Videostroboscopy of human vocal fold paralysis.

Previous stroboscopic studies of human vocal cord paralysis have been infrequent and have lacked documentation of the site of lesion. In order to study human laryngeal paralysis, the recurrent and superior laryngeal nerves were infiltrated unilaterally with lidocaine hydrochloride in three human volunteers. Vagal paralysis was simulated by combined (superior and recurrent) infiltration in one volunteer. Additionally, 20 patients with untreated laryngeal paralysis were studied from the voice laboratory at UCLA. In addition to videostroboscopic analysis, photoglottography and electroglottography were performed and synchronized with the stroboscopic images. The most significant finding in stroboscopy of the paralyzed larynx was the asymmetry of traveling wave motion. The traveling wave on the normal vocal fold had a faster wave velocity that created a phase difference in the vibration of the two folds. The wave also traversed a greater distance along the vocal fold mucosa on the normal side. No patient or volunteer with untreated laryngeal paralysis had a symmetric traveling wave, either in superior or recurrent laryngeal nerve paralysis. Synchronization with glottography indicated that the differentiated electroglottographic waveform provides useful information about the timing of glottic opening and closure in states of asymmetric laryngeal vibration. Implications for future studies and for the diagnosis of laryngeal paralysis are discussed.     

Relationships between the degree of lesion and that of vocal dysfunction in vocal fold polyp

Relationships between the degree of lesion and that of vocal dysfunction were investigated in 122 cases of vocal fold polyp. A normalized size of polyps and glottic gap were correlated to the results of phonatory ability tests, stroboscopic investigations, acoustic analyses, and perceptual evaluations. There was no significant correlation between the size and the gap. The size of polyp was negatively correlated to fundamental frequency, whereas it was positively correlated to roughness of voice, asymmetry of vocal fold vibration, irregularity of vocal fold vibration, pitch perturbation quotient, amplitude perturbation quotient, and normalized noise energy. The glottic gap showed negative correlations to maximum phonation time and sound pressure level, and positive correlations to mean airflow rate and fundamental frequency.     

DiHA (dextranomers in hyaluronan) injections for treatment of insufficient closure of the vocal folds: early clinical experiences

OBJECTIVE: To determine the clinical effects of injecting DiHA (a mixture of dextranomer molecules and 1% hyaluronan solution in equal proportions) as a "space filler" into the vocal folds of patients experiencing insufficient closure of the vocal folds resulting from either unilateral vocal fold paralysis or bowed vocal folds. STUDY DESIGN: A consecutive series of patients with insufficient closure of the vocal folds treated with DiHA injections and prospectively followed up with videostroboscopy and voice recordings that were evaluated by expert panels. METHODS: During a 21/2-year period, 14 patients with insufficient closure of the vocal folds were included. Six had a unilateral vocal fold palsy and 8 patients had "bowed" vocal folds. DiHA was injected into one vocal fold. Laryngoscopic examination and voice recordings were performed pre- and postoperatively. Expert panels did the evaluation of the stroboscopy examination and the perceptual voice analysis. RESULTS: Three patients were operated on with local and 11 under general anesthesia. All patients with unilateral palsy improved their stroboscopic status regarding both the wave and the closure after injection. Also, their voice parameters were significantly improved. Among the patients with bowed vocal folds, all except 2 showed an improvement in the glottic wave, 5 of 8 improved in glottic closure, and 3 improved their voice parameters significantly. CONCLUSION: This early clinical experience indicates that DiHA fulfills most of the requirements of an ideal "space-filling" substance for voice restoration in patients experiencing insufficient vocal fold closure.     

Outcome analysis of benign vocal cord lesions by videostroboscopy, acoustic analysis and voice handicap index

Benign vocal cord lesions affect vibratory vocal fold function resulting in significant dysphonia. A prospective study of 30 patients with benign vocal fold lesions was undertaken at our centre to compare the pre and post operative voice using videostroboscopy, voice analysis and voice handicap index. The vibratory pattern of the cord improved as evidenced by the stroboscopic parameters-symmetry, mucosal wave and glottic closure (p<0.05). Voice analysis showed a trend towards normalcy but the values obtained did not attain statistical significance. Voice handicap index showed a reduction in the total and the subscales scores. Videostroboscopy along with acoustic analysis and voice handicap index are useful tools in the objective and subjective assessment of the effectiveness of treatment in patients with benign vocal cord lesions. Their routine use in a voice clinic is recommended.     

