Original article
The Use of the Mobile Voice Laboratory in the Operating Room During Type I Thyroplasty With Gore-Tex®
Uso del laboratorio móvil de voz en la sala de operaciones durante tiroplastia tipo I con Gore-Tex®
Marco Guzmana,b,
, Crystal Colemanc, Adam D. Rubind,e, Joseph Belangerf, Cristina Jackson-Menaldid,g
Corresponding author
a Lakeshore Professional Voice Center and Department of Otolaryngology, School of Medicine, Wayne State University, Detroit, MI, USA
b Professor at School of Communication Sciences, University of Chile, Santiago, Chile
c Otolaryngology/Facial Plastic Surgery Resident, POH Regional Medical Center, Pontiac, MI, USA
d Lakeshore Ear, Nose and Throat Center, Lakeshore Professional Voice Center, St. Clair Shores, MI, USA
e Department of Otolaryngology-HNS, University of Michigan Medical Center, Ann Arbor, MI, USA
f Otolaryngology Lakeshore Ear, Nose and Throat Center, Lakeshore Professional Voice Center, St. Clair Shores, MI, USA
g School of Medicine, Wayne State University, Detroit, MI, USA
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Type I thyroplasty is probably the most frequently used permanent surgical intervention and should be performed only once it has been determined that the vocal fold will not regain function. It is typically performed when the patient is awake, so that he or she may perform phonatory tasks to help the surgeon design the optimal implant. The surgeon must work quickly, as intraoperative edema will affect the voice and make it difficult to determine when the ideal implant has been fashioned.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A number of implant materials have been described for type I thyroplasty, including silastic,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Gore-Tex<span class="elsevierStyleSup">®</span>,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> hydroxylapatite,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and others. An advantage of Gore-Tex<span class="elsevierStyleSup">®</span> is that subtle alterations may be made to the implanted Gore-Tex<span class="elsevierStyleSup">®</span> during the procedure without removing it or needing to recarve a more solid implant. This allows for quicker fine-tuning of the voice.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The success of the surgery is dependent on the ability of the surgeon to fashion and position an implant to create the ideal glottic configuration to yield the strongest voice. The surgeon's ear and ability to perceptually analyze the voice are critical.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Some have suggested, however, that fewer than 50% of surgeons’ expected outcomes based on perceptual judgments are predictable due to the complexity of voice production.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Therefore, having the ability to obtain intra-operative objective voice measures could help in the decision-making process. Certainly the surgeon's ear is the primary determinant, but using the mobile voice laboratory provides additional data that may facilitate the surgeon's decision to alter the implant.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Objective voice analysis, assessment, and treatment by the voice pathologist are valuable in the care of the patient with UVFP. In some cases, voice therapy alone may provide significant improvement in voice quality and obviate the need for surgery.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In all cases, the voice pathologist can provide detailed preoperative and postoperative assessment.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Objective voice data are obtained through computerized voice analysis. Such data are useful for evaluating efficacy of treatment. Computerized voice analysis can also be performed on recordings of patients’ voices prior to their injury (e.g. from an answering machine recording, home video, or professional recording) and in the operating room. This additional data may help the surgeon design an implant to try to recover the patient's pre-injury voice.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The purposes of this study are to demonstrate the use of the mobile voice lab in type I thyroplasty with Gore-Tex<span class="elsevierStyleSup">®</span> using analysis of spectrogram and fundamental frequency in the operating room, and also to show how to do this procedure.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">An exemption was obtained from the institutional review board for the publication of this study. This retrospective study included 8 male and 7 female patients with UVFP who were selected from Lakeshore Professional Voice Center, Lakeshore Ear, Nose and Throat Center. Initial diagnosis of UVFP was made with dynamic voice evaluation and videostroboscopy by a laryngologist (ADR). A formal computerized voice evaluation was then performed by a voice pathologist (CJM). The evaluation includes a complete detailed objective and perceptual analysis of the patient's digitally DAT recorded with a Professional Voice Recorder Marantz (PMD670) and the recording analyzed with the Kay CSL 4400. A perceptual voice analysis (GRBAS scale) and V-RQOL questionnaire (voice-related quality of life) are also performed during the initial voice evaluation.The V-RQOL is a validated, patient-completed, 10 item, five-point instrument that measures the physical and social/emotional impact of dysphonia. A standard algorithm is used to calculate domain or overall score from 0 to 100, with higher scores indicating better VRQOL.