Evitts Et Al-2016-American Journal of Speech-Language Pathology

AJSLP
Research Article
The Impact of Dysphonic Voices on

Healthy Listeners: Listener Reaction
Times, Speech Intelligibility, and
Listener Comprehension
Paul M. Evitts,a,c Heather Starmer,b Kristine Teets,c
Christen Montgomery,a Lauren Calhoun,a Allison Schulze,a
Jenna MacKenzie,a and Lauren Adamsa
Purpose: There is currently minimal information on Results: Statistical results showed significant differences
the impact of dysphonia secondary to phonotrauma between RT ratio and number of speech intelligibility errors
on listeners. Considering the high incidence of voice between healthy and dysphonic voices. There was not a
disorders with professional voice users, it is important significant difference in listener comprehension errors. Multiple
to understand the impact of a dysphonic voice on their regression analyses showed that voice quality ratings from
audiences. the Consensus Assessment Perceptual Evaluation of Voice
Methods: Ninety-one healthy listeners (39 men, 52 women; (Kempster, Gerratt, Verdolini Abbott, Barkmeier-Kraemer,
mean age = 23.62 years) were presented with speech & Hillman, 2009) were able to predict RT ratio and speech
stimuli from 5 healthy speakers and 5 speakers diagnosed intelligibility but not listener comprehension.
with dysphonia secondary to phonotrauma. Dependent Conclusions: Results of the study suggest that although
variables included processing speed (reaction time [RT] listeners require more time to process and have more
ratio), speech intelligibility, and listener comprehension. intelligibility errors when presented with speech stimuli
Voice quality ratings were also obtained for all speakers from speakers with dysphonia secondary to phonotrauma,
by 3 expert listeners. listener comprehension may not be affected.
I
t has been estimated that nearly 25% of the work Roy, Merrill, Thibeault, Gray, & Smith, 2004). In fact, a
force in the United States have jobs where vocal use recent study of university teachers found that 52% of female
is considered to be critical to their employment and 33% of male instructors reported hoarse voices (Korn,
(Williams, 2003), and another 3% of the working popula- de Lima Pontes, Abranches, & de Lima Pontes, 2015).
tion have jobs where vocal use is required for public safety Other research has found that 39% of fitness instructors
(Titze, Lemke, & Montequin, 1997). In addition, an esti- report chronic hoarseness (Rumbach, Khan, Brown, Eloff,
mated one third of the workforce relies on their voice for & Poetschke, 2015). For those professional voice users
work (Vilkman, 2004). These professional voice users include with voice disorders, there are a number of consequences
teachers, air traffic controllers, and attorneys among others, in terms of economic, psychosocial, and voice-related qual-
and research has repeatedly shown that they are at risk for ity of life. For example, Van Houtte, Claeys, Wuyts, and
developing voice disorders (e.g., Ramig & Verdolini, 1998; Van Lierde (2011) reported that 20% of teachers had missed
a minimum of 1 day of work due to voice problems. Roy
et al. (2004) found that teachers experienced reduced activi-
a
ties or interactions with others as a result of their voice dis-
Towson University, MD
b order. In addition, Chen and colleagues (2010) found that
Stanford University School of Medicine, CA
c
Johns Hopkins University School of Medicine, Baltimore, MD
teachers with a voice disorder reported decreased ability
to communicate effectively, had reduced social activities,
Correspondence to Paul M. Evitts: pevitts@towson.edu
made fewer phone calls, and that the voice disorder had a
Editor: Krista Wilkinson
significant impact on their overall emotional state. Although
Associate Editor: Preeti Sivasankar
this is just a sample of the literature, there is a growing
Received October 20, 2014
Revision received April 11, 2015
Accepted March 31, 2016 Disclosure: The authors have declared that no competing interests existed at the time
DOI: 10.1044/2016_AJSLP-14-0183 of publication.
American Journal of Speech-Language Pathology • Vol. 25 • 561–575 • November 2016 • Copyright © 2016 American Speech-Language-Hearing Association 561
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body of research showing the negative impact that voice The synthetic speech literature has long embraced the
disorders have on professional voice users. use of RTs to measure the impact of an altered acoustic
Furthermore, there is also a large body of research signal on healthy listeners. In general, this body of research
on the treatment efficacy of voice disorders (see Ramig & has shown that listeners require more time to process syn-
Verdolini, 1998, for a review) and the impact of the voice thetic speech compared to normal speech. For example,
disorder on the person (e.g., Roy et al, 2004; Van Houtte Pisoni (1981) used a lexical decision task to measure RTs
et al., 2011). However, there is minimal information on the for both normal and synthetic speech and found that lis-
impact of the resultant disordered signal on the listener. teners required more time to process the synthetic speech.
Considering the types of employment for many of these Reynolds and Fucci (1998) used a true/false paradigm with
speakers, a better understanding of the impact of the normal and synthetic speech stimuli of equal intelligibility
dysphonic voice is clearly warranted. The following section and found that listeners had significantly longer RTs when
contains a brief review of commonly used objective measures presented with synthetic speech. Evitts and Searl (2006) also
that been used to investigate the impact of a disordered included synthetic speech stimuli in their study on alaryngeal
acoustic signal on a listener. speakers and also found that listeners had significantly
longer RTs when presented with synthetic speech than
normal speech. These authors attributed the longer RTs
Listener Reaction Times and increased cognitive workload to the listener requiring
Reaction times (RTs) have long been used as an more time to extract basic acoustic-phonetic information
index of cognitive workload placed on a listener (Gough, from the synthetic speech due to the degraded or impover-
1965), where longer RTs are associated with increased ished nature of the acoustic signal (Evitts & Searl, 2006;
cognitive workload (e.g., Duffy & Pisoni, 1992; Gatehouse Pisoni, 1981).
& Gordon, 1990; Gough, 1965; Pisoni, 1981). Cognitive Although there are currently no studies on the RTs
workload is referred to here as the amount of mental demand of listeners when presented with dysphonic voices, there
imposed on a listener’s cognitive system when performing a is reason to believe that listeners would require additional
specific task (Paas, Tuovinen, Tabbers, & Van Gerven, 2003) processing time compared to typical speech. Support for
and has been used in a variety of patient populations. For this may be drawn from research on the acoustics and
example, Jones, Fox, and Jacewicz (2012) used a dual-task voice quality of dysphonia. For example, dysphonia has
paradigm and reported increased cognitive workload as been found to have increased perturbation (Niebudek-
measured by RTs in adults who stutter compared to adults Bogusz, Kotylo, Politanski, & Silwinska-Kowalska, 2008)
who did not stutter. Kraiuhin et al. (1989) used a discrimi- and increased spectral noise levels (Emanuel & Sansone,
nation task and also reported longer RTs in adults with 1969). Subjective measurements of voice quality have also
Alzheimer’s disease relative to healthy controls. More shown significant differences between normal and dyspho-
recently, RTs have been used in the dysphagia literature nic voices (Murry, Medrado, Hogikyan, & Aviv, 2004).
as a means of measuring the amount of mental resources Similar to alaryngeal, foreign-accented, and synthetic
needed to complete a motor task (Brodsky, McNeil, et al., speech, listeners may need additional processing time
2012; Brodsky, Verdolini Abbott, et al., 2012). when presented with a dysphonic voice due to the altered
Although the literature is replete with information nature of the signal. Given the relationship between RTs
on the cognitive workload and RTs (i.e., processing speeds) and cognitive workload, it is important to understand
of various populations, there is much less information on how a dysphonic voice impacts listener RTs and, ulti-
the impact of a disordered acoustic signal on the RTs of mately, the amount of cognitive workload placed on the
typical, healthy listeners. In the alaryngeal speech literature, listener.
