Quantitative measures of laryngeal function following teflon® injection or thyroplasty type I

Laryngeal/voice function was evaluated in six patients with unilateral true vocal fold paralysis following treatment with Teflon® injection (TEF) compared to six patients treated with thyroplasty type I (THY). Auditory perceptual, aerodynamic, and endoscopic assessments were conducted. Three judges rated nine voice characteristics. Aerodynamic measures included estimated subglottal pressure, airflow, and laryngeal resistance. Two judges rated laryngeal characteristics from flexible fiberoptic assessment. The THY group had significantly better voice quality and better quantitative aerodynamic findings compared to the TEF group. The TEF group also was more likely to have an irregular vocal fold edge, an irregular glottal closure pattern, a higher occurrence of hyperfunction and hypertrophy of the false vocal folds, edema, and erythema of the paralyzed folds. Results suggest that THY was associated with more favorable measures of laryngeal/voice function than TEF. It is likely that the poorer perceptual, aerodynamic, and endoscopic findings associated with TEF injection may be due to violation of the true vocal fold cover, particularly increased true vocal fold mass and stiffness.     

Radiological findings in lipoid proteinosis

The radiological findings in six patients suffering from lipoid proteinosis have been described and discussed. Laryngeal examination showed thickened epiglottis, swollen arytenoids and aryepiglottic folds, thickened irregular false and true vocal cords, and increased stiffness of the vocal cords. The ventricles and subglottic region were free. Bean-shaped suprasellar calcifications were found in two cases who were free of neurological symptoms. The chest and upper gastro-intestinal tract were radiologically free.     

The effects of breath-holding on vocal fold adduction: implications for safe swallowing

OBJECTIVE: To determine the effects, if any, of 3 different breath-holding techniques on a person's ability to attain vocal fold closure (VFC) to successfully complete swallowing maneuvers. DESIGN: Prospective, randomized study. SETTING: Private practice. PATIENTS: A total of 150 healthy volunteers recruited from private practice patients and community volunteers.Intervention Group 1 received the easy breath-hold instruction; group 2 received the inhale/easy breath-hold instruction; and group 3 received the hard breath-hold instruction. MAIN OUTCOME MEASURE: Closure of true and false vocal folds following the breath-hold instruction. RESULTS: In the easy breath-hold group, true VFC occurred in 82% of the subjects, and closure of both the true and false vocal folds occurred in 30%. In the inhale/easy breath-hold group, true VFC occurred in 62%, and closure of both folds occurred in 46%. In the hard breath-hold group, true VFC occurred in 86%, and closure of both folds occurred in 64%. The differences among the 3 groups were significant for true VFC (chi2=9.242; P=.01) and for closure of both folds (chi2=11.625; P=.003). CONCLUSIONS: The hard breath-hold instruction was the most effective method to attain full laryngeal closure, and the inhale/easy breath-hold instruction was the least effective method to attain true VFC for safe swallowing.     

Larynx preservation with supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Correlation of videostroboscopic findings and voice parameters.

Classically, the formation of a mucosal wave is dependent on the pliable mucosa present in the vocal fold. The supracricoid partial laryngectomy with cricohyoidoepiglottopexy is an organ preservation surgical technique in which both true vocal folds, both false vocal folds, both paraglottic spaces, and the entire thyroid cartilage are resected. The functional goal is speech and swallowing without a permanent tracheostomy. In an effort to further study voice production in these patients, we performed laryngeal stroboscopy in 5 patients. Analysis was performed with a modified Bless grading system. In addition, speech and voice parameters were also measured and correlated with stroboscopic findings. The key finding in this study was the presence of a periodic mucosal wave on the anterior aspect of the arytenoid cartilage, where it abuts the epiglottic cartilage. Patients with lower periodicity and symmetry scores tended to have lower jitter and shimmer percentages.     