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">During type I thyroplasty in operating room, objective measures using fundamental frequency and narrow band spectrogram are taken immediately before the procedure and as the implant is fashioned until the optimal subjective voice quality is achieved and judged by the laryngologist and voice pathologist. The spectrographic analysis and fundamental frequency obtained help to compare the voice before and during the procedure. The fundamental frequency and spectral analysis are obtained using a real time spectrogram with a narrow band filter, sample rate recording at 44.1<span class="elsevierStyleHsp" style=""></span>kHz, and a view cut spectrogram at 4<span class="elsevierStyleHsp" style=""></span>kHz. To test the voice, the patient is asked to produce the following phonatory tasks: sustained vowel /a/, days of the week, months, sing “Happy Birthday”, and perform a glissando in a supine position. The narrow-band analysis is preferred because the goal is to display frequency resolution, as in the analysis of harmonics for a human's voice.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The mobile voice laboratory consists of a laptop computer with Windows XP, a pre-amplifier M-Audio, a condenser professional microphone Shure 16-A, and real-time spectrogram software (WaveSurfer<span class="elsevierStyleSup">®</span> version 1.5.8 and Audio<span class="elsevierStyleSup">®</span> version 1.0) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). These programs can be opened in multiple windows, so multiple samples can be analyzed simultaneously. Therefore, precious time is not wasted during the procedure. The patient's new voice, with the Gore-Tex<span class="elsevierStyleSup">®</span> in place, is compared to the recordings and voice parameters of the pre-paralyzed vocal fold voice. It is important that the patient is not sedated during this part of the procedure.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Fundamental frequency and spectrograms were compared in every patient from recordings from preoperative assessment, during the procedure, and six weeks postoperatively (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Spectrogram prints without sound were evaluated by a blind panel of four judges on a 100<span class="elsevierStyleHsp" style=""></span>mm visual analogue scale, where 0=no harmonics are present in the spectrogram, only noise, and 100=there are only harmonics from the bottom to the top of the spectrogram. No noise is present. Using external judges with expertise in reading spectrograms without using perceptual analysis of the same phonatory tasks before, during and after surgery allows us to know if the mobile voice laboratory in the operating room helps the laryngologist to have another tool besides the perceptual voice judgment to decide how much implant the patient needs. Raters were asked to mark with an “x” the point of the visual analogue scale which best describes the spectrogram. All three time points were compared and statistical analysis performed. The four judges were voice pathologists with more than 10<span class="elsevierStyleHsp" style=""></span>years of experience in voice disorders and acoustical analysis of voice.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Raters were given written instructions with forty-five spectrogram pictures; fifteen before surgery, fifteen during surgery, and fifteen postoperative. All spectrograms were ordered randomly to avoid pattern recognition. Raters were allowed to see every spectrogram as many times as needed to make their assessments.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using SPSS<span class="elsevierStyleSup">®</span> v.18.0 for Windows. Reliability analysis and the inter-class correlation coefficient (ICC) were applied to measure the inter-rater agreement in the spectrogram rates. Repeated measures analysis of variance (ANOVA) also was applied to test for differences over time (preoperative versus postoperative). <span class="elsevierStyleItalic">P</span> value <.05 was considered statistically significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Fifteen patients (eight male and seven female) with UVFP were included in this study. Fundamental frequency and spectrograms were compared in every patient via recordings from the preoperative assessment, during the procedure, and six weeks postoperatively. The mean ratings and standard deviations for the spectrogram judgment on a 100<span class="elsevierStyleHsp" style=""></span>mm visual analogue scale are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Mean values for preoperative spectrograms were rated at 24.65, intraoperative spectrograms at 56.40, and six-week postoperative spectrograms at 43.62. These results show a significant change in the judges’ ratings over the three times points (before, during, and after). The mean differences of before, during and after are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Significant statistical differences were observed between before/during, and before/after. No significant difference was observed between during and after scores.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The reliability analysis and the ICC measured the inter-rater agreement in the spectrogram rates, considering the three time points (before, during and after). The overall ICC value was 0.546 (<span class="elsevierStyleItalic">P</span><.001). This data shows consistency between the judges’ evaluation of the spectrograms.