Evitts and Searl (2006) used a single-task paradigm by
presenting stimuli from speakers who used different modes
of alaryngeal speech (i.e., tracheoesophageal, esophageal, Speech Intelligibility
electrolaryngeal) to healthy listeners and found that lis- Aside from RTs, speech intelligibility is perhaps the
teners required more cognitive workload when presented most commonly used measure to determine the impact of a
with alaryngeal speech stimuli. Munro and Derwing (1995) disordered signal on healthy listeners. Although numerous
reported that healthy listeners had significantly longer RTs definitions exist, speech intelligibility is generally considered
when presented with foreign-accented speech compared to to be an index of how well a listener is able to retrieve a
native English. In a similar manner, Wilson and Spaulding speaker’s intended message (Hustad, 2008; Kent, Weismer,
(2010) used RTs to measure the RTs of healthy listeners Kent, & Rosenbek, 1989; Yorkston & Beukelman, 1980).
when presented with Korean-accented speech and native This is a useful tool as it serves as an “index of the severity
English speech stimuli. Results showed that listeners had of the overall functional limitation” (Yorkston, Beukelman,
the longest RTs when presented with moderately intelligible Strand, & Bell, 1999, p. 237). Speech intelligibility is typically
Korean-accented speech, followed by highly intelligible measured by presenting a series of sentences to a listener
Korean-accented speech. Listeners had the shortest RTs and calculating the number of orthographic transcription
when presented with native English speech stimuli (Wilson errors. Percent intelligibility scores can then be calculated
& Spaulding, 2010). for different speakers with a variety of speech disorders.
562 American Journal of Speech-Language Pathology • Vol. 25 • 561–575 • November 2016

These scores commonly speak to the integrity of the acoustic harder at listening.” Results of the comprehension tests
signal (Hustad & Beukelman, 2002). showed that students had significantly decreased language
Decreased speech intelligibility has been shown in comprehension scores when information was presented
numerous populations ranging from people with dysarthria with the dysphonic voice. Rogerson and Dodd (2005) also
(e.g., Garcia & Cannito, 1996), people with hearing loss investigated the impact of a dysphonic voice on children’s
(e.g., Brentari & Wolk, 1986), and people who have had a processing of verbal language but included two speakers
laryngectomy (e.g., Searl, Carpenter, & Banta, 2001). With with dysphonia, one rated as mild and one rated as severely
regard to dysphonia, Bender, Cannito, Murry, and Woodson dysphonic.1 Results showed improved performance on the
(2004) compared the speech intelligibility of 10 healthy comprehension task when stimuli were presented in the
speakers to 10 individuals with severe adductor spasmodic normal voice and no difference in performance between
dysphonia and found significantly reduced intelligibility the mild and severely dysphonic voices. Last, Lyberg-
for the speakers with dysphonia. In addition, a case study Åhlander, Haake, Brännström, Schötz, & Sahlén (2015)
by Cannito (2001) provided further evidence of reduced investigated the impact of a simulated dysphonic voice on
speech intelligibility in a speaker with spasmodic dysphonia young children during a language performance test using
with a baseline intelligibility of 17%. Other than these studies, a recording of a typical, healthy voice and a simulated
research related to speech intelligibility and dysphonia is mild-to-moderately deviant voice. Results showed signifi-
limited. One possible explanation for this may be a focus cantly lower scores on certain subtests of the standardized
on the articulatory component rather than the voicing comprehension test with the dysphonic voice. Results of
source (Bender et al., 2004). The articulators clearly play these studies suggest that when presented with a disordered
a large role with speech intelligibility as changes at the signal, the children were required to expend additional cog-
level of the vocal folds determine the “level of energy which nitive resources, which occurred at the expense of compre-
the resonator will receive” (Kent & Read, 2002, p. 23). hension (Lyberg-Åhlander et al., 2015; Rogerson & Dodd,
The primary task of the resonator (articulators) is then to 2005).
shape that energy from the source into meaningful units. Although these three studies provide important in-
This is the basis of the source-filter theory of speech pro- sight into the processing of a dysphonic voice, all of these
duction (Kent & Read, 2002). However, Ramig (1992) sug- studied children and had limited types and degrees of
gested that voice-related parameters such as quality, pitch, severity of dysphonia, with one study including a simulated
and prosody may also play a substantial role with intelligi- dysphonic voice. Because age-related changes exist in
bility. Regardless, there is minimal information available the auditory processing system (e.g., Harris, Mills, He, &
on the speech intelligibility of speakers with dysphonia, in Dubno, 2008) and there is a large degree of variability with
particular dysphonia secondary to phonotrauma. Consider- dysphonic voices (e.g., Rogerson & Dodd, 2005), it is
ing that intelligibility implies how well a listener is able to difficult to generalize the results. Therefore the question
retrieve the intended message of a speaker (Hustad, 2008), it of how a dysphonic voice affects listener comprehension is
is important to be able to understand the impact of a dys- still unclear. Given that listener comprehension encompasses
phonic voice on a speaker’s intelligibility. a listeners’ ability to either summarize (Higginbotham et al.,
1994) or answer questions from a speaker’s message (Hustad
& Beukelman, 2002), and that professional voice users are
Listener Comprehension at an increased risk for dysphonia, more insight is warranted.
Listener comprehension may be considered to be an Furthermore, although the studies above provide insight
extension of speech intelligibility in that it measures a into how listeners comprehend a dysphonic voice, there is
listener’s ability to either summarize information from a still a paucity of research on other outcome measures, such
speaker’s message (Higginbotham, Drazek, Kowarsky, as RTs or speech intelligibility. Whether this paucity is
Scally, & Segal, 1994) or answer questions about the mes- related to a focus on the articulatory patterns of disordered
sage (Hustad & Beukelman, 2002). Reduced listener com- speakers as suggested by Bender et al. (2004) or for differ-
prehension has been found when listeners are presented ent reasons, the impact of a disordered acoustic signal from
stimuli from speakers with dysarthria (e.g., Hustad & a speaker with dysphonia has yet to be clearly established.
Beukelman, 2002) and with synthetic speech (e.g., Drager Considering the high incidence of professional voice
& Reichle, 2001). users that experience dysphonia secondary to phonotrauma
Similar to speech intelligibility, there are limited and the potential for a breakdown to occur at any part
studies on the impact of dysphonia on listener comprehen- of the perceptual process, it is important to increase our
sion. Morton and Watson (2001) investigated the impact understanding of the impact on the listener. Therefore,
of a dysphonic voice on children’s ability to process verbal there are two overall purposes of this study: (a) to deter-
language by presenting a recorded series of short passages mine the impact of a dysphonic voice (i.e., secondary to
—half of the passages presented by one woman with a
normal voice and half by one woman with a moderate-to- 1
In the methods section, the authors noted that the severely dysphonic
severe dysphonic voice. Subjective results showed that voice was actually rated as moderately dysphonic using the GRBAS
students had more negative feelings towards the dysphonic subjective assessment but categorized it as “severe” due to that speaker
voice with comments including how they “had to work receiving the most severe ratings amongst the voices used in the study.
Evitts et al.: Impact of Dysphonic Voices on Healthy Listeners 563

phonotrauma) on listener RTs, speech intelligibility, and who had each completed a fellowship in laryngology. Audio
listener comprehension of typical healthy listeners; and recordings were made during the initial evaluation with
(b) to determine the relationship between these objective the SLP.
measures and subjective impressions of speakers with Listeners for the study included 91 healthy individuals
dysphonia secondary to phonotrauma. Specific research (39 men, 52 women, mean age = 21.8 years) with no reported
questions for this study include: history of speech, language, cognitive, attention, or learning
impairments. All listeners passed a hearing screening at
1. Is there a difference in listener RTs, speech
500, 1000, 2000, and 4000 Hz dB SPL. Listeners were
intelligibility, and listener comprehension between
recruited from a variety of majors and programs at a mid-
typical healthy and dysphonic voices?