Phonomicrosurgery for benign vocal Fold lesions - our experience

Benign lesions of glottis creates stiffness of the vocal fold and inefficient glottal valve, aerodynamically effecting the vocal quality by preventing smooth vocal edge closure. Introduction of phonomicrosurgical techniques based on Hirano ’s principle of vocal fold epithelium have revolutionized results of voice surgery. Our experience in the management of benign vocal fold lesions by phonomicrosurgical techniques with pre and post operative stroboscopic, perceptual and computerized acoustic voice analysis is described.     

Voice therapy for vocal fold paralysis

There is no doubt that vocal fold paralysis is a debilitating condition affecting an individual's general health and quality of life. Optimal management of a patient with vocal fold dysfunction by an otolaryngologist, speech scientist, and speech language pathologist results in detailed objective videostroboscopic evaluation of glottal configuration during phonation, acoustic and aerodynamic measures, laryngeal EMG (if appropriate), and the patient's self-rating of vocal disability. Profound glottal incompetence is typically managed surgically with a few voice therapy sessions after surgery to ensure optimal vocal function. Patients with more adequate glottal closure are often seen for voice therapy and lost to follow-up when their voices improve enough to satisfy their vocal needs. It is essential that a complete battery of assessments, including perceptual, aerodynamic, acoustic, and stroboscopic measures, be obtained at periodic intervals in surgical and nonsurgical patients so as to evaluate vocal function over time. One of the few rigorous studies of perceptual, acoustic, aerodynamic, and videofiberscopic findings in patients after medialization with fat and thyroplasty assessed patients before surgery and at short (1-3 months),middle (4-6 months), and long (7-12 months) intervals after surgery. Improvement in most parameters at short- and long-term intervals was noted but not in the middle interval. The best results were obtained in women. Continued difficulty in increasing and maintaining subglottal pressure for high-intensity phonation was observed in both male and female patients. This fine study raises a number of questions as follows. What objective phonatory measures should be assessed before and after intervention and at what time intervals? Why were the women's results better than the men's results when no correlation of age, pulmonary function, or severity of preoperative voice and aerodynamic impairment was observed? Should voice therapy be initiated at the 4- to 6-month interval when voice quality diminished or within 1 to 2 months after surgery so that the decrement in vocal function might not occur? Why did vocal function ultimately improve after 7 to 12 months? Heuer et al and Colton and Casper found similar outcome satisfaction in patients electing surgery compared with those that were seen for voice therapy; however, the patients with lesser glottal incompetence in both studies opted for therapy. Can we better define vocal parameters that help to predict which patients may need surgery rather than therapy? Should all patients with high airflow measures but near-normal subglottal pressures and MPT greater than 10 seconds undergo 6 weeks of voice therapy rather than medical intervention? If all surgical patients were seen for 6 weeks of postoperative therapy, would voice satisfaction ratings increase to greater than 70%? Can we perceptively or objectively differentiate patients whose postoperative voices will be excellent from those whose voices will be merely adequate? These questions can only be answered by the development and implementation of a rigorous protocol studying women and men of varying ages with unilateral vocal fold paralysis choosing medialization surgery and electing voice therapy. Standardized assessments must include perceptual,aerodynamic, acoustic, stroboscopic, and patient satisfaction measures during soft- and loud-intensity tasks before and at periodic intervals after the two interventions.     

Acoustic, aerodynamic, and videostroboscopic features of bilateral vocal fold lesions