Disarrangement of collagen fibers in Reinke's edema

Objective/Hypothesis: To describe the arrangement of collagen fibers in the superficial layer of the lamina propria of the vocal folds with Reinke' edema. Study Design: Cross sectional analysis of the lamina propria of the vocal folds with Reinke's edema (RE). Method: The picrosirius polarization method was used to study the arrangement of collagen fiber. Findings of collagen disarrangement were categorized semiquantitatively and correlated with RE severity, age, cigarette smoking and duration of dysphonia. Results: Analysis of 20 specimens of vocal folds with RE showed that the intertwined network of collagen fibers resembling a wicker‐basket normally observed in vocal folds was disarranged in RE. The collagen fibers were loosely arranged, fragmented and intermixed with varying amounts of myxoid stroma. Moderate and large areas of disarrangement (90% of cases) predominated. Collagen fiber arrangement in the region underneath the epithelium was better preserved when compared with fibers in the deeper region of the superficial layer of the lamina propria. There was a statistical difference in collagen disarrangement between grade II and grade III severity (P = .007) that appeared to be due to the large areas of disarrangement observed in 73% of patients with grade III severity and in 44% of grade II severity. Age was the only variable correlated with collagen fiber disarrangement (r = 0.47, P = .037). Conclusion: Our findings suggest that the flexible framework which maintains the uniformity of the lamina propria was lost in RE caused by the disarrangement of the collagen fibers.     

Treatment of Ventricular Dysphonia With Botulinum Toxin

Ventricular dysphonia, traditionally known as dysphonia plica ventricularis, is a voicing disorder in which the false vocal folds are used as a vibratory source in addition to or instead of the true vocal folds. Traditional treatment of ventricular dysphonia has been voice therapy, which may be slow to produce results if the false fold activity masks an underlying problem of the true folds, is long standing, or has produced hypertrophy of the supraglottic structures. We present seven cases of ventricular dysphonia treated with botulinum toxin injection into the false vocal folds followed by speech therapy. The addition of botulinum toxin to the treatment regimen speeds recovery of normal voicing and allows immediate evaluation of dynamic true vocal fold function by the treating professional.     

Correlation between glottal area and photoglottographic signal in normal subjects

Photoglottography (PGG) is an established technique for depicting the vibratory patterns of the vocal folds. The present study investigates the correlation between the glottal area and the corresponding PGG signal. Six normal (five male, one female) subjects who did not use their voices professionally were investigated during constantly sustained phonation at spontaneous pitches. Laryngostroboscopy was performed in combination with PGG. The simultaneously recorded laryngostroboscopic images and PGG signals were directly digitized and stored on a computer. The correlation between the glottal area and the corresponding PGG amplitudes across each vibratory cycle of the vocal folds was calculated and they were found to be highly and positively correlated (r = 0.973, p < 0.001). The PGG signal reflects changes in the glottal area during the vibration cycle of the vocal folds. The proposed simultaneous laryngostroboscopic and PGG technique has proved to be useful for facilitating the interpretation of changes in glottal area.     

Oral breathing challenge in participants with vocal attrition.

Vocal folds undergo osmotic challenge by mouth breathing during singing, exercising, and loud speaking. Just 15 min of obligatory oral breathing, to dry the vocal folds, increases phonation threshold pressure (Pth) and expiratory vocal effort in healthy speakers (M. Sivasankar & K. Fisher, 2002). We questioned whether oral breathing is more detrimental to phonation in healthy participants with a history of temporary vocal attrition. The effects of a 15-min oral or nasal breathing challenge on Pth and perceived expiratory vocal effort were compared for participants reporting symptoms of vocal attrition (N = 18, ages 19-38 years) and normal controls (N = 20, ages 19-33 years). Post-challenge-prechallenge differences in Pth (deltaPth) and effort (deltaEffort) revealed that oral breathing, but not nasal breathing, increased Pth (p < .001 ) and effort (p < .001) at low, comfortable, and high pitch. deltaPth was significantly greater in participants with vocal attrition than in normal controls (p < .001). Nasal breathing reduced Pth for all controls but not for all participants reporting vocal attrition. deltaPth was significantly and linearly correlated with deltaEffort (rvocal attrition = .81, p < .001; rcontrol = .84, p < .001). We speculate that the greater increases in Pth in participants reporting vocal attrition may result from delayed or inadequate compensatory response to superficial laryngeal dehydration. Obligatory oral breathing may place voice users at risk for exacerbating vocal attrition. That sol layer depletion by obligatory oral breathing increased Pth and vocal effort provides support for the role of superficial hydration in maintaining ease of phonation.     