Atlantic university. Finally, this study was approved by
2. What is the relationship between voice quality the Institutional Review Boards of both Towson University
ratings and objective measures of listener RTs, and the Johns Hopkins School of Medicine.
speech intelligibility, and listener comprehension?
3. What is the relationship among listener RTs, speech Recording
intelligibility, and listener comprehension?
Speakers were recorded while seated in a quiet room
Results of the study may provide additional insight with a headset microphone (AKG C-420 III, AKG Acous-
into the impact of a dysphonic voice on healthy listeners. tics, Vienna, Austria) placed 2 in. from the corner of their
Given the high prevalence of voice disorders among profes- mouth. The audio production was recorded at 48 kHz
sional voice users, such information may be an important sampling rate via an acoustic analysis software program
piece of education for health care professionals to share with (Computerized Speech Laboratory 4500, KayPentax,
their patients with dysphonia as well as to provide direction Montvale, NJ) and saved as a wave file. Audio samples
for future research to determine how to decrease any po- were then digitally edited using an acoustic analysis soft-
tential negative effects of the disordered voice on listeners. ware program (Adobe Audition, Adobe Systems, San Jose,
CA) and individual wave files were created for each stimu-
lus. To increase consistency among stimuli, the acoustic
Participants analysis software program was used to bracket the begin-
There were two groups of participants in this study: ning and ending of each word or sentence defined as the
speakers (n = 10) and listeners (n = 91). Inclusion criteria immediate point of onset or offset of any acoustic energy
for the speakers included age between 18 and 50 years, associated with a stimulus.
female, and no other cognitive, speech, or language distur-
bances or impairments that affect their voice or speech. Listening Tasks and Procedures
These inclusionary criteria were chosen in order to better This study included three different listening tasks that
extrapolate the results to a specific group of professional listeners individually completed in one 75-min. appointment.
speakers (i.e., teachers). Women were chosen as 82% of Following consent, each participant was seated in a sound-
teachers in the US are women (Feistritzer, 2011) and the proof booth in front of a table with a 22-in. LCD monitor
age range was chosen as approximately 70% of teachers (Acer LCD AL2216W, Acer American, San Jose, CA) and
are under 50 years of age (Feistritzer, 2011). Aside from two speakers (Bose Companion 2 Series II, Bose Corpora-
the demographic reasons, there are also significant voice tion, Framingham, MA) placed on either side of the mon-
changes associated with age (Kent, 1994; Linville & Fisher, itor. For all participants, the tasks were in the following
1985) and it was determined that participants under the order: RT, speech intelligibility, and listener comprehen-
age of 50 years would be most appropriate and would not sion. This was done so that participants would not be able
add an additional variable (i.e., aging voice). to increase their familiarity with the disordered voice sam-
Healthy speakers included five healthy women (mean ples, which has been shown to have an impact on RTs (e.g.,
age = 26 years) with no history of a speech, voice, or cog- Smith, 1967; Young, McWeeny, Hay, & Ellis, 1986) and
nitive impairment and with perceptually normal voice qual- intelligibility measures (e.g., Hustad, 2008; Tjaden & Liss,
ity as verified by three licensed and certified speech-language 1995).
pathologists (SLPs) each with greater than 5 years of ex-
perience with clinical voice disorders. Native speakers of
American-English with a diagnosis of phonotrauma were Listener RTs
recruited from the Department of Otolaryngology-Head The single-task RT paradigm used in this study was
and Neck Surgery at the Johns Hopkins School of Medi- based on methods from a number of other studies (Chase
cine and included five women (mean age = 33 years) diag- & Posner, 1965; Cole, Coltheart, & Allard, 1974; Evitts &
nosed with dysphonia as a result of vocal nodules, vocal Searl, 2006; Weiner & Falk, 1972). For this task, the lis-
polyps, and/or phonotraumatic behaviors including second- tener indicated whether a word that was visually presented
ary muscle tension dysphonia. Initial diagnosis of phono- on an LCD computer screen was the same or different as
trauma was made following a thorough case history and a an auditory stimulus (i.e., SAME or DIFFERENT task).
videostroboscopic exam by board-certified otolaryngologists The latency of the response was then considered to be the

amount of time required for processing of the auditory stim- For this task, listeners remained seated in front of
ulus and a reflection of the amount of cognitive workload the computer monitor and speakers. Following instructions
required to process the signal. Longer RTs are then associ- and two samples, listeners were presented with 121 individ-
ated with greater cognitive workload (Duffy & Pisoni, 1992; ual sentences randomly produced by the 10 speakers and
Evitts & Searl, 2006; Gough, 1965; Pisoni, 1981). then asked to transcribe each sentence on a record form.2
Stimuli included 20 words from the Multiple Word Listeners were provided with an 11-s pause in between
Intelligibility Test (MWIT; Kent et al., 1989) produced each sentence in order to write their response. In an attempt
by each speaker. MWIT stimuli included in the RT experi- to control for potential order effect, three master lists were
ment were staggered so that listeners only heard each stim- created that randomized 10 sentences from each speaker
ulus item no more than two times across all speakers. For plus an additional 10% (121 total sentences) for intra- and
example, Speaker 1 produced MWIT stimulus Items 1–20, interrater reliability.
Speaker 2 produced stimulus Items 21–40, and so forth.
This was done to reduce any potential familiarity with
individual stimulus items, which has been associated with
Listener Comprehension
decreased RTs (Schwartz & Goldman, 1975). Twenty MWIT After the speech intelligibility task, listener compre-
words were used from each of the 10 speakers for a total hension was assessed by playing a standardized reading
of 200 words presented to each listener. In addition, the passage designed to test auditory comprehension (Boning,
RT experiment was designed to automatically and randomly 1976, as cited in Pashek & Brookshire, 1982). Listeners
present one half of the trials where the correct listener were randomly presented with only one reading passage
response was SAME and one half where the correct listener produced either by one of two speakers with dysphonia or
response was DIFFERENT. Last, following methodology one of four healthy speakers. The disparate number of
from Evitts and Searl (2006), only correct responses were speakers for the comprehension task was due to recording
used in the final data set. errors. Rather than eliminating the comprehension task
The RT experiment started with each participant altogether, it was determined to include the limited number
being provided verbal instructions as well as four practice of speakers as it was felt that the information could still
stimuli. Software specifically designed for RT data collection provide preliminary insight into the comprehension of dys-
and analysis was used (E-Prime version 1.0, Psychology phonic voices. Overall mean voice quality ratings from
Software Tools, Inc., Sharpsburg, PA). RTs were collected the Consensus Assessment Perceptual Evaluation of Voice
via a serial response box (E-Prime, version 1) placed in front (CAPE-V; Kempster, Gerratt, Verdolini Abbott, Barkmeier-
of the participant on the table with two visible buttons. Kraemer, & Hillman, 2009) for these two speakers with
The left button was labeled as S (same) and the right button dysphonia were as follows: overall severity = 48.84 mm,
was labeled as D (different). Participants were instructed 60.5 mm; roughness = 50 mm, 42.25 mm; breathiness =
that they would see a word on the computer monitor and 23.27 mm, 43.25 mm; strain = 13.18 mm, 53.25; and pitch =
then hear a word through the speakers and determine as 20.06 mm, 16.22 mm. These mean values were similar to
quickly as possible if the words were the same or different. the overall mean ratings of the other speakers with dyspho-
To reduce any possible confusion among stimuli and the nia for four of the five voice qualities. The mean rating for
foils, care was taken to ensure that the orthographic stimuli strain across all speakers with dysphonia was 32.27 mm,
were different than the auditory stimuli in both semantics thus indicating these two speakers may be outliers for that
and phonology—that is, the two words were not of the one voice quality. Therefore, listener comprehension data
same semantic category (e.g., animals, household items) or are based on 91 listeners and six standardized reading pas-
phonologic structure (i.e., at least two differences among sages (four healthy and two dysphonic). Overall, 58 listeners
manner, placing, and voicing for the initial sound and dif- were presented with a reading passage produced by one of
ferent vowel structure of the orthographic word). four speakers with a healthy voice and 33 listeners were pre-
sented with a reading passage produced by one of two speakers
with dysphonia. Following the auditory recording, listeners
Speech Intelligibility were instructed to answer the 16 yes/no questions related to
The speech intelligibility task used was similar to other the passage.
studies in the literature (e.g., Evitts, Portugal, Van Dine,
& Holler, 2010; Yorkston, Beukelman, & Traynor, 1988).