Successful treatment of bilateral vocal fold lesions depends on the accuracy of the diagnosis. For example, the preferred treatment for vocal fold nodules is voice therapy: in contrast. treatment for a unilateral vocal fold lesion with a contralateral reactive vocal fold lesion (UVFL/RL) usually involves phonosurgery and voice therapy. Differentiation between vocal fold nodules and a UVFL/ RL is often challenging. The purpose of this study was to facilitate diagnostic accuracy and improve treatment for patients with bilateral vocal fold lesions by attempting to identify distinct features of patients with either vocal fold nodules or a UVFL/RL with acoustic, aerodynamic, stroboscopic, and patient self-perception measures. The objective voice analysis, Voice Handicap Index, and laryngovideostroboscopic examinations of 85 patients with bilateral vocal fold lesions were reviewed. The results indicated that the patients with a UVFL/RL presented a diagnostic profile that was significantly different from that of patients with vocal fold nodules. Statistically significant differences were found for 1) symmetry of vocal fold vibration, 2) amplitude perturbations, 3) estimated subglottic pressure, and 4) Voice Handicap Index. These results suggest that a composite assessment of acoustic, aerodynamic, and videostroboscopic phonatory features facilitates differentiation between patients with vocal fold nodules and those with a UVFL/RL. The improved diagnostic accuracy afforded by multiparametric assessment provides a comprehensive framework for the treatment of these two distinct vocal fold disorders.     

Videostroboscopic assessment of unilateral vocal fold paralysis after augmentation with autologous fascia

Vocal fold augmentation by injection laryngoplasty is a simple and fast procedure. The aim of this prospective study was to assess the glottal closure and the travelling mucosal wave by videostroboscopic images after autologous fascia augmentation in unilateral vocal fold paralysis (UVFP) with a special reference to objective analysis of voice. A total of 14 UVFP patients with poor voice and open glottal gap were assessed by videostroboscopy, blinded perceptual evaluation of running speech and acoustical analysis of sustained vowel. Data were collected before the procedure and at a supplementary evaluation 5–32 months (mean: 13 months) after injection of autologous fascia deep into the paralysed vocal fold. Mean age was 59 years; there were eight women and six men. Frame-by-frame video analysis revealed that before the operation 10 out of 12 had large glottal gaps without any contact between vocal folds on phonation. After the procedure seven gaps were completely closed, four partly, and two had no mucosal contact in stroboscopic examination. Maximum gap between vocal folds decreased from 7.21 units to 1.65 units (paired t-test P<0.001). Mucosal wave amplitude symmetry and phase synchrony were present in most subjects with partial closure and phase synchrony in every patient with a proper glottic closure. A panel of listeners rated voice to be significantly better (P<0.01) ) after the procedure, and the improvement in acoustical parameters was also statistically significant (P<0.01). There was a good correlation between objective voice analysis and videostroboscopy. Residual glottal gap was the major reason for less than optimal postoperative voice. No signs of hampered mucosal wave were noticed. Videostroboscopy and objective voice analysis suggest that augmentation by autologous fascia does not induce scar or fibrous tissue in the subepithelial space. Slight over-correction should be attempted initially in order to accomplish sufficient augmentation. This might enhance complete glottic closure and improve the outcome.     

Vocal function following carbon dioxide laser surgery for glottic carcinoma

Vocal function following laser surgery for glottic T1a carcinoma was evaluated in 17 patients and compared to vocal function following radiotherapy in 14 patients. The results are summarized as follows. 1) A slight degree of hoarseness was found more frequently following laser surgery than following radiotherapy. The quality of hoarseness was rough and breathy in most cases. 2) In stroboscopic examination, incomplete glottal closure and diminution or lack of vibration of the operated vocal fold were frequently observed following laser surgery. 3) There was no marked difference in maximum phonation time, mean airflow rate, fundamental frequency range of phonation, intensity range of phonation, and intensity-flow ratio between the laser and the radiotherapy groups. On the basis of these results, we conclude that there is little difference in vocal function between postlaser and postradiotherapy patients as far as conversational voice is concerned.     

早期嗓音训练对改善甲状腺术后声带麻痹患者嗓音质量的疗效观察

目的 探讨早期发声训练对改善甲状腺术后声带麻痹患者嗓音质量的效果.方法 选取西安交通大学第一附属医院耳鼻咽喉头颈外科甲状腺术后声带麻痹的48例患者为研究对象,随机分为实验组及对照组(各24例).实验组自术后1周开始进行系统嗓音训练,对照组不进行干预.对两组术后1周、12周及24周的嗓音主客观评估及频闪喉镜评估数据进行对...     

