2.32 (0.08) Mild conductive hearing loss, % 19.4 15.3
Smoothed amplitude perturbation sAPQ 3.56 (0.11)
quotient, %
Peak amplitude variation, % vAM 15.10 (0.77)
3.5 ∗ Control Group
Noise and Tremor Evaluation Measurements Vocal Fold
Noise-harmonic ratio NHR 0.11 (0.002) 3.0 Nodule Group
Voice turbulence index score VTI 0.05 (0.002)
2.5
Soft phonation index score SPI 9.80 (0.968)
∗ ∗
Percentage

Fo tremor intensity index score, % FTRI 0.49 (0.034) 2.0 ∗

Amplitude tremor intensity index score, % ATRI 4.05 (0.328)
1.5
Voice Break, Subharmonic, and Voice Irregularity Measurements
1.0
Degree of voice breaks, % DVB 0
Degree of subharmonics, % DSH 1.66 (0.46) 0.5
Degree of voiceless, % DUV 0.04 (0.03)
No. of voice breaks NVB 0 0
Jitt RAP PPQ sPPQ
No. of subharmonic segments NSH 1.41 (0.39) Frequency Perturbation Measurement
No. of unvoiced segments NUV 0.03 (0.02)
Figure 2. Frequency perturbation measurements in the control and vocal fold
nodule groups. Asterisk indicates P⬍.001; Jitt, jitter; RAP, relative average
*Data derived from boys older than 12 years are excluded.
perturbation; PPQ, pitch period perturbation quotient; and sPPQ, smoothed
PPQ. Values are expressed as mean ± 1.96 ⫻ SEM.

tiple linear regression revealed a statistically significant
association between the fundamental frequency mea-
surements and the independent variables of age and sex.
This association was strongly affected by the peripubes-
cent changes in the male voice pattern. All other vari-
ables were not affected by age and sex. When boys 12
years and older were excluded from the analyses, the as-
sociation between the fundamental frequency measure-
ments and age and sex was not significant (Figure 1).
The independent variables of height, weight, and body
mass index were not associated with any of the acoustic
variables.
The mean value of each of the acoustic variables is
presented in Table 1. The corresponding SEM is also pre-
sented to provide an estimate of the variability in the popu-
lation at large. To eliminate the effect of peripubescent
voice changes on the fundamental frequency measure-
ments, the summary data in Table 1 do not include data
from boys 12 years and older.
CASE-CONTROL STUDY
Twenty-six patients (19 boys and 7 girls) with vocal fold
nodules were recruited into the case-control study. Three
boys older than 12 years were excluded. The voice pro-
files of the remaining 23 patients were compared with
the normative database that included all girls and boys
younger than 12 years. The demographic data for the 2
groups were similar (Table 2). Consistently, patients
with vocal fold nodules had statistically significant el-
evations in their frequency perturbation measurements
(absolute jitter, jitter percentage, relative average per-
turbation, pitch period perturbation quotient [PPQ], and
smoothed PPQ) (P⬍.001 for all) (Figure 2). The sig-