Steroid injection for Reinke's edema using fiberoptic laryngeal surgery

OBJECTIVE: Since 1990, we have performed steroid injections into the vocal fold under topical anesthesia using fiberoptic laryngeal surgery (FLS) in an outpatient clinic. The aim of this study was to retrospectively assess the usefulness of this treatment method in 44 patients with mild Reinke's edema. MATERIAL AND METHODS: Using fiberoptic monitoring of the larynx, a curved injection needle was inserted via the oral cavity and triamcinolone acetonide was injected into Reinke's space of the bilateral vocal fold. RESULTS: Remission or improvement was observed in almost all patients in terms of both patients' self-rating of hoarseness and endoscopic vocal fold findings The maximum phonation time was a mean of 9.0 s before operation and 11.4 safter operation, and this increase was significant (p < 0.01). Voice pitch also improved, from 168 to 181 Hz, in female patients, and this increase was also significant (p < 0.05). CONCLUSION: Steroid injection is considered to be useful for treating mild Reinke's edema.     

Rhabdomyoma of the larynx: case report and clinical and pathologic review

We describe a case involving a 79-year-old man with symptoms of slowly progressive hoarseness resulting from a rhabdomyoma originating deep to the right true and false vocal folds. We also review the pathology and radiologic findings of rhabdomyoma.     

Smoke inhalation injuries

Up to a third of all victims of major burns suffer smoke-related injury and may die as a result of inhalation injury. The management of the upper airway depends on a thorough understanding of the mechanisms of injury, including carbon monoxide toxicity, thermal injury, and smoke inhalation. Establishing and maintaining an airway for resuscitation requires a high index of suspicion, as early and severe upper airway swelling may preclude safe intubation under direct vision. Nasotracheal intubation is preferred in burn patients but is only indicated for patients in acute respiratory distress and a select group at high risk for developing progressive upper airway compromise and pulmonary injury. The use of the flexible bronchoscope and nasopharyngoscope is a safe and effective means of evaluating the respiratory tract and assisting in pulmonary therapy. Early tracheotomy is indicated only in rare cases because of increased morbidity and mortality in burn patients. The use of steroids is still controversial and is probably indicated only for refractory bronchospasm or secretions. Aggressive evaluation and management of inhalation burns will reduce the mortality rate of a frequently fatal injury.     

Exudative laryngeal diseases of Reinke's space: a clinicohistopathological framing

OBJECTIVE: To establish the relationship between the macroscopic and histologic diagnosis of nodules, polyps, and Reinke's edema of the true vocal folds and to propose a clearer clinical definition of them in the hope of settling the difference of opinion between otolaryngologists and pathologists. DESIGN: Retrospective study SETTING: Otolaryngology Department of "La Sapienza" University of Rome. METHODS: The pathologic reports of 203 patients subjected to direct laryngoscopy were studied. MAIN OUTCOME MEASURES: Examination of the histologic specimen of the epithelium and the chorion. RESULTS: Microscopic examination revealed a high percentage of normal epithelium both for nodules (33.79%) and polyps (40.65%). No dysplasia was observed, whereas dysplasia was present in 10 cases of Reinke's edema (7 laryngeal intraepithelial neoplasia 1 and 3 laryngeal intraepithelial neoplasia II). Five different stages of histologic progression resulted from the examination of the chorion in both nodules and polyps. CONCLUSIONS: Our suggestion is to consider polyps as "older" lesions and nodules as "younger" lesions. A polyp may be defined as an abnormal unilateral growth of vocal folds, a nodule as a bilateral growth situated between the anterior and medium third of the vocal fold, and Reinke's edema as a bilateral wound that extends to the whole of the true vocal fold.     

