喉内肌、声门下压力、气流率在调节基频中的作用

当16名正常受试者从最低音、中音、高音及假声发元音“i”时，对其环甲肌、甲杓肌做了肌电图检查。同时对20名音乐学院声乐系学生个音域的频率、声强、声门下压力、气流率进行了测量。结果表明：随着发音频率的升高，环甲肌及甲杓肌的电激动逐渐增强。在最低音发音时环甲肌的电活动较小，没有甲杓肌强。在高音及假声发音时，环甲肌电活动最强，尤其在假声音域，环甲肌与甲杓肌共同协作作用来完成对频率的调节。当发音频率逐渐升高时，声强及声门下压力同样也逐渐升高，呈正相关（P＜0．01）。频率与气流率也为正相关（P＜0．01，除2个男低音之外），有10名受试者在发高音和假声时，气流率的值呈现零值和负值。声门下压力及喉内肌的电活动在调节基频中起到了重要的作用，气流率在调节基频中也有一定的作用，但在发高音和假声时，有1／2的受试者的气流率几乎没有起作用，呈现零值或负值。     

假声发声气流率及口腔压力的观察

对１０例（２０个声样）２６－４５岁健康人分别以胸声及假声发持续性元音“ｉ”及重复性章节“Ｐｉ”进行了纤维喉镜及气流动力学检查。结果表明：（１）假地声门闭合程度较胸声明显降低；（２）假声时气流率罗胸声时高，这与假声门闭合降低有关；（３）当胸声转为假声时，口腔压力升高，这可能与增加声带张力及维持声带振动频率有关。     

声带息肉与声带小结患者发声空气动力学研究

目的探讨声带息肉、声带小结患者发声时空气动力学指标的变化。方法采用嗓音功能分析仪（Aerophone II Voice Function Analyzer）对30例声带息肉、28例声带小结患者及30例正常人进行发声空气动力学检测,对平均气流率（mean airflow rate）、口腔压（intraoral pressure）、声门阻力（glottal resistance）、声门效率（glottal efficiency）进行分析、比较。结果声带息肉、声带小结患者的平均气流率、声门阻力、声门效率分别为254．50±36．02ml／s、33．55±4．63cmH2O／（L·S）、2．46±1．49和177．45±25．93ml／s、38．83±8．88cmH20／（L·S）、7．75±3．71,与正常人118．44±29．98ml／s、53．04±8．64cmH2O／（L·S）、9．17±3．87比较,差异有统计学意义（P〈0．01）;声带息肉患者声门下压力为8．97±1．36cmH2O,与正常人6．24±0．99cmH2O比较,差异有统计学意义（P〈0．01）;声带息肉与声带小结患者平均气流率、声门下压力和声门效率比较,差异有显著统计学意义（P〈0．01）。结论声带息肉患者的声门闭合程度、发声时的效率比声带小结患者更差,空气动力学检测可以对声带息肉、声带小结患者的嗓音功能作出量化的、客观的评价。     

声带小结患者发音矫治前后电声门图参数变化

目的 比较分析声带小结患者发音矫治前后电声门图参数变化，评价发音矫治对声带小结的疗效。方法 对48例声带小结（软性小结）患者发音矫治（3～6个月）前后分别进行电声门图检测，并对其主要参数进行比较分析。结果 发音矫治后平均基频、接触率较矫治前有显菩性升高（P〈0．05），基频微扰、振幅微扰、噪声能量较矫治前有显著性下降（P〈0．05）。结论 发音骄治前后电声门圈参数变化结果提示，发音矫治对声带小结具有一定的治疗效果。     

喉全切除术食管发音机制研究

目的 探讨喉全切除术后食管言语的特点。方法 对北京同仁医院40例训练食管发音患者的噪音声学、言语、形态特征及发音时食管压力变化进行分析。以50例健康男性作为对照。结果 食管发音不良8例，发音良好32例。发音不良黏膜痉挛，气流无法送出；发音基频小于60Hz无法评估。发音良好者食管人口黏膜松驰，振动明显；其噪音声学特征与健康对照差异有显著性（P值＜0．05或＜0．01）。食管发音不良者训练发音年龄、言语清晰度、速度、呼吸发音协调程度与发音良好者差异有显著性（P值＜0．05或＜0．01）。食管发音时食管上、中段压力明显高于健康对照组（P值＜0．05或＜0．01），其中发音不良者压力增加更为明显，特别是食管中段压力。结论 食管发音声道振动及动力器官均与正常发音存在本质区别，通过代偿机制瞬间发音可达良好效果，但在自然、持续言语交流中存在明显障碍。     