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 Table 3. Two-by-Two Tables Generated by Dichotomizing Data for Frequency Perturbation Measurements
in Individuals With and Without Vocal Fold Nodules*
Acoustic Threshold Value,
Variable Mean + 1.96 ⴛ SD†
Jita ⱕ95.23
⬎95.23
Jitt ⱕ2.52
⬎2.52
RAP ⱕ1.54
⬎1.54
PPQ ⱕ1.44
⬎1.44
sPPQ ⱕ1.54
⬎1.54
*OR indicates odds ratio; CI, confidence interval; Jita, absolute jitter; Jitt, jitter percentage; RAP, relative average perturbation; PPQ, pitch period perturbation
quotient; and sPPQ, smoothed PPQ.
†Threshold value equals the upper limit of the 95% CI of the control value. P⬍.001 by ␹2 test for all.
nificant increase in frequency perturbation measure-
ments corroborates the findings of the perceptual voice
evaluation performed by the speech language patholo-
gist. The perceptual evaluation revealed anomalies in the
control of pitch rather than in the control of intensity.
When the control (n = 94) and vocal fold nodule
(n=23) group data were dichotomized relative to the de-
fined normative threshold values (mean + 1.96⫻ SD), a
significant distribution of the data was observed for each
of the frequency perturbation measurements (P⬍.001 by
␹2 test). The calculated odds ratios suggest a high risk of
having vocal fold nodules with a variable value greater
than the assigned threshold value. The calculated odds
ratios range from 28.4 to 41.6, and the 95% confidence
intervals do not approach unity (Table 3).
COMMENT
The functional assessment of pathologic voices is com-
monly achieved using perceptual and equipment-based
clinical tools.1 Perceptual analyses such as the Wilson
Voice Profile System and the GRBAS (grade, roughness,
breathy, asthenic, strained) scale are based on the sub-
jective interpretation of the individual speech language
pathologist.1,2 The lack of consistency and standardiza-
tion in the basic methods of perceptual assessment con-
tinues to be a major clinical problem. Instrumental
diagnostic modalities such as video stroboscopy, elec-
troglottography, and phonetography are indispensable
components of a modern voice laboratory.1 These equip-
ment-based tools, however, require costly and special-
ized instrumentation, an experienced operator, coopera-
tive patients, and interpretation of complicated graphs
and mathematical formulas.
The assessment of pediatric dysphonia presents
unique challenges to the voice scientist. First, it is diffi-
cult for children to cooperate with lengthy, uncomfort-
able examinations. Fiberoptic endoscopy, for example,
is often rushed in the uncooperative child. Second, pe-
diatric normative data are unavailable. Therefore, the ques-
tion arises as to whether a given voice measurement is
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Group No.
Control Vocal Fold Nodule
(n = 94) (n = 23) OR (95% CI)
88 6 41.6 (12.0-144.4)
6 17
87 7 28.4 (8.8-92.1)
7 16
88 7 33.5 (10.0-112.9)
6 16
88 7 33.5 (10.0-112.9)
6 16
89 8 33.4 (9.6-115.8)
5 15
normal or pathologic and, if pathologic, how severe. Com-
puter-assisted voice analysis, such as the MDVP, repre-
sents a clinically important contribution to the assess-
ment of pediatric dysphonia. This system provides
objective and reproducible results. Assessments are non-
invasive, completed in a short time, and well tolerated
by patients as young as 4 years. However, the develop-
ment and characterization of a normative pediatric da-
tabase is a prerequisite to the application of this tech-
nology to the assessment of pediatric voice pathologic
abnormalities.
The main objective of this study was to establish and
characterize the first pediatric normative database for the
MDVP. Multiple linear regression was used to assess the
association between the derived acoustic variables and
the independent variables of age, sex, height, weight, and
body mass index. In general, we found that girls of all
ages and boys younger than 12 years had the same vocal
profiles. However, age and sex were significantly asso-
ciated with fundamental frequency measurements when
boys aged 12 years and older were included in the sta-
tistical analyses. Fundamental frequency measure-
ments in boys sharply decreased and approached adult
values beginning at age 12 years. No association was de-
tected between the acoustic variables and the indepen-
dent variables of height, weight, and body mass index.
Our findings are consistent with previously published
study results.9,10 Sussman and Sapienza9 examined the de-
velopmental and sex trends in fundamental frequency in
17 boys and 14 girls aged 6.1 to 9.2 years. They found
that the fundamental frequency for vowel production of
boys and girls (aged ⬍12 years) was not significantly dif-
ferent but were markedly different from men. Harries and
colleagues10 reported abrupt changes in male speaking
and singing fundamental frequencies during puberty be-
tween Tanner stages G3 and G4, corresponding to an av-
erage age of 13 years.
Vocal fold nodules are a common cause of pediat-
ric dysphonia. In fact, 38% to 78% of children evaluated
for chronic hoarseness have vocal fold nodules.11 Nod-
ules are the result of voice misuse or abuse, and they oc-
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cur at the junction of the anterior and middle third of
the vocal folds, often bilaterally. Nodules result from in-
jury to the superficial layer of the lamina propria and the
basement membrane zone caused by extensive vibra-
tion that destroys the tissue.12,13 An aberrant healing re-
sponse occurs with excessive deposition of collagen type
IV and fibronectin.
The normative acoustic data were compared with
the vocal profiles of patients with vocal fold nodules us-
ing a retrospective, case-control study design. Patients
with vocal fold nodules demonstrated a consistent acous-
tic profile characterized by markedly elevated fre-
quency perturbation measurements. This finding was ex-
emplified by abnormal jitter values. Jitter is defined as
the cycle-to-cycle variation of frequency.14 In other words,
it is a measure of unintended frequency unsteadiness dur-
ing prolonged phonation. This abnormality was corrobo-
rated by the perceptual analysis, which demonstrated an
inability of these patients to control pitch. Further-
more, several of our patients who were treated with voice
therapy demonstrated normalization of their frequency
perturbation measurements as the size of their nodules
decreased.
Abnormally elevated frequency perturbation mea-
surements in children with vocal fold nodules have been
reported in the literature.7,15,16 In a small series of 10 pa-
tients, aged 6 to 8 years, Kane and Wellen15 demon-
strated a correlation between perceptual severity rat-
ings and elevated PPQ measurements. In 1997, Boltezar
and colleagues16 failed to reveal an elevation in PPQ in
11 adolescents (aged 10-17 years) with vocal fold nod-
ules compared with a control group (jitter and relative
average perturbation were not measured). However, PPQ
measurements were abnormally elevated compared with
adult values published in the literature.
To evaluate the ability of the MDVP to detect vocal
pathologic abnormalities, the frequency perturbation mea-
surement data were dichotomized in controls and pa-
tients according to an assigned threshold value. The cal-
culated odds ratios strongly suggest that an elevated
frequency perturbation measurement is highly associ-
ated with the presence of vocal fold nodules. Indeed,
the strong statistical association suggests that the MDVP
may be useful in detecting early, subclinical pathologic
abnormalities and in monitoring treatment. The role of
the MDVP in detecting other vocal pathologic abnor-
malities, such as respiratory papillomatosis, polypoid
degeneration, and congenital sulcus vocalis, needs to be
further investigated.
In conclusion, the MDVP is an objective, noninva-
sive diagnostic tool that complements existing func-
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tional voice analysis modalities. It represents an impor-
tant advancement in the assessment of pediatric
dysphonia. The normative database may be used to re-
liably assess the voices of girls and prepubescent boys.
However, boys older than 12 years should be compared
with age-matched controls.
Accepted for publication September 10, 2001.
Presented in part at the 2000 Annual Meeting of The
American Academy of Pediatrics, Section on Otolaryngol-
ogy and Bronchoesophagology, Chicago, Ill, October 29,
2000.
We thank the Gustav Levinschi Foundation, Mon-
treal, Quebec, for donation of the Voice and Speech Labo-
ratory.
Corresponding author and reprints: Ted L. Tewfik, MD,
FRCSC, Director of Otolaryngology, The Montreal Children’s
Hospital, 2300 Tupper St, Suite B240, Montreal, Quebec,
Canada H3H 1P3.
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