Steroid Injection for Reinke's Edema Using Fiberoptic Laryngeal Surgery

Objective Since 1990, we have performed steroid injections into the vocal fold under topical anesthesia using fiberoptic laryngeal surgery (FLS) in an outpatient clinic. The aim of this study was to retrospectively assess the usefulness of this treatment method in 44 patients with mild Reinke's edema.

Material and Methods Using fiberoptic monitoring of the larynx, a curved injection needle was inserted via the oral cavity and triamcinolone acetonide was injected into Reinke's space of the bilateral vocal fold.

Results Remission or improvement was observed in almost all patients in terms of both patients' self-rating of hoarseness and endoscopic vocal fold findings The maximum phonation time was a mean of 9.0 s before operation and 11.4 safter operation, and this increase was significant (p < 0.01). Voice pitch also improved, from 168 to 181 Hz, in female patients, and this increase was also significant (p < 0.05).

Conclusion Steroid injection is considered to be useful for treating mild Reinke's edema.     

Early laryngeal inhalation injury and its correlation with late sequelae

OBJECTIVE: Inhalation injury can permanently alter normal laryngeal function. The aim of this study was to examine the early changes in voice, swallowing, and breathing in laryngeal inhalation injuries. STUDY DESIGN: This was a prospective analysis of nine patients with inhalation injuries at a tertiary care institution. METHODS: Laryngeal function of patients admitted for inhalation injury requiring intubation was documented using videostroboscopy and swallowing evaluation by the speech pathology service. Bronchoscopy was used to classify the degree of inhalation injury. Association among total body surface area, facial burns, severity of laryngotracheal injuries, and loss of function was attempted. RESULTS: All three patients with severe tracheal inhalation injury presented persistent hoarseness at 1-year follow up with abnormal videostroboscopy findings. No association was found between inhalation injury and total body surface area burned. None of the patients in this series presented permanent swallowing dysfunction. CONCLUSION: The otolaryngologist plays an important role in the initial and long-term management of inhalation injuries. Inhalation injuries should be managed in a multidisciplinary fashion. There may be a correlation between the degree of tracheal injury and laryngeal injury and hoarseness.     

Angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter review and an algorithm for airway management

Angioedema is a nonpitting edema of which the presentation ranges from benign facial swelling to airway obstruction managed by intubation or tracheotomy. The presentation of this disease is reviewed, and a treatment algorithm based on initial signs and symptoms is proposed for proper airway management. We performed a retrospective review of 108 patients treated in 2 tertiary care centers in the Washington, DC, area over a 5-year period. Ninety-eight patients (90.7%) were African-American, and 81 (75%) were female. Seventy-four patients (68.5%) were taking angiotensin-converting enzyme inhibitors (ACEIs). A classification system was developed based on the location of the edema at initial presentation: 1) isolated facial swelling and oral cavity edema, excluding the floor of the mouth; 2) floor of mouth and/or oropharyngeal edema, and 3) oropharyngeal edema with glottic and/or supraglottic involvement. Fourteen patients (13%) needed airway intervention, 2 of whom underwent a cricothyrotomy after a failed intubation attempt. Eleven (78.6%) were taking ACEIs. The indication for each intubation was massive tongue and floor of mouth edema. The patients were extubated 48 to 72 hours later. No patient demonstrated symptom progression after medical treatment was initiated. Therapy included discontinuation of the ACEI or other inciting agent, a high-humidity face tent, an initial dose of intravenous antihistamines, and a continued course of intravenous steroids. Within 48 hours, most patients had a resolution of their edema. Only cases of significant tongue and oropharyngeal edema took longer than 48 hours to resolve. The ACEIs are a common cause of angioedema. Left untreated, angioedema may progress to involve the oropharynx and supraglottis, resulting in a life-threatening airway compromise. Marked floor of mouth and tongue edema are the indications for airway intervention. An algorithm based on the initial presentation is essential for proper airway and patient management. Once treatment has begun, angioedema is nonprogressive and often resolves within 24 to 48 hours.     