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The average and standard deviations for fundamental frequency (F0) are presented in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. Even though there is a trend in F0 change (male F0 decreases, female F0 increases), the time–gender interaction is not statistically significant.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The pre-thyroplasty median V-RQOL score was 48.08, whereas the post-thyroplasty median score was 85.08. The average difference from initial to final V-RQOL measurement was an increase of 44<span class="elsevierStyleHsp" style=""></span>units. The final V-RQOL measurements were significantly higher than the initial VRQOL measurements (<span class="elsevierStyleItalic">P</span><.001).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The primary goal of a type-I thyroplasty is to improve glottic closure; thus improving patient voice and swallowing function.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The “ideal” glottic configuration is the one that yields the optimal voice quality. The patient should be kept awake during thyroplasty, so that his or her voice may be tested and heard. Thus, the shape and placement of the implant may be altered to improve vocal quality. The surgeon's ability to perceptually analyze the voice during the procedure in an expedient fashion is critical. This ability will vary amongst even technically gifted surgeons. Having the ability to obtain intra-operative objective voice measures may assist the surgeon in the decision-making process.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The spectrogram demonstrates the strength of the harmonics in a voice sample. Improvement in spectral pattern can be monitored in the operating room and is a useful measure of the improvement in vocal quality. As the voice becomes clearer, the spectrogram demonstrates less “noise”, and the harmonics extend into higher frequencies. The judges in the study demonstrated a significant improvement in the intraoperative spectrograms compared to preoperative ratings. Although the ratings 6-weeks postoperatively were slightly worse, there was no significant difference from the intraoperative scores. The 6-week scores were significantly better than the preoperative ratings. This suggests that the improvement seen in spectral pattern intraoperatively is maintained even when postoperative swelling resolves.</p><p id="par0100" class="elsevierStylePara elsevierViewall">One criticism of the study is that it is difficult to rate spectrograms. We used a visual analogue scale to try to obtain a numerical score for each spectrogram. Although this is not a validated outcome measure, inter-rater reliability was fairly good.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although the F0 ANOVA pair-wise comparisons were not statistically significant, the trend of the F0 makes sense. Male voices with UVFP tend to start out higher in frequency, as they strain to obtain stronger voice. As the glottic insufficiency is corrected, the male F0 should be lower. The fundamental frequency of a woman's voice tends to drop with a vocal fold paralysis. However, once glottic closure is improved, the F0 should rise.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Harries and Morrison<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> wrote, “the degree of patient satisfaction is one of the most important parameters of the success of surgical treatment, perhaps more than any objective changes”. The V-RQOL is a validated voice outcome measure. The statistical significance of the student t-test analysis performed upon the V-RQOL data indicated a high patient satisfaction rating six weeks after surgery (<span class="elsevierStyleItalic">P</span><.001). Hogikyan et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> performed a similar V-RQOL analysis upon post-thyroplasty patients at the University of Michigan in 2000. The improvement demonstrated in our study is consistent with their findings. The study does not prove that using the mobile voice laboratory yields better voice results during thyroplasty than using only the surgeon's ear. However, it does demonstrate that the improvement seen in these patients’ spectrogram scores is consistent with improvement in their own perceptions of their voice quality.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The UVFP patient's best chance of achieving an optimal voice is with the first thyroplasty. Revision surgeries tend to be difficult and risky.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> Intraoperative vocal fold edema will affect the patient's voice and may compromise the ultimate result of the surgery. The surgeon must proceed in a timely manner to get the truest assessment of vocal quality. The use of Gore-Tex<span class="elsevierStyleSup">®</span> allows the surgeon to make millimeter adjustments without taking the time to remove and recarve a traditional silastic implant. Using the mobile voice laboratory provides additional data that can facilitate the surgeon's decisions to alter the implant.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Other problems with this study include a small sample size and the fact that it is a retrospective study. Unfortunately, only a fraction of the patients on whom we performed thyroplasty completed a postoperative voice evaluation. Furthermore, a prospective study comparing thyroplasty results when and when not using the mobile voice laboratory might better demonstrate its usefulness. Such a study could be considered in the future. However, the purpose of this study was not to suggest that the mobile voice laboratory is required to perform this surgery well. Rather, we are suggesting that it may be a useful tool to assist the surgeon. Furthermore, by bringing the voice pathologist into the operating room, a collaborative, team approach to the voice patient is continued.