Factors predicting patient perception of dysphonia caused by benign vocal fold lesions

OBJECTIVES/HYPOTHESIS: To assess factors that may be predictive of patient perception of dysphonia severity, as quantified by the Voice Handicap Index (VHI) score. We hypothesize that 1) level of vocal demand; 2) auditory-perceptual evaluation of dysphonia severity; and 3) vocal function, as defined by phonatory glottal closure and mucosal wave vibration, are the most significant predictors of VHI score. STUDY DESIGN:: Retrospective review of 100 patients with benign vocal fold lesions. METHODS: Variables assessed for predictive value to VHI score are level of vocal demands, auditory-perceptual evaluation of dysphonia severity, integrity of mucosal wave vibration and phonatory glottal closure, lesion type, duration of current complaint, smoking, age, and sex. Harmonic to noise ratio was assessed in a subset of 50 patients. RESULTS: Patients with routine voice use had significantly lower VHI scores than those with more intensive (nonsinging/acting) vocal demands. Patients who quit smoking had greater VHI scores than those who currently smoke or never started. Patients with long-standing dysphonia tended to have lower VHI scores than those with shorter duration vocal complaints. Auditory-perceptual assessment of dysphonia severity and harmonic to noise ratio were weak predictors of VHI score. Age, sex, lesion type, phonatory glottal closure, and mucosal wave vibration were not significant predictors of VHI score. CONCLUSIONS: Patient perception of dysphonia severity is independent of many factors commonly assessed during the evaluation of voice disorders. It appears to be an important independent element in the assessment of the effect of a benign vocal fold lesion and critical to therapeutic decision-making.     

Study of movements of individual structures of the larynx during swallowing

OBJECTIVE: The purpose of this study was to reveal movements of individual structures of the larynx during swallowing. METHODS: Subjects were 7 healthy adults, aged 24 to 32 years (average 27 years), who had no organic or functional disease of the pharynx and larynx and 2 adults with unilateral recurrent nerve palsy, aged 49 and 60 years, respectively. We used the Toshiba IIDR system, which is composed of an X-ray TV system and a digital image managing circuit. One-fifth diluted Omnipark 300 was used as contrast medium (lohexol), with 15 cc for each swallow. The mask image for subtraction was designated as the frame before laryngeal elevation during swallowing for subtraction. We obtained the images for observation and analysis after subtracting the mask image from continuously obtained images. These images were captured into a personal computer at 30 frames per s and thereafter frame-by-frame observation and analysis were performed by means of NIH image 1.56. RESULTS: We observed that the vocal folds underwent a series of movements during swallowing. (1) They adduct slowly and do not ascend; (2) then begin to ascend and continue adducting; whereby (3) they abduct for a moment while ascending. (4) Again, they adduct and achieve closure. (5) While maintaining closure, vocal folds elevate further to reach their maximal elevation; and (6) begin to abduct rapidly while maintaining maximal elevation. Finally, (7) they begin to descend and undergo repeated irregular abduction and adduction while descending. In examining the relationship between closure and opening at levels of the vocal fold and false vocal fold, we found that closure at the false vocal fold level precedes that at the vocal fold level and that opening at the vocal fold level precedes that at the level of the false vocal fold. CONCLUSION: Closure of the false vocal fold level appears important in the protection of the lower respiratory tract during swallowing.     

二氧化碳激光与常规冷器械切除声带良性病变的疗效比较

目的 比较二氧化碳激光与常规冷器械切除声带良性病变的手术效果。方法 选取2017年12月—2020年12月于四川省会理市人民医院和四川省肿瘤医院接受治疗的200例良性声带病变患者,依据双盲法随机分为A组(100例)与B组(100例)。A组行常规冷器械法治疗,B组二氧化碳激光切除术治疗,术后对各组视频频闪、声学分析和语音障碍指数(VHI)进行评价。结果 两组结节、息肉、囊肿、黏膜白斑分布例数对比无明显差异(P>0.05)。两组术后3个月的闪烁噪声、嗓音抖动、基频均小于术前,术后3个月的最大发声时间大于术前。但两组术前和术后3个月的闪烁噪声、嗓音抖动、基频、最大发声时间对比差异无统计学意义(P>0.05)。两组患者术后3个月的VHI的躯体、功能、情感、总计得分均小于术前,但经比较差异无统计学意义(P>0.05)。结论 两种手术方法在处理良性声带病变方面都有良好的疗效,但各有其优缺点。     