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.     

CO2 laser treatment of bilateral vocal cord paralysis in adduction

This study presents results obtained from 83 patients with bilateral vocal cord paralysis in adduction treated between 1982 to 2001, with CO(2) laser microlaryngoscopy. In relation to the different types of surgery followed, three distinct treatment groups were included: group 1 (1982-1984) included 5 patients treated with vaporization of the vocal process of the arytenoid and the homolateral posterior third of the true vocal cord. Group 2 (1983-1990) contained 19 patients who were treated with arytenoidectomy and removal of the homolateral posterior half of the true vocal cord and group 3 (1990-2001), including 59 patients who were treated with arytenoidectomy and removal of the homolateral posterior half or two thirds of both the true and false vocal cord. Functional results were assessed by means of spirometry, spectrography and aerophonic examinations performed at 5, 90, 180, and 240 days postoperatively. The results show that removal of the posterior third of the true vocal cord and false vocal cord, combined with arytenoidectomy, is the surgical treatment of choice to resolve respiratory insufficiency in these patients.     

Unilateral vocal fold adductor paralysis after tracheal intubation

Vocal fold immobility is a relatively rare complication that can occur after tracheal intubation. Differential diagnoses include a rare clinical entity called unilateral vocal fold adductor paralysis in which only branches entering the thyroarytenoid and lateral cricoarytenoid muscles of the recurrent laryngeal nerve become paralyzed. Computed tomography and laryngeal electromyography are required to distinguish this condition from others such as cricoarytenoid dislocation/subluxation. Here, we describe two patients who developed vocal fold adductor paralysis after intubation. Patient 1 was a 56-year-old man who underwent living-donor liver transplantation and was extubated on day 7 after surgery. Patient 2 was a 52-year-old man who received life support measures including intubation due to ventricular fibrillation, and was extubated two days later. Both were hoarse soon after extubation. Endoscopic laryngeal examination revealed normal abduction and insufficient adduction of paralyzed vocal folds. Computed tomography ruled out cricoarytenoid dislocation/subluxation and laryngeal electromyography confirmed unilateral vocal fold adductor paralysis. Laryngologists should consider this rare pathogenesis.     

Aphonia and dysphagia after gastrectomy

A 67-year-old male was referred to our otolaryngological clinic because of aphonia and dysphagia. His voice was breathy and he could not even swallow saliva following a total gastrectomy for gastric carcinoma performed 2 weeks previously. Laryngeal fiberscopy revealed major glottal incompetence when he tried to phonate. However, both vocal folds abducted over the full range during inhalation. The patient could not swallow saliva because of a huge glottal chink, even during phonation. Based on these findings, he was diagnosed as having bilateral incomplete cricoarytenoid dislocation after intubation. The patient underwent speech therapy; within 1 min his vocal fold movement recovered dramatically and he was able to phonate and swallow. There have been few case reports of bilateral cricoarytenoid dislocation, and no effective rehabilitation has been reported. We believe that our method of vocal rehabilitation serves as a useful reference for physicians and surgeons worldwide.     

布地奈德混悬液(雾化吸入)对咽炎合并声带水肿患者的临床效果及价值体会

目的探究布地奈德混悬液(雾化吸入)对咽炎合并声带水肿患者的临床效果及价值。方法以2016年1月-2020年1月咽炎并声带水肿患者100例为研究对象,采用动态随机化法,进行分组,其中对照组治疗中,雾化吸入地塞米松,实验组治疗中,雾化吸入布地奈德混悬液,分析2组患者,其治疗结果的差异。结果总有效率相比,实验组更高,P<0.05;咽炎消失时间、声带水肿消失时间相比,实验组更低,P<0.05;不良反应发生率相比,2组差异较小(P>0.05)。结论咽炎并声带水肿治疗中,实施布地奈德混悬液雾化吸入干预,效果好,同时可缩短康复的时间,具有较高的安全性,意义重大。