Speech intelligibility stimuli included a series of phonemically
Voice Quality Ratings
balanced sentences (the Hearing in Noise Test [HINT]; Aside from the objective measures described above,
Nilsson, Soli, & Sullivan, 1994). The HINT stimuli contain voice quality ratings were obtained for all 10 speakers used
25 lists of 10 sentences each. Similar to the MWIT staggered in the study. This was done to determine the relationship
stimuli, speakers were recorded producing two different between the objective measures (RT ratio, speech intelligi-
HINT lists (20 sentences each speaker), which reduced any bility errors, and listener comprehension errors) and voice
potential familiarity with sentences. Thus, listeners did not
hear any sentence more than once (other than the additional 2
The original data set included 11 speakers but one speaker was
sentences included for reliability purposes). ultimately excluded due to a secondary diagnosis of Reinke’s edema.

quality ratings. For this, three expert, licensed, and certified 2. Assessment of intra- and interlistener agreement on
SLPs, each with a minimum 5 years of experience with clinical speech intelligibility. Reliability was calculated by
voice disorders were individually provided with a random- methods similar to Hustad (2006) and Hustad and
ized list of the HINT sentences that were used as part of Beukelman (2002). Point-by-point reliability for
the recording protocol produced by each of the 10 speakers. intralistener agreement was calculated for a random
The expert raters then completed a CAPE-V for each speaker. 25% of the listeners (n = 23). To calculate this, the
Measurements were recorded using an electronic digital number of agreements was divided by the number
caliper (Avenger Products, Henderson, NV) and were re- of agreements plus the number of disagreements and
corded in millimeters. Because the CAPE-V is specifically then multiplied by 100. Intralistener reliability
intended for trained clinicians and researchers (Kempster across the random 25% of listeners ranged from
et al., 2009), ratings of voice quality were obtained from 96% to 100%. Using the same formula, interlistener
experienced voice clinicians rather than from the naive lis- reliability across all listeners was 99.82%. These
teners who served as listeners for the other measures. This percentages indicate strong support for the use of
was done in an attempt to increase the ecological validity speech intelligibility as a dependent variable (Hustad,
of the study by replicating actual clinical practice where 2006).
speakers with dysphonia are evaluated by SLPs. 3. Assessment of the interrater reliability of voice quality
ratings by expert listeners. To ensure reliability among
the expert listeners on the CAPE-V, a Pearson
Results product-moment correlation was calculated, which
Preliminary Analysis showed medium-large correlations for all categories
of the CAPE-V (r values ranged from .441 to .972)
Before proceeding with the primary analysis, the data among all three listeners except for the loudness
were evaluated in various ways to help determine the ap- category (r value −.100 between Listener 1 and 2).
propriate final data set to be used to answer the research Due to the weak correlation for this voice quality,
questions. All statistical analyses utilized a statistical analysis loudness was not included in the final data set and
program (IBM SPSS Statistics, version 21). The preliminary the remaining voice quality ratings were collapsed
analyses included the following assessments. into one mean score for each voice quality for the
healthy and the dysphonic speakers.
Assessment of Differences in Stimulus Duration Between
Healthy and Disordered Voice 4. Assessment of normal versus disordered voice quality
Because different durations of stimuli may have an ratings. To ensure that the healthy and dysphonic
impact on listener RTs, Munro and Derwing (1995) suggested speakers were accurately identified, aggregated voice
accounting for these potential differences by using a ratio quality ratings from the CAPE-V were compared using
a paired-samples t test, which showed a significant
of the stimulus duration to the measured RT rather than
difference in voice quality ratings between the two
the absolute RT. The suggested formula for the ratio is stim-
groups, t = −10.94, p < .001.
ulus duration/RT and is referred to as the RT ratio (Evitts
& Searl, 2006). The mean duration for the healthy MWIT
stimuli was 519 ms, whereas the mean duration for the Primary Analysis
speakers with dysphonia was 480 ms. A one-way analysis
The first research question involved comparing mean
of variance (ANOVA) showed this to be a significant differ-
RT ratios and speech intelligibility errors between the
ence, F(1, 20057) = 505, p < .001. Therefore, RT ratios
two types of voicing (i.e., healthy, dysphonia). For this, a
were used as the dependent variable and not the absolute
one-way ANOVA for repeated measures was performed.
RT. Smaller RT ratios are associated with increased RTs.
Because listener comprehension involved listeners only be-
1. Assessment of listener learning and fatigue effects. In ing presented stimuli from one random speaker, a one-way
addition to determining if durational differences ANOVA was calculated. The second research question
existed, it was also of interest to determine if there involved the relationship between voice quality ratings and
was a learning or fatigue effect. For this, a one-way each dependent variable. For this, three stepwise multiple
ANOVA was calculated using the RTs of the first, regressions were calculated using the CAPE-V ratings as
middle, and final third stimuli, which showed a the independent variables (i.e., overall severity, roughness,
learning effect but no fatigue effect. Rather than breathiness, strain, pitch). Last, a Pearson test of correlation
discarding the entire first third of all the RTs, additional was used to determine the relationship among the dependent
steps were taken to determine a cut-off point for variables.
the learning effect. The one-way ANOVA ultimately
showed significantly increased RTs for the first
44 stimuli indicating a learning effect. Therefore, the Listener RTs
first 44 stimuli from each listener were not included, Descriptive analysis of the RTs and RT ratios are
resulting in a final data set of 13,737 RT stimuli presented in Table 1. As discussed above, because there
(14,196 stimuli – 459 incorrect responses). were significant differences in stimulus durations between

Table 1. Descriptive analysis of overall mean data.
or no questions immediately following, listeners had 3.76 mean
errors (SD = 2.3) when presented with a healthy voice and
Healthy Dysphonia
2.84 mean errors (SD = 1.8) when presented with a dysphonic
Experimental task M (SD) M (SD) voice (see Table 2). A one-way ANOVA showed no signifi-
cant difference between the two modes, F(1, 90) = 2.85,
Listener RT (ms) 751 (139) 759 (142) p = .095. Observed power was low at .386 and partial eta
RT ratio 0.743 (0.114) 0.691 (0.109)
Speech intelligibility (mean 3.99 (3.3) 14.18 (7.2) squared value was .031.
number of errors)
Listener comprehension (mean 3.76 (2.3) 2.84 (1.8)
number of errors)
Voice Quality Ratings
Note. RT = reaction time. All values are mean values. RT ratio is The second research question investigated the rela-
calculated as the mean RT divided by the stimulus duration. Smaller
tionship between the dependent variables (RT ratio, speech
RT ratios are associated with increased cognitive workload.
intelligibility, and listener comprehension) and expert lis-
tener ratings using voice qualities on the CAPE-V. Table 2
shows the mean values across all three expert listeners for
healthy and dysphonic speakers, the RT ratio was used as each voice quality category on the CAPE-V. For example,
the dependent variable. For this, a smaller RT ratio indicates the mean rating of overall severity across the three expert
the listener required more processing time and more cognitive listeners and for all of the speakers with dysphonia was
workload (Evitts & Searl, 2006; Munro & Derwing, 1995). 51.90 mm. Again, due to the limited agreement among the
Because there were only two levels to the voice type (healthy, expert listeners for loudness, which has also been reported
dysphonic), sphericity was not tested (Kinnear & Gray, 2010). with pediatric patients (Kelchner et al., 2010), this CAPE-V
There was a 7% difference in RT ratio between healthy and category was not included in the final analysis. Mean voice
dysphonic voices. A repeated measures one-way ANOVA quality ratings from the CAPE-V for the healthy speakers
was calculated and showed a significant main effect for voic- was 1.8 mm. Mean voice quality ratings from the CAPE-V
ing type for RT ratio, Wilks’s Λ = .164, F(1, 91) = 465.5, for the speakers with phonotrauma was 33.84 mm.