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Intra-operative objective voice measures can be useful in the decision making process during type I thyroplasty with Gore-Tex<span class="elsevierStyleSup">®</span>. Although subjective assessment of voice quality is critical while fashioning an implant, the mobile voice laboratory provides additional objective data which may help the surgeon make timely decisions. The real time spectrogram and fundamental frequency can be analyzed in the operating room despite the background noise of the operating equipment, unlike many other voice parameters. Improvement in spectrogram persists at the 6-week postoperative evaluation. The mobile voice laboratory also provides an opportunity for the surgeon and voice pathologist to continue to collaborate in the treatment of the patient with UVFP.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres95033" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction and objective" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec82185" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres95032" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción y objetivos" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec82184" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-02-29" "fechaAceptado" => "2012-03-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82185" "palabras" => array:4 [ 0 => "Spectrogram" 1 => "Mobile voice laboratory" 2 => "Unilateral vocal fold paralysis" 3 => "Type I thyroplasty" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82184" "palabras" => array:4 [ 0 => "Espectrografía" 1 => "Laboratorio móvil de voz" 2 => "Parálisis unilateral de cuerda vocal" 3 => "Tiroplastia tipo I" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The purposes of this study are to demonstrate the use of the mobile voice lab in type I thyroplasty with Gore-Tex<span class="elsevierStyleSup">®</span> using analysis of spectrogram and fundamental frequency in the operating room, and also to show how to do this procedure.</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Voice samples were recorded in the operating room immediately before and during type I thyroplasty. Six-week postoperative samples were also taken in the voice laboratory. Fundamental frequency and spectral analysis were analyzed. Spectrograms were evaluated by a blind panel of 4 judges on a 100<span class="elsevierStyleHsp" style=""></span>mm visual analogue scale. All three time points were compared and statistical analysis performed. Pre and postoperative V-RQOL scores were also compared.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Significant improvement in spectrogram ratings were seen between before and during (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001), and before and after voice samples (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.017). There was no significant difference between during and after scores, suggesting the persistence of the intraoperative improvement in this measure. Changes in fundamental frequency were not statistically significant, although fundamental frequency tended to increase in women and decrease in men after type I thyroplasty. Mean V-RQOL scores improved from 48.08 to 85.08 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001).</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The mobile voice laboratory may be useful during type I thyroplasty with Gore-Tex<span class="elsevierStyleSup">®</span>. It offers an opportunity for the surgeon and voice pathologist to continue to collaborate in the treatment of patients with unilateral vocal fold paralysis.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los objetivos de este estudio fueron la demostración del uso del laboratorio móvil de voz durante la tiroplastia tipo I con Gore-Tex<span class="elsevierStyleSup">®</span>, utilizando análisis de espectrograma y frecuencia fundamental en el quirófano, además de mostrar el modo de realización de este procedimiento.</p> <span class="elsevierStyleSectionTitle">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las muestras de voz fueron grabadas en la sala de operaciones inmediatamente antes, y durante la tiroplastia tipo I. También se tomaron muestras 6 semanas después de la cirugía. Se realizó un análisis de la frecuencia fundamental, y un análisis espectral de la voz. Los espectrogramas fueron evaluados por 4 jueces externos, utilizando una escala visual de 100 mm. Se compararon los 3 puntos temporales (antes, durante y después), y posteriormente se realizó un análisis estadístico. Adicionalmente se realizó una comparación de las puntuaciones del cuestionario V-RQOL pre y poscirugía.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se obtuvo una mejoría significativa de los valores de los espectrogramas tomados antes y durante la cirugía (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001), y antes y después de la cirugía (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,017). No hubo diferencia entre las muestras tomadas durante y después, resaltando la importancia de la mejoría intraoperatoria de esta medición. Los cambios en la frecuencia fundamental no fueron estadísticamente significativos, aunque este parámetro mostró una tendencia al incremento en mujeres y una disminución en varones tras la tiroplastia. El promedio del cuestionario V-RQOL experimentó un incremento de 48,08 a 85,08 (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001).