Cough and paradoxical vocal fold motion

OBJECTIVES: The differential diagnosis and treatment of patients with chronic cough, paradoxical vocal fold motion, and disordered breathing can be a challenge to most practicing otolaryngologists. Tracheobronchial (ie, asthma, bronchitis, and tracheal stenosis), laryngeal (ie, vocal fold paralysis and neoplasms), and rhinologic (ie, allergies and rhinosinusitis) etiologies are commonly diagnosed and treated effectively. However, occasionally one is faced with patients who are refractory to medical treatment and have no obvious rhinologic, laryngeal or pulmonary cause. STUDY DESIGN AND SETTING: We conducted a review of the literature. METHODS: We present a thorough review of the current medical literature exploring the complex neurologic mechanisms involved in the production of cough and the relationship between gastroesophageal reflux disease, vagal neurapathy, and paradoxical vocal fold motion. RESULTS: The diagnosis and successful treatment of chronic cough can be complex. It requires a thorough understanding of the neurologic mechanisms behind cough excitation and suppression. Successful treatment strategies include aggressive management of the patient's reactive airway disease, gastroesophageal reflux disease, and, in select cases, paradoxical vocal fold motion. This may involve a well-coordinated effort among pulmonologists, otolaryngologists, gastroenterologists, and speech pathologists. CONCLUSION: Gastroesophageal reflux disease, vagal neuropathy, and paradoxical vocal fold motion are additional causes of chronic cough and disordered breathing that need to be considered, in the absence of obvious laryngotracheal and/or rhinologic pathology. A high index of suspicion is essential in making the diagnosis and formulating an effective multidisciplinary treatment plan for these patients.     

Thyrohyoid vocal fold augmentation with calcium hydroxyapatite

OBJECTIVES: To review the clinical results of the thyrohyoid approach for in-office vocal fold augmentation with calcium hydroxyapatite. STUDY DESIGN: Retrospective chart review. METHODS: The charts of all persons who underwent in-office thyrohyoid vocal fold augmentation between June 1, 2005 and June 1, 2007 were reviewed. Information with respect to patient demographics, indications, complications, and clinical outcome was abstracted. RESULTS: Fifty-one thyrohyoid vocal fold augmentations were performed in 33 patients (26 men; mean age, 66 years). Six (13%) procedures were aborted as a result of an inability to achieve an appropriate injection angle. Two (6%) self-limited complications included a vasovagal episode and a small ulcer near the petiole of the epiglottis. Pre- and postprocedure data were available for 62.5%. The mean 10-item Voice Handicap Index improved from 27.9 (+/-8.40) preprocedure to 13.5 (+/-10.52) postprocedure (P < 0.001). CONCLUSION: In-office vocal fold augmentation with the use of the thyrohyoid approach demonstrates excellent clinical results. It has become our technique of choice for vocal fold medialization with the patient under local anesthesia in the office setting. Complications are rare.     

A submucosal true vocal fold infusion needle

This simple, inexpensive device for submucosal true vocal fold saline infusion into Reinke's space improves the diagnosis and treatment of small vocal cord lesions and is a useful addition to our microlaryngoscopy instrumentation.     

Laser tenotomy and vocal process resection for bilateral midline vocal fold fixation

Background: The present retrospective study presents the outcomes of a group of 21 patients with laryngeal obstruction caused by bilateral vocal fold fixation. All of these patients were treated by laser assisted muscle tenotomy and vocal process resection ? a modification of the technique described by Michael and Eugene Rontal in 1994. 1 Methods: Between January 1997 and March 2002 the senior author performed muscle tenotomy and vocal process resection for bilateral vocal fold fixation on 21 patients. Results: The mean follow‐up time was 2.3 years. The technique was successful in achieving an adequate airway and good voice with no aspiration in every case. Conclusions: Laser assisted muscle tenotomy and vocal process resection is a proven treatment for bilateral medial vocal fold fixation with the provision of a good airway, good voice and the avoidance of aspiration.     

Autologous fat injection laryngoplasty for unilateral vocal fold paralysis

Background: Fat injection laryngoplasty has been used at the Sydney Voice Clinic for selected cases of unilateral vocal fold paralysis since 1989. Methods: Forty‐five consecutive cases deemed suitable for treatment by this technique are presented in this paper. Results: Mean follow up for this group of patients was 33 months. Over the period of follow up, 39 of the 45 patients achieved normal or near normal voice, with four patients requiring additional surgical intervention. Conclusion: Fat injection laryngoplasty is a quick, simple, inexpensive and reliable procedure, with few complications and good long‐term results in suitable selected cases of unilateral vocal fold paralysis.     