p < .001. Observed power approached 100% and the overall Although there were a large number of independent
partial eta squared was .836 indicating that 84% of the vari- variables and thus a possibility of multicollinearity (Mertler
ability associated with RT ratio was attributed to voicing & Vanatta, 2002), correlations among the variables were
type. not calculated and a factor analysis was not completed. These
were not done due to the widespread clinical use of the
Speech Intelligibility CAPE-V and a desire to not collapse its ratings. Therefore,
stepwise multiple regression analyses with RT ratio, number
Descriptive statistics for speech intelligibility are also of speech intelligibility errors, and number of listener com-
presented in Table 1 and show a 255% increase in the number prehension errors across both voice types served as the de-
of speech intelligibility errors when listeners were presented pendent variables and voice quality ratings on the CAPE-V
with dysphonic voices. A repeated measures one-way ANOVA (overall severity, roughness, breathiness, strain, pitch) as
was calculated, which showed a significant main effect for the independent variables were completed.
voicing type for speech intelligibility, Wilks’s Λ = .241, Results of the regression analysis for RT ratio are
F(1, 87) = 274.3, p < .001. Observed power approached presented in Table 3. The regression showed five different
100% and the overall partial eta squared was .759, indicat- models that were predictive of RT ratio. The model which
ing that 76% of the variability associated with the number included all five voice qualities from the CAPE-V was able
of intelligibility errors was attributed to voicing type. To de- to predict nearly 3% of the variance of RT ratio: R2 = .029,
termine if listener transcription errors were related to content F(1, 17,888) = 106.22, p < .001. R2 change values indicated
words (e.g., listener transcribed milk for cake) or article
errors (e.g., listener transcribed the for a), all transcription
Table 2. Mean voice quality ratings of expert listeners.
errors were reviewed. The error analysis showed that listeners
had 2.0 mean article errors for the healthy speakers and Healthy Dysphonia
1.7 for the speakers with dysphonia. In addition, listeners
had 2.0 mean content errors with the healthy speakers and CAPE-V rating M (SD) M (SD)
12.5 content errors with the speakers with dysphonia. A
Overall severity 3.17 (1.59) 51.90 (7.93)
paired samples t test showed no significant difference between Rough 3.84 (2.43) 47.18 (6.66)
the article errors ( p = .245) but a significant difference was Breathy 0.01 (0.004) 16.12 (16.56)
present for the content words ( p < .001). Strain 2.37 (1.44) 32.27 (16.28)
Pitch 0.02 (0.03) 21.74 (5.46)
Listener Comprehension Note. Mean values are measured in millimeters from a 100-mm
visual-analog scale. Higher values are associated with increasingly
When presented with a standard reading passage of disordered voices within each rating category.
a smaller subset of the speakers and asked to answer 16 yes

Table 3. Results of the stepwise multiple regression analysis for reaction time (RT) ratio
Model 1 Model 2 Model 3 Model 4 Model 5

Variable B SE B β B SE B β B SE B β B SE B β B SE B β
Constant 0.733 0.002 0.743 0.003 0.743 0.003 0.748 0.003 0.751 0.003
Breathiness −0.002 0 −0.116* −0.002 0 −0.09* −0.003 0 −0.162* −0.003 0 −0.145* −0.002 0 −0.14*
Roughness −0.001 0 −0.055* −0.001 0 −0.135* −0.002 0 −0.227* −0.001 0 −0.128*
Strain 0.002 0 0.158* 0.02 0 0.154* 0.003 0 0.189*
Pitch 0.002 0 0.107* 0.001 0 0.102*
Overall −0.001 0 −0.133*
severity
R2 0.013 0.016 0.023 0.027 0.029
F for change 242.97* 42.26* 141.05* 70.20* 29.35*
in R2
Note. Dependent variable = RT ratio. Variables entered = age (constant), overall severity, roughness, breathiness, strain, and pitch.
*p < .001.
each voice quality contributed a range of .02 to .013 to the was calculated, which showed a weak but significant cor-
variance. For intelligibility, there were two different models relation (Cohen, 1988) between RT ratio and number of
that were predictive of speech intelligibility (see Table 4). intelligibility errors (r = −.152, p = .045). No other correla-
The model that included overall severity and strain was tions among the dependent variables were found to be
able to predict 36% of the variance associated with intelligi- significant with r values of .015 and −.090 and p values
bility errors: R2 = .36, F(1, 174) = 81.3, p < .001. Overall of .409 and .888.
severity contributed 32% to the variance and strain contrib-
uted 4% to the variance. Beta coefficients for voice quality
ratings ranged from −0.349 to 0.849 for the speech intelligi- Discussion
bility multiple regression and −0.09 to −0.227 for the RT The overall purpose of this study was to investigate
ratio multiple regression. This indicates that for every unit the impact of a dysphonic voice on healthy listeners using
increase in voice quality ratings, the number of speech intel- measures of RT, intelligibility, and comprehension. Dyspho-
ligibility errors changed by 0.34 to 0.85 and the RT ratio nia secondary to phonotrauma was targeted due to the high
changed by 0.09 to 0.227. Last, regression analysis for lis- prevalence of voice disorders in professional speakers (e.g.,
tener comprehension showed none of the voice qualities Roy et al., 2004) and the need to understand the impact
from the CAPE-V were predictive of comprehension errors. of the dysphonic voice on their audiences. Results of the
current study suggest that when healthy listeners are pre-
sented with speech stimuli produced by speakers with dys-
Relationship Among Dependent Variables phonia, listeners require significantly greater processing
Last, the final research question investigated the rela- time and have significantly more errors in intelligibility, but
tionship among the three dependent variables: RT ratio do not have more errors in comprehension. In addition,
number of speech intelligibility errors, and number of lis- results provided insight into the impact of different voice
tener comprehension errors. For this, a Pearson correlation qualities (e.g., breathy, strain) on measures of listener RT,
speech intelligibility, and listener comprehension. Specific
research questions are discussed in more depth below.
Table 4. Results of the stepwise multiple regression analysis for
speech intelligibility.
RTs and Dysphonia
Model 1 Model 2
Results of the study indicate that when presented
Variable B SE B β B SE B β with a dysphonic voice, listeners require additional time
to process the signal than when presented with a typical,
Constant 4.664 0.682 4.425 0.667
healthy voice. This increased processing speed is equated
Overall severity 0.161 0.018 0.564* 0.242 0.03 0.849*
Strain −0.145 0.043 −0.349* with increased cognitive workload on the part of the lis-
R2
0.318 0.36 tener. Although the difference was slight (7% increase when
F for change in R2 81.3* 11.11* listeners were presented with dysphonic voices), 84% of
Note. Dependent variable = number of speech intelligibility errors.