</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los resultados muestran que el laboratorio móvil de voz puede ser útil durante la tiroplastia tipo I con Gore-Tex<span class="elsevierStyleSup">®</span>. Esta herramienta ofrece una oportunidad de colaboración conjunta entre el cirujano y el logopeda en el tratamiento de pacientes con parálisis unilateral de cuerda vocal.</p>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Guzman M, et al. Uso del laboratorio móvil de voz en la sala de operaciones durante tiroplastia tipo I con Gore-Tex<span class="elsevierStyleSup">®</span>. Acta Otorrinolaringol Esp. 2012;63:364–9.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara">Work presented at the 39th Annual Symposium of the Voice Foundation, on June 5th, 2010, Philadelphia, PA, USA.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1563 "Ancho" => 2083 "Tamanyo" => 487687 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Use of the mobile voice laboratory in the operating room.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1155 "Ancho" => 3258 "Tamanyo" => 472730 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Spectrograms, preoperative assessment, during the procedure, and six weeks postoperatively.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">During \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.67 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.30 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179886.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The Mean Ratings and Standard Deviations for the Spectrogram Judgment on a 100<span class="elsevierStyleHsp" style=""></span>mm Visual Analogue Scale.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Measure 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Measure 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Significance \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">During \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.017 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">During \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.197 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179887.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The Main Differences of Preoperative, Intraoperative and Postoperative Ratings.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">F0 before</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">179.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">156.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">F0 during</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">188.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">158.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">F0 after</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">191.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">149.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179885.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The Average and Standard Deviations for F0.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La voz patológica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 1 | 0 | 1 |
| 2021 March | 0 | 1 | 1 |
| 2021 February | 0 | 2 | 2 |
| 2021 January | 0 | 2 | 2 |
| 2020 October | 0 | 1 | 1 |
| 2020 August | 0 | 1 | 1 |
| 2020 March | 13 | 5 | 18 |
| 2020 February | 15 | 5 | 20 |
| 2020 January | 23 | 6 | 29 |
| 2019 December | 25 | 16 | 41 |
| 2019 November | 13 | 8 | 21 |
| 2019 October | 11 | 4 | 15 |
| 2019 September | 11 | 4 | 15 |
| 2019 August | 9 | 0 | 9 |
| 2019 July | 17 | 16 | 33 |
| 2019 June | 27 | 17 | 44 |
| 2019 May | 91 | 49 | 140 |
| 2019 April | 37 | 13 | 50 |
| 2019 March | 3 | 3 | 6 |
| 2019 February | 8 | 3 | 11 |
| 2019 January | 5 | 5 | 10 |
| 2018 December | 2 | 1 | 3 |
| 2018 November | 13 | 3 | 16 |
| 2018 October | 8 | 3 | 11 |
| 2018 April | 5 | 3 | 8 |
| 2018 March | 4 | 1 | 5 |
| 2018 February | 9 | 1 | 10 |
| 2018 January | 6 | 2 | 8 |
| 2017 December | 10 | 0 | 10 |
| 2017 November | 7 | 2 | 9 |
| 2017 October | 7 | 4 | 11 |
| 2017 September | 12 | 2 | 14 |
| 2017 August | 15 | 4 | 19 |
| 2017 July | 11 | 5 | 16 |
| 2017 June | 18 | 5 | 23 |
| 2017 May | 14 | 0 | 14 |
| 2017 April | 13 | 3 | 16 |
| 2017 March | 28 | 12 | 40 |
| 2017 February | 15 | 9 | 24 |
| 2017 January | 9 | 0 | 9 |
| 2016 December | 15 | 5 | 20 |
| 2016 November | 25 | 5 | 30 |
| 2016 October | 33 | 6 | 39 |
| 2016 September | 16 | 5 | 21 |
| 2016 August | 19 | 3 | 22 |
| 2016 July | 12 | 2 | 14 |
| 2016 June | 17 | 7 | 24 |
| 2016 May | 18 | 21 | 39 |
| 2016 April | 19 | 15 | 34 |
| 2016 March | 25 | 15 | 40 |
| 2016 February | 26 | 13 | 39 |
| 2016 January | 26 | 12 | 38 |
| 2015 December | 20 | 8 | 28 |
| 2015 November | 21 | 7 | 28 |
| 2015 October | 18 | 13 | 31 |
| 2015 September | 15 | 2 | 17 |
| 2015 August | 16 | 4 | 20 |
| 2015 July | 8 | 7 | 15 |
| 2015 June | 4 | 0 | 4 |
| 2015 May | 13 | 3 | 16 |
| 2015 April | 24 | 12 | 36 |
| 2015 March | 28 | 4 | 32 |
| 2015 February | 21 | 3 | 24 |
| 2015 January | 36 | 7 | 43 |
| 2014 December | 49 | 14 | 63 |
| 2014 November | 29 | 2 | 31 |
| 2014 October | 37 | 11 | 48 |
| 2014 September | 40 | 3 | 43 |
| 2014 August | 31 | 5 | 36 |
| 2014 July | 18 | 4 | 22 |
| 2014 June | 8 | 0 | 8 |
| 2014 May | 9 | 2 | 11 |
| 2014 April | 11 | 2 | 13 |
| 2014 March | 12 | 1 | 13 |
| 2014 February | 13 | 5 | 18 |
| 2014 January | 6 | 3 | 9 |
| 2013 December | 8 | 2 | 10 |
| 2013 November | 11 | 4 | 15 |
| 2013 October | 16 | 4 | 20 |
| 2013 September | 7 | 1 | 8 |
| 2013 August | 10 | 1 | 11 |
| 2013 July | 1 | 0 | 1 |
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