声带下方收敛角度在声门闭合不全发声困难中可能的作用机理

目的 探讨喉三维CT重建下声带下方收敛角度的测量方法,探索声门闭合不全对声带下方收敛角度的影响,分析声门闭合不全发声疲劳可能的气流动力学原因.方法 采用双源薄层CT,嘱受试者发/i:/音时扫描10例正常人的20侧声带(声门闭合组),深吸气时扫描8例单侧声带麻痹患者的麻痹侧声带(声门闭合不全组),经深吸气时扫描另10例正常人的20侧声带(声带外展组);导入影像数据于Mimics软件,构建声带及气道的3D模型,联合这两模型测量声带下方收敛角度;采用单因素方差分析,比较3组受试者声带下方收敛角度的差异;并尝试采用材料的斜截面应力分配原理进行声门下压力分析,探讨声门下收敛角度对启动发声时声带振动可能的影响.结果 声门闭合组、声门闭合不全组及声带外展组的声带下方收敛角度分别为33.49°±3.75°、55.03°±2.61°及75.02°±7.32°,三组间差异有统计学意义(P<0.01),声带下方收敛角度随声门闭合不全程度增加而增加.结论 声带下方收敛角度可以通过声带及气道的3D模型进行有效测量,声门闭合不全程度增加会引起该角度增大,可能会导致声门下压力作用于声带下方的剪切力和正应力的分力发生变化,从而引起发声困难.     

针灸联合嗓音矫治治疗原发性肌紧张性发声障碍

目的探讨针灸联合嗓音矫治对原发性肌紧张性发音障碍患者的治疗效果。方法将40例原发性肌紧张性发音障碍患者随机分为嗓音矫治组及针灸联合嗓音矫治组(针灸联合治疗组),每组20例。嗓音矫治组采用放松训练、轻松发音、口腔共鸣及情景对话四阶段循环嗓音矫治方法治疗,针灸联合嗓音矫治组在嗓音矫治的基础上加用6处穴位的针灸治疗三周,比较两组治疗前后的基频微扰(jitter)、振幅微扰(shimmer)、最长发声时间(MPT)、嗓音障碍严重指数(dysphonia severity index,DSI)、频闪喉镜检查、嗓音障碍指数(VHI)评估、嗓音主观评分(GRBAS)、康复时间及3月后复发率。结果①治疗前上述指标两组之间无显著性差异(P>0.05);治疗后,两组患者jitter、shimmer、VHI及G评分均较治疗前显著减小(P<0.05),MPT及DSI较治疗前显著升高(P<0.05);但两组之间治疗后jitter、shimmer、MPT、DSI及G评分均无显著性差异(均P>0.05),针灸联合治疗组VHI评分低于嗓音矫治组,差异有统计学意义(P<0.05)。②两组患者至治疗结束时频闪喉镜检查均表现为声门上区挤压消失,室带收缩显著缓解,声带均可正常暴露并观察到正常粘膜波,声门后裂隙不同程度减小甚至消失。③针灸联合治疗组康复时间(中位数32.15天)显著短于嗓音矫治组(中位数41.07天)(P<0.01);针灸联合治疗组3月后复发5例(25.0%,5/20),嗓音矫治组3月后复发6例(30.0%,6/20),治疗后两组复发率比较差异无统计学意义(P>0.05)。结论针灸及嗓音矫治治疗原发性肌紧张性发声障碍均有良好的治疗效果,两者联合能够缩短疗程,更有利于改善患者的主观症状。     

Effectiveness of laryngostroboscopy for monitoring the evolution of vocal nodules after rehabilitator treatment

Objective

The aim of this study is to evaluate the effectiveness of the laryngostroboscopy for monitoring the evolution of patients with vocal nodules before and after the logopedic vocal treatment.

Methods

We performed a prospective observational study of 97 dysphonic patients diagnosed of vocal nodules, where we analyzed four stroboscopic parameters (glottal closure, vocal fold vibration, mucosal wave and phase symmetry) by a protocol based on systematic subjective evaluation of the stroboscopic images before and after the rehabilitator vocal treatment; and the results were stratified according to the clinical course.