the variance of RT ratio could be attributed to the presence
Variables entered = overall severity, roughness, breathiness, strain, or absence of dysphonia. Although direct comparison to
and pitch. other RT studies may not be prudent given different tasks,
*p < .001 the magnitude of difference in the current study is smaller
than others. For example, results from Munro and Derwing

(1995) found approximately a 20% difference between Speech Intelligibility and Dysphonia
foreign-accented speakers with high and low comprehensibil-
The current study found that listeners had a 255%
ity. Wilson and Spaulding (2010) also showed approximately
increase in the number of speech intelligibility errors (3.99
a 20% difference in RTs when listeners were presented
and 14.18 errors with healthy and dysphonic voices, respec-
with native English speech and high-intelligibility Korean
tively) when presented with a dysphonic voice and that
accented speech. However, using a similar RT task with
76% of the variability associated with these errors could be
alaryngeal speech, Evitts and Searl (2006) reported a 6%
difference in RT ratios between laryngeal speech and esoph- attributed to the presence of dysphonia. Even though the
ageal speech and an 18% difference between laryngeal dysarthria literature is replete with studies showing de-
speech and electrolaryngeal speech RT ratios. Results such creased intelligibility with dysarthric speakers (e.g., Garcia
as these suggest that listeners expend similar cognitive effort & Cannito, 1996; Garcia & Dagenais, 1998; Hustad &
when presented with speech from people who have had a Beukelman, 2002), the extent of intelligibility errors in the
laryngectomy and use esophageal speech and who have dys- current study was not anticipated. Explanations from the
phonia secondary to phonotrauma. Overall, it may be that dysarthria literature typically attribute the reductions in in-
the amount of cognitive effort exerted by listeners is related telligibility to impaired articulation. Because the speakers
to the presence of a disorder (e.g., phonotrauma, laryngec- with dysphonia used in the current study had normal articu-
tomy) rather than normal differences such as a speaker with lation and the primary difference between the speakers was
a foreign-accent. the presence or absence of dysphonia, other factors must
Aside from the differences found in the current study, have played a role.
the overall RT results were not surprising given results from One possible explanation offered by Bender et al.
related fields. As described earlier, similar differences in lis- (2004) to explain reductions in speech intelligibility for
tener cognitive workload as measured by RTs have been speakers with adductor spasmodic dysphonia is that dys-
reported when listeners are presented with alaryngeal speech phonic speakers may be compensating for their vocal im-
(Evitts & Searl, 2006) and with foreign-accented speech pairment by altering their laryngeal posture—that is, some
(Munro & Derwing, 1995; Wilson & Spaulding, 2010). The of the errors made by listeners may have been related to
current finding provides support to the overall body of liter- adjustments in laryngeal posturing possibly resulting in
ature showing that a degraded acoustic signal requires the confusion of cognate pairs (e.g., /p, b/). Support for this
listener to expend additional processing resources to decode is provided by Hartl, Crevier-Buchman, Vaissière, and
the signal. Similar to studies that have found increased RTs Brasnu (2005), who found increased errors in stop conso-
with synthetic (e.g., Reynolds & Fucci, 1998) and alaryngeal nant production when listeners were presented with stimuli
speech (Evitts & Searl, 2006), the increased RTs (i.e., RT from speakers with unilateral vocal fold paralysis. This is
ratios) in the current study are most likely related to the de- also consistent with numerous studies in the alaryngeal
graded acoustic nature of the dysphonic voice signal (Pisoni, literature that have shown significant reductions in speech
1981), which has been shown to be markedly different than intelligibility (e.g., Evitts, Portugal, Van Dine, & Holler,
a typical, healthy voice (e.g., Emanuel & Sansone, 1969). 2010; McCroskey & Mulligan, 1963; Searl et al. 2001),
Although there may be limited research on cognitive which have been attributed to the new vibratory source
workload and disordered voices, in particular dysphonia, (Searl et al., 2001). The dysphonic speakers in the current
there is research on a related topic—listener effort. Previous study may have been using a compensatory laryngeal pos-
studies that have measured listener effort are pertinent as ture that reduced the clarity of specific phonemes. If true,
using RTs to measure cognitive workload may be similar this would suggest that the bulk of intelligibility errors were
to using subjective reports of listener effort. For example, attributed to the larynx and not the articulators.
Morton and Watson (2001) investigated children’s compre- On the other hand, it is possible that such compensa-
hension scores when information was presented with a tory laryngeal adjustments found in disordered speakers
mildly dysphonic voice and found that children would result in articulatory changes that may affect intelligibility.
describe the disordered voice as “sore to listen to” and re- If so, this would suggest that the intelligibility errors in the
ported that they “felt they had to work harder at listening.” current study were attributed to the articulators and not
Similar findings have been reported in the alaryngeal speech due to changes made at the larynx. Support for this is also
literature but described in terms of listening effort, or the found in the alaryngeal literature. For example, tracheoe-
“amount of work needed to listen to a speaker” (Nagle sophageal speakers have been shown to have markedly dif-
& Eadie, 2012, p. 243). In addition, there appears to be a ferent articulatory patterns than laryngeal speakers such
strong association between listening effort and speech ac- as increased oral pressure during bilabial production (Searl,
ceptability (Eadie et al., 2007) with at least one study sug- 2007) and different velopharyngeal orifice sizes and nasal
gesting that the two terms express the same information airflow rates (Searl & Evitts, 2004) apparently because of
(Nagle & Eadie, 2012). Therefore, it appears that regardless the altered voicing source. Although extreme, these exam-
of whether the outcome measure used is subjective (e.g., rat- ples provide support for the argument that overall speech
ings of listener effort) or objective (e.g., RTs), a disordered intelligibility includes the collective effects of both the im-
voice requires additional cognitive resources on the part of pairment and compensatory strategies used by the speaker
the listener. (Yorkston et al., 1999). Regardless, the primary difference

between the two groups of speakers in the current study increased RTs (i.e., decreased RT ratios) were related
was the presence or absence of dysphonia secondary to to the performance on the comprehension task or due
phonotrauma and the speakers with dysphonia had signifi- to other factors not explored in this study. Clearly more
cantly more errors in intelligibility. Whether the errors research with a larger number of speakers is warranted
were the result of laryngeal changes or articulatory changes to shed more light on the relationship among RTs, speech
in response to laryngeal changes, the role of the voicing intelligibility, and listener comprehension.
source as a contributor to impaired speech intelligibility is Although there are no studies for comparison in the
consistent with information from Ramig (1992) and Bender adult dysphonia literature, the current results appear to
et al. (2004). be in contrast to three similar studies on children and the
Although 76% of the variance associated with the impact of a dysphonic voice. These three studies all showed
intelligibility errors was accounted for by the presence or a significant decrease in listener comprehension scores
absence of dysphonia, factors related to the other 24% also when the information was presented either by a speaker
deserve additional attention. One such factor may include with dysphonia or one simulating a dysphonic voice (Lyberg-
variability across listeners. Support for this is provided Åhlander et al., 2015; Morton & Watson, 2001; Rogerson
by McHenry (2011) who found significant variability across & Dodd, 2005). It should be noted that a small number
228 listeners during an intelligibility task. Additional support of speakers was also used in these studies, which hinders
is offered by Choe, Liss, Azuma, and Mathy (2012), who the ability to generalize the results. One could speculate
showed that different listeners exhibit different lexical bound- that the difference in results may be attributed to the par-
ary error patterns as cues to intelligibility when presented ticipants’ age—that is, children typically use more bottom-
with a degraded auditory signal. Although the variability up processing skills compared to adults, who use more
of intelligibility errors for the healthy stimuli was relatively top-down processing skills, which has been attributed to
small, the variability of errors for the dysphonic stimuli increased exposure and experience with language (Lyberg-
represented nearly 50% of the total mean errors. It is plausi- Åhlander et al., 2015). The current results support the
ble that given the same degraded signal, individual differ- notion that as adults mature, there may be less of a depen-
ences within the listeners themselves may constitute a dency on lower level processing, which may be based on
proportion of the variability in intelligibility. In fact, exten- discrete units and is shifted to higher levels of processing
sive variability has been reported among listeners in speech such as propositional content or the integration of knowl-
recognition tasks during adverse listening conditions (e.g., edge within the speaker (Hustad, 2008; Singer, 2000; van
Tamati, Gilbert, & Pisoni, 2013). Taken as a whole, this Dijk & Kintsch, 1983). This notion is supported by the
may place an additional emphasis on the listener when study- ability of the listeners in the current study to be able to
ing disordered speech intelligibility (Klasner & Yorkston, extract the overall meaning of the passages (listener compre-
2005) but clearly more research on the reductions in speech hension) even while exhibiting significant deficits in extract-
intelligibility for speakers with dysphonia is warranted. ing the discrete units (speech intelligibility). Again, although
it may be difficult to generalize the results of the current
study due to the limited number of speakers with dyspho-
Listener Comprehension and Dysphonia nia used for the comprehension task, results of the current
In the current study, listeners utilized significantly study provide some preliminary insight into the relation-
more cognitive workload and had significantly more errors ship among the three variables.