Diplophonia in unilateral vocal fold paralysis and intracordal cyst

Diplophonia is the production by the voice of 2 separate tones through quasiperiodic variations in the vocal fold vibration (Ward PH, Moore GP. Ann Otol Rhinol Laryngol 1969;78:771-7). Clinically, diplophonia can be observed in patients with unilateral vocal fold paralysis with incomplete glottal closure and a mass lesion of the vocal fold, intracordal cyst, and granuloma (Kiritani S, et al. Ann Bull RILP 1991;25:55-62; Hirano M, et al. Ann Otol Rhinol Laryngol 1989;98:791-5). In this study we report 16 subjects with unilateral vocal cord paralysis or an intracordal cyst characterized perceptually by diplophonia. Diplophonia during tension imbalance may occur after surgery and is characterized by an improved perceptual score, a reduced number of vibratory cycles in each quasiperiodic waveform, and a reduced occurrence rate of the diplophonic waveform. During mass imbalance, no diplophonia occurred after surgery. Regarding the relationship of diplophonia with glottal condition at production of stops, in our study diplophonia varied significantly according to the different phonologic environments of stops during tension imbalance. We presume that there is a close relationship between the occurrence of diplophonia and the glottal conditions in tension imbalance, but not in mass imbalance.     

A grading scale for pediatric vocal fold nodules.

OBJECTIVE: To design a grading scale for vocal fold nodules in pediatric patients. STUDY DESIGN AND SETTING: We conducted a prospective study in which a grading scale for vocal nodule size and contour based on static fiberoptic images of pediatric larynges was developed to achieve the scale presented here. RESULTS: Twenty-eight health care professionals each rated 28 images of pediatric vocal fold nodules. The intraclass correlation for nodule size was strong (0.77; 95% confidence interval, 0.67-0.87). The kappa statistic for nodule contour was mild (0.35; 95% confidence interval, 0.33-0.37). Agreement between experienced and other raters found no significant difference for the nodule size or contour grade of a given image. CONCLUSIONS: A grading scale for pediatric vocal fold nodules is presented. Interrater reliability for nodule size is high and can be reliably used by health care professionals with varying levels of experience. SIGNIFICANCE: A validated grading scale facilitates objective analysis of outcomes when studying and following patients with vocal nodules.     

Phonatory vocal fold function in the excised canine larynx

The development of valid objective measurements of vocal cord vibration during phonation is a goal of current research in laryngeal physiology. An excised canine larynx was used to study the effects of vocal cord tension, air flow rate, and glottic width on glottographic parameters. The electroglottographic and photoglottographic wave-forms were simultaneously recorded as the vocal cord tension, glottic width, and air flow rate were systematically varied. These glottographic waveforms were analyzed to determine the open quotient and speed quotient. Multiple regression analysis of the data obtained from 10 larynges showed the open quotient to be directly related to vocal fold tension (p less than 0.001), glottic width (p less than 0.01), and fundamental frequency (p less than 0.001). Speed quotient was inversely related to glottic width and and subglottic pressure (p less than 0.05). Regression analysis also showed frequency of vibration to be directly related to tension (p less than 0.001) and inversely related to glottic width (p less than 0.001), with different combinations of glottic tension and width capable of producing the same frequency. The open and speed quotients thus reflect the changes in the vibratory patterns of the vocal folds produced by alterations in tension and width. The clinical implications of these results will be discussed, with emphasis on glottography as an objective assessment of the various laryngeal framework procedures being performed.     

Medialization thyroplasty for cancer-related unilateral vocal fold paralysis.

OBJECTIVE: To justify the application of medialization thyroplasty in Chinese patients with symptomatic cancer-related unilateral vocal fold paralysis (UVFP). STUDY DESIGN AND SETTING: Retrospective chart review from February 2000 to March 2006. RESULTS: Eighty-seven Chinese patients undergoing medialization thyroplasty for UVFP were included; there were no significant differences between the cancer-related and benign groups in terms of the speech and swallowing rehabilitation outcome and the perioperative complication rate (P > 0.05). The median survival time of cancer-related UVFP patients from the date of medialization to death was 129 days. Age more than 65 years was identified as the only factor for a shorter survival period after medialization (P = 0.040). CONCLUSION: Medialization thyroplasty restores satisfactory speech and swallowing and has a low perioperative complication rate in Chinese patients with cancer-related UVFP. Postmedialization survival period was also reasonable. SIGNIFICANCE: Medialization thyroplasty is a justifiable treatment option for cancer-related UVFP.     