Results

All patients, before the treatment, had some abnormality in at least one of the four analyzed aspects. After the vocal treatment, we found improvement of the four parameters in different degrees. Also, we found a statistically significant relationship between the evolution of each parameter and the clinical course.

Conclusion

We believe that the laryngostroboscopy, systematized through a protocol, is a useful technique for the diagnosis of structural abnormalities in patients with vocal nodules and is a useful technique for evaluating the results after the rehabilitator treatment, as there is a statistically significant relationship between clinical course and the change in the stroboscopic findings. However it should not be the only technique used for these proposes.     

The effects of frequency and intensity level on glottal closure in normal subjects

The degree of glottal closure during phonation has an influence on voice quality and it is related to the robustness of the voice source. To quantify glottal closure a frame of reference was created by investigating 47 healthy men and 92 healthy women with no vocal complaints using videolaryngostroboscopy. Observing recorded images the degree of glottal closure was rated with a percentage. Results indicate that men have better glottal closure than women (P < 0.001). An increase in vocal intensity is related to improved glottal closure (P < 0.001), and in women a negative relationship was established between pitch and glottal closure (P < 0.001). Normal glottal closure in men is a complete closure, whereas in women a closure of at least 90% should be attained. If these percentages cannot be established during loud phonation, it suggests the presence of a less robust larynx. To evaluate and quantify the function of the voice source, in clinical practice the larynx should not be observed at only one intensity level, but at a variety of intensity and frequency levels.     

Quantitative Criteria for Predicting Thyroplasty Type I Outcome

The purpose of this study was to ascertain the relation between preoperative glottal gap and postoperative vocal function in thyroplasty type I. Twenty-two of 64 patients who underwent thyroplasty type I between 1987 and 1994 were studied. In preoperative digitized laryngostroboscopic images, the glottal-gap width (GGW), shape, and area were examined at the maximum closure of vibration and normalized by membranous vocal-fold length (MVFL). Postoperative vocal function analysis was performed with aerodynamic and acoustic measurements and compared with preoperative videostroboscopic images. In patients with preoperative posterior GGW of less than 10% of MVFL, postoperative vocal function was significantly better than in other patients. Although thyroplasty type I is an excellent medialization technique, it may need to be combined with a posterior closure procedure in patients with large posterior gaps.     

声带癌T1的激光与放射治疗对喉发声机能的影响

目的 探讨声带癌Ｔ１的ＣＯ２激光治疗与放射治疗对喉发声机能有何不同影响。方法 ２４例声带癌Ｔ１患者,９例行ＣＯ２激光治疗,７例放射治疗,８例ＣＯ２激光与放射联合治疗。于治疗前后行频闪喉镜检查,噪音声学分析（ＡＰＱ,ＰＰＱ,ＮＮＥｂ,ＮＮＥａ）,喉平均呼气流率（ＭＦＲ）检测及噪音听觉评价分析。结果 放射加激光联合治疗对发声功能较单独应用激光或单独应用放射的影响大。ＣＯ２激光治疗组噪音音质改变为粗糙型     

The effect of surface electrical stimulation on vocal fold position

OBJECTIVES/HYPOTHESIS: Closure of the true and false vocal folds is a normal part of airway protection during swallowing. Individuals with reduced or delayed true vocal fold closure can be at risk for aspiration and may benefit from intervention to ameliorate the problem. Surface electrical stimulation is currently used during therapy for dysphagia, despite limited knowledge of its physiological effects. DESIGN: Prospective single effects study. METHODS: The immediate physiological effect of surface stimulation on true vocal fold angle was examined at rest in 27 healthy adults using 10 different electrode placements on the submental and neck regions. Fiberoptic nasolaryngoscopic recordings during passive inspiration were used to measure change in true vocal fold angle with stimulation. RESULTS: Vocal fold angles changed only to a small extent during two electrode placements (P < or = .05). When two sets of electrodes were placed vertically on the neck, the mean true vocal fold abduction was 2.4 degrees; while horizontal placements of electrodes in the submental region produced a mean adduction of 2.8 degrees (P = .03). CONCLUSIONS: Surface electrical stimulation to the submental and neck regions does not produce immediate true vocal fold adduction adequate for airway protection during swallowing, and one position may produce a slight increase in true vocal fold opening.