in intelligibility when presented with speech stimuli pro-
duced by speakers with dysphonia. However, it was surpris-
Relationship Between Voice Quality Ratings
ing that listeners were still able to comprehend the signal
and the intended message from the limited set of speakers and Objective Measures
with dysphonia given the 255% increase in intelligibility In the area of voice disorders, it is often said that the
errors with the dysphonic voices and the fact that these ear of the listener is the gold standard for the clinical eval-
errors were primarily on content words. Although preliminary uation. Thus, it was important to investigate the relation-
due to the limited number of speakers, this may be related ship between the objective outcome measures used in the
to the additional cognitive resources that were expended current study and subjective analyses of the voice qualities
when processing the dysphonic voices. This is evidenced from the CAPE-V (e.g., breathy, rough) for those speakers.
by the increased RTs and smaller RT ratios. The increased On the basis of results of the regression analyses, it appears
cognitive workload may have been devoted to acquiring that individual voice qualities are not reliable predictors
the overall message (comprehension) from the speaker of RT ratio or listener comprehension. Results moreso
rather than focusing on individual, discrete phonetic units suggest that the combination of different voice qualities is
(intelligibility). On the other hand, it has been suggested more important, especially with regard to RT ratio. For
that when listeners are faced with increasingly complex example, the regression analysis for RT ratio resulted
tasks, RTs actually decrease due to the increased cognitive in five different models and included all five of the voice
workload (Bess & Hornsby, 2014). Because there is no qualities on the CAPE-V. However, the five voice qualities
“gold standard” for measuring cognitive workload (Bess combined only accounted for nearly 3% of the total vari-
& Hornsby, 2014), it is difficult to determine whether the ance associated with RT ratio, with breathiness accounting

for 1.3% of the total. Although the regression analysis comprehension task required listeners only answer yes or
found that voice qualities were not predictive of the number no questions on the basis of the speaker’s message. Thus,
of listener comprehension errors, this may have been due increased cognitive workload may assist the listener during
to the limited number of speakers. The low observed power a comprehension task but may have a deleterious effect
(.386) may also reflect this limited data set. Voice qualities on the listener during an intelligibility task. On the other
appear to be more predictive of speech intelligibility with hand, one could argue that without the increased cognitive
two voice qualities, overall severity and strain, accounting workload during the intelligibility task, listeners would
for 36% of the variance. The general voice quality of over- have had a much higher number of intelligibility errors,
all severity, in particular, accounted for nearly 32% of the thus also serving to assist the listener during both the in-
variance suggesting that listeners may rely on this “global, telligibility and comprehension tasks. The 255% increase
integrated impression of voice deviance” (Kempster et al., in the number of speech intelligibility errors with the dys-
2009, p. 127) more than other quality features. This would phonic voices would, however, likely support the former
be especially true in relation to the intelligibility of a speech explanation.
signal. Considering that the mean overall severity rating Although the authors of this current study are un-
for the five speakers with dysphonia was 51.9 mm, it appears aware of any studies in the disordered literature that have
that dysphonic speakers rated as moderately deviant in included some measure of cognitive workload along with
overall severity on the CAPE-V may have reduced intelli- intelligibility and comprehension, similar results have been
gibility. This is valuable information for the health care reported in the foreign-accented speech literature. Using
professional to be able to relay to the patient. similar outcome measures, Wilson and Spaulding (2010)
Although results of the multiple regression indicated reported a moderately weak negative correlation (r = −.31)
that 84% of the variance in RT ratio and 76% of the vari- between RTs and comprehension accuracy when listeners
ance in speech intelligibility could be accounted for by were presented with speech produced with a foreign accent.
the presence of dysphonia, other factors not related to Results also suggested a linear relationship between intelligi-
voice quality must be considered. One possible reason for bility and RTs (Wilson & Spaulding, 2010). The authors
this may be related to problems associated with perceptual stated that RTs appear to depend on the speakers’ intelligi-
evaluation of voice (e.g., Kreiman & Gerratt, 1988). Even bility (Wilson & Spaulding, 2010) but this was not borne
though the raters in this study were considered expert with out in the current study.
multiple years of experience and had acceptable reliability The area with, arguably, the strongest work on the
across the voice qualities on the CAPE-V (r values ranged relationship between speech intelligibility and listener com-
from .441 to .992), there was not perfect agreement. This prehension comes from the dysarthria literature with at
may have significantly affected the results of the regression least one study showing a strong and positive relationship
analyses. More research on the relationship between voice between the two (Beukelman & Yorkston, 1979). However,
quality ratings and objective outcomes measures is clearly Hustad and Beukelman (2002) and Hustad (2008) reported
warranted. a weak and nonsignificant relationship between speech
intelligibility and listener comprehension. Hustad (2008)
suggested that although a relationship exists between intel-
Relationship Among Dependent Variables ligibility and comprehension, that relationship is comple-
Results of the correlational analyses showed only one mentary, and the two “tap into different phenomena and
significant but weak (r = −.152) correlation, which was that listener performance on one measure does not neces-
between RT ratio and speech intelligibility. Recalling that sarily reflect performance on the other” (p. 564). Hustad
smaller RT ratios are associated with longer RTs, this nega- (2008) also suggested that indices of speech intelligibility
tive correlation suggests that increased cognitive workload may not be good predictors of how well listeners are able
(i.e., shorter RT ratios) may be associated with increased to comprehend an overall message and that perhaps clini-
speech intelligibility errors. The small r value, however, may cians should move away from focusing on speech intelligi-
preclude any attempts to generalize the results. The sugges- bility towards a focus on “communicative functioning”
tion that increased cognitive workload (i.e., longer RTs) or the speaker’s overall ability to convey their message.