The importance of hyaluronic acid in vocal fold biomechanics

OBJECTIVE: This study examined the influence of hyaluronic acid (HA) on the biomechanical properties of the human vocal fold cover (the superficial layer of the lamina propria). Study design: Vocal fold tissues were freshly excised from 5 adult male cadavers and were treated with bovine testicular hyaluronidase to selectively remove HA from the lamina propria extracellular matrix (ECM). Linear viscoelastic shear properties (elastic shear modulus and dynamic viscosity) of the tissue samples before and after enzymatic treatment were quantified as a function of frequency (0.01 to 15 Hz) by a parallel-plate rotational rheometer at 37 degrees C. RESULTS: On removing HA from the vocal fold ECM, the elastic shear modulus (G' ) or stiffness of the vocal fold cover decreased by an average of around 35%, while the dynamic viscosity (eta') increased by 70% at higher frequencies (>1 Hz). CONCLUSION: The results suggested that HA plays an important role in determining the biomechanical properties of the vocal fold cover. As a highly hydrated glycosaminoglycan in the vocal fold ECM, it likely contributes to the maintenance of an optimal tissue viscosity that may facilitate phonation, and an optimal tissue stiffness that may be important for vocal fundamental frequency control. SIGNIFICANCE: HA has been proposed as a potential bioimplant for the surgical repair of vocal fold ECM defects (eg, vocal fold scarring and sulcus vocalis). Our results suggested that such clinical use may be potentially optimal for voice production from a biomechanical perspective.     

Biomechanical effects of hydration in vocal fold tissues.

OBJECTIVE: It has often been hypothesized, with little empirical support, that vocal fold hydration affects voice production by mediating changes in vocal fold tissue rheology. To test this hypothesis, we attempted in this study to quantify the effects of hydration on the viscoelastic shear properties of vocal fold tissues in vitro. Study Design: Osmotic changes in hydration (dehydration and rehydration) of 5 excised canine larynges were induced by sequential incubation of the tissues in isotonic, hypertonic, and hypotonic solutions. Elastic shear modulus (G'), dynamic viscosity eta' and the damping ratio zeta of the vocal fold mucosa (lamina propria) were measured as a function of frequency (0.01 to 15 Hz) with a torsional rheometer. RESULTS: Vocal fold tissue stiffness (G') and viscosity (eta) increased significantly (by 4 to 7 times) with the osmotically induced dehydration, whereas they decreased by 22% to 38% on the induced rehydration. Damping ratio (zeta) also increased with dehydration and decreased with rehydration, but the detected differences were not statistically significant at all frequencies. CONCLUSION: These findings support the long-standing hypothesis that hydration affects vocal fold vibration by altering tissue rheologic (or viscoelastic) properties. SIGNIFICANCE: Our results demonstrated the biomechanical importance of hydration in vocal fold tissues and suggested that hydration approaches may potentially improve the biomechanics of phonation in vocal fold lesions involving disordered fluid balance.     

Vocal fold injection of collagen for unilateral vocal fold paralysis caused by chest diseases.

BACKGROUND: Patients having malignant chest diseases sometimes suffer from vocal fold paralysis. Treatment for vocal fold paralysis is important for such patients, because vocal fold paralysis causes lack of the versatility of the human voice which is essential for our communication. METHODS: Seventeen patients suffering from unilateral vocal fold paralysis were treated with vocal fold injections of collagen. Three patients received twice, and 20 treatments were conducted. A flexible bronchofiberscope was used under local anesthesia in order to observe the whole procedure of vocal fold injection. Using an injector and a long needle, collagen was injected with transcutaneous technique mainly through the cricothyroid membrane. The amount of collagen was determined with bronchoscopic findings. RESULTS: During and after treatment, no complication was observed. Of 20 treatments, a marked improvement was observed in 8, and moderate improvement was observed in 9 treatments. CONCLUSIONS: Vocal fold injection of collagen is a very useful and safe treatment for unilateral vocal fold paralysis caused by chest diseases.