resulting in decreased accuracy may seem counterintuitive. The results of the current study support this notion—that
However, it is plausible that as listeners expend more cogni- is, although listeners had a 255% increase in the number
tive effort to decode a signal, that additional processing of speech intelligibility errors when presented with a dys-
time and effort results in the listener not being able to keep phonic voice, those same listeners were still able to com-
pace with the incoming information. Depending on the prehend and answer questions on the overall meaning of
task, this increased cognitive workload may serve to either those dysphonic speakers’ message. Furthermore, the con-
help or hinder the listener. For example, listeners in the tention that intelligibility and comprehension “tap into
current study had increased number of speech intelligibility different phenomenon” (Hustad, 2008) is also supported
errors even though results suggest the listeners were exerting by results of the current study. As suggested above, in-
more cognitive workload (i.e., decreased RT ratios). The creased cognitive workload may either help or hinder the
intelligibility task required listeners to process and transcribe listener depending on the nature of the task. Intelligibility
the discrete units of the speaker’s message, whereas the tasks require the listener to individually analyze and

reconstruct discrete phonetic units from the speaker. Com- ranges to better generalize the results across different age
prehension tasks, on the other hand, require the listener to groups and to better determine the potential impact of dys-
understand the overall meaning of the speaker’s intended phonia and phonotrauma on different audiences. Fourth,
message. Because the outcomes of these two tasks are in- listeners were presented with a reading passage from only one
herently different and require different levels of processing speaker for the listener comprehension task, which resulted
(Hustad, 2008), cognitive workload may be one of those in a much smaller sample size for this task. Although this
different phenomenon referred to by Hustad (2008). was done primarily due to time constraints as listener com-
Aside from cognitive workload, researchers have prehension was only one of the outcome measures, future
introduced other novel approaches to investigate intelligi- studies should present listeners with stimuli from multiple
bility and the amount of work required by the listener. speakers. Fifth, the use of a single-task paradigm to mea-
Prodi, Visentin, and Farnetani (2010) introduced the con- sure RTs rather than a dual-task paradigm as recommended
cept of listening efficiency, which factors in both the intelli- by other researchers (e.g., Gosselin & Gagné, 2011; Lavie,
gibility of the signal and the amount of listening effort Hirst, de Fockert, & Viding, 2004; Sarampalis, Kalluri,
required to process it. In a similar manner, Nagle and Eadie Edwards, & Hafter, 2009) may have affected listener pro-
(2012) introduced the concept of listener burden, which cessing speeds. Future research on listener RTs associated
incorporates the amount of work required by the listener with dysphonia could use both a single-task and a dual-task
to process a signal and may be related to the overall intelli- paradigm to provide insight on the type of task and its
gibility of the speaker. Due to the equivocal results from impact on listener RTs. Sixth, the fact that the three expert
varying literature fields, clearly there is a need for contin- listeners who provided the voice quality ratings were differ-
ued investigation on the relationship among the amount ent than the listeners in the study may affect the ability to
of effort required by a listener to process a signal, the intel- generalize the results. However, the use of expert listeners
ligibility of the speaker, and how well a listener is able to was done in an attempt to increase ecological validity—that
comprehend the speaker’s intended message. is, a professional speaker with dysphonia would be evalu-
ated and treated by an SLP. That SLP would likely use
an assessment, such as the CAPE-V, to assess the person’s
Limitations voice. Using results from this study, the SLP may be able
There were multiple limitations to this study that to educate the speaker on the potential impact that his or
may prevent the results from being generalized to all her voice will have on an audience. Last, the cognitive de-
speakers with dysphonia. First and foremost, the current mands placed on the listeners during the study were minimal
study used a relatively small number of speakers with dys- and future research should increase the task demands placed
phonia secondary to phonotrauma, which makes generali- on the listener while measuring the cognitive workload,
zation to all speakers with dysphonia difficult. Results speech intelligibility, and listener comprehension. It may
from the listener comprehension task, in particular, are be that a divided attention task or increased duration of
based on only two speakers with dysphonia. Differences the tasks may have even a greater impact on the dependent
in articulation, voice quality, and prosody, which were variables. This is an important consideration due to the
highlighted by Ramig (1992) as potential contributors to types of employment for those professional voice users with
speech intelligibility, were not accounted for and may have dysphonia and their audiences. There are numerous em-
also contributed to the results. Future studies should in- ployment settings where listeners would be simultaneously
clude a larger sample size of speakers with different voice processing the dysphonic voice while performing other
disorders and include multiple speakers across the entire tasks or experiencing an increased mental load. Therefore,
continuum of severity. Second, the three experiments were an increased understanding of how accurately the listener
not randomized across listener participants, which may can process the disordered acoustic signal in such situations
have resulted in an order effect. However, it was determined is critical.
a priori that this was necessary due to potential familiariza-
tion with the disordered signal and its impact on RTs.
Because increased familiarity has been associated with Conclusions
decreased RTs (e.g., Smith, 1967; Young et al., 1986) and The purpose of this study was to determine the impact
intelligibility (e.g., Hustad, 2008; Tjaden & Liss, 1995), it on the listener of dysphonia secondary to phonotrauma.
was necessary to reduce this potential by having participants Results showed that when presented with a dysphonic voice
complete the experiments in a specified, nonrandom order. compared to a typical healthy voice, listeners required addi-
Although significant differences were still found in RT ratio tional time to process the signal (RT ratio) and were less
and the number of speech intelligibility errors between the accurate transcribing the speakers’ intended message (speech
healthy and dysphonic speakers, it is possible that this intelligibility). However, there was no difference in the
difference may have been even larger. More research with listeners’ ability to comprehend the message between the
only one listening task would shed light on this issue. Third, healthy and dysphonic speakers (listener comprehension).
the listeners used in the current study had a mean age of Although preliminary, the findings suggest that when pre-
21.8 years. Although these listeners are considered adults, sented with a dysphonic voice, listeners may compensate
future studies should take care to include additional age for the degraded acoustic signal by increasing the amount

of cognitive workload. This increased amount of cognitive Choe, Y., Liss, J., Azuma, T., & Mathy, P. (2012). Evidence of
workload may assist the listener during a comprehension cue use and performance differences in deciphering dysarthric
task but may have deleterious effects during an intelligibil- speech. Journal of the Acoustical Society of America, 131,
EL112–EL118. doi:10.1121/1.3674990
ity task. Furthermore, regression analyses suggest that al-
Cohen, J. (1988). Statistical power analysis for the behavioral sci-
though an overall severity rating of moderately deviant was ences (2nd ed.). Mahwah, NJ: Erlbaum.
able to account for nearly one third of the variance associ- Cole, R. A., Coltheart, M., & Allard, F. (1974). Memory of a
ated with speech intelligibility errors, other individual voice speaker’s voice: reaction time to same- or different-voiced letters.
ratings or combinations of voice quality ratings from the The Quarterly Journal of Experimental Psychology, 26, 1–7.
CAPE-V were less predictive of listener processing speed Drager, K., & Reichle, J. (2001). Effects of age and divided at-
and the number of comprehension errors. Due to the high tention on listeners’ comprehension of synthesized speech.
incidence of voice disorders with professional voice users Augmentative and Alternative Communication, 17, 109–119.
and the types of vocation held by these individuals, it is Duffy, J., & Pisoni, D. (1992). Comprehension of synthetic speech
produced by rule: A review and theoretical interpretation.
vital to have a thorough understanding of how the listener
Language and Speech, 35, 351–389.
processes the voice of a speaker with dysphonia secondary Eadie, T., Nicolici, C., Baylor, C., Almand, K., Waugh, P., &
to phonotrauma. Maronian, N. (2007). Effect of experience on judgments of
adductor spasmodic dysphonia. Annals of Otology, Rhinology,
and Laryngology, 116, 695–701.
Acknowledgments Emanuel, F., & Sansone, F., Jr. (1969). Some spectral features of
The authors would like to first thank all of the participants normal and simulated rough vowels. Folia Phoniatrica (Basel),
for volunteering their time and voices to this study. The authors 21, 401–415.
would like to also extend a sincere thank you to Barbara Messing Evitts, P. M., Portugal, L., Van Dine, A., & Holler, A. (2010).
of the Greater Baltimore Medical Center for acting as an expert Effects of audiovisual information on alaryngeal speech intelli-
listener and to Dr. Mary Carter, Towson University, for her gibility. Journal of Communication Disorders, 43, 92–104.
expert statistical assistance. The authors would also like to thank Evitts, P., & Searl, J. (2006). Reaction times of normal listeners to
Dr. Krista Wilkinson and Dr. Preeti Sivasankar along with two laryngeal, alaryngeal, and synthetic speech. Journal of Speech,
other anonymous reviewers for their thoughtful and supportive Language, and Hearing Research, 49, 1380–1390.
edits on previous versions of this manuscript. Portions of this article Feistritzer, C. E. (2011). Profiles of teachers in the U.S. 2011.
were presented at the annual convention of the American Speech- National Center for Education Information. Retrieved from
Language-Hearing Association, Chicago, IL in 2013. http://www.edweek.org/media/pot2011final-blog.pdf
Garcia, J., & Cannito, M. (1996). Influence of verbal and nonverbal
contexts on the sentence intelligibility of a speaker with dysar-
thria. Journal of Speech and Hearing Research, 39, 750–760.
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