鼻阻塞的主观评价与客观鼻测量的相关性研究

目的探讨鼻阻塞时检查者和患者的主观评价与客观鼻测量之间是否有相关性。方法检查者和患者均采用视觉模拟量表（visualanalogscale，VAS）对鼻阻塞程度进行评价。客观鼻测量采用主动后鼻测压仪和鼻声反射测量仪进行。以配对t检验分析检查者的临床评价和患者VAS均数的差异，以Spearman等级相关分析评价客观鼻测量结果单侧鼻气流阻力与单侧鼻道容积、单侧鼻腔最小横截面积的关系，以及检查者的临床评价、患者VAS与上述客观鼻测量结果的相关性。结果本组病例经统计学分析，316例患者中，减充血前后单侧鼻气流阻力与单侧鼻道容积、单侧鼻腔最小横截面积间呈负相关（r值分别为-0．430、-0．554、-0．373、-0．600，P值均〈0．001）。减充血前后，检查者的临床评价与患者VAS均数呈正相关，差异均有统计学意义（r值分别为0．630、0．526，P值均〈0．001），二者均与鼻气流阻力有一定的正相关关系（减充血前：检查者的临床评价与鼻气流阻力r=0．530，P=0．000，患者VAS与鼻气流阻力r=0．351，P=0．000；减充血后：检查者的临床评价与鼻气流阻力r=0．452，P=0．000，患者VAS与鼻气流阻力r=0．216，P=0．000），与鼻道容积和鼻腔最小横截面积均有一定的负相关关系（减充血前：检查者的临床评价与鼻道容积r=-0．411，P=0．000，患者VAS与鼻道容积r=-0．325，P=0．000，检查者的临床评价与鼻腔最小横截面积r=-0．507，P=0．000，患者VAS与鼻腔最小横截面积r=-0．384，P=0．000；减充血后：检查者的临床评价与鼻道容积r=-0．391，P=0．000，患者VAS与鼻道容积r=-0．209，P=0．000，检查者的临床评价与鼻腔最小横截面积r=-0．471，P=0．000，患者VAS与鼻腔最小横截面积r=-0．286，P=0．000）。检查者的临床评价与客观鼻测量参数的相关系数大于患者VAS与客观鼻测量参数的相关系数。结论鼻阻力测压与鼻声反射测量的结果有一定的相关性。检查者的临床评价与患者VAS存在一定的正相关关系。两者均与客观鼻测量参数存在一定的直线相关关系。     

两种无喉言语的比较研究

目的：比较无假体气管食管分流音与食道音在最大发声时间，可懂度和阅读时间等方面的差异，方法，研究对象包括年龄，性别和术后发声时间相当的两组无喉言语者，其中，食管音组21名，无假体气管食管音组30名，采集了两组的最大发声时间，可懂度和阅读时间的数据，用t检验分析最大发音时间和阅读时间（P＜0．05），H检验分析言语可懂度（P＜0．05），结果：食管音在这三个项目上均较气管食管分流音差；言语可懂度略差于气管食管分流音；言语流利度和最大发声时间均明显差于气管食管分流音。结论：无假体管食管音的言语效果优于食管音，而且其手术方法简单，容易训练，利于推广。     

半喉发音的研究

设计一套研究喉发育的方法，对半喉发音的运动和空气力学的资料进行分析和对照。试验用的狗再重25～30kg，共9只，在麻醉状态下手术切取半离体喉，检测后再将左侧声带切除并用一块垂直的有机玻璃板代替，将其固定后用lugersoll（30型）常规空气压缩机输入空气，温度要求35～38”C，湿度要求95～IO0％。通过改变声门下压力测定并记录发声闽值压力级，平均声门气流率、基频、声带振动幅等资料。发现声带振动发生子声门下压力超过0．78kpa时，它随着基频改变，在暂短的停顿发音时振动仍存在，声门下压力同时保持在O．2～0．4kpa。随着声门下…     

自体筋膜移植填充治疗声带沟

目的探讨筋膜移植填充术在声带沟治疗中的价值及预后转归。方法23例双侧声带沟患者全麻显微镜下行声带沟瘢痕松解、筋膜移植填充手术，合并声带肌萎缩者同时行声门旁间隙脂肪注射。患者手术前、后行嗓音声学、气流动力学及频闪喉镜检查。结果4例手术失败者未进行疗效评价。19例术后6—8周患者发音开始改善，术后3个月发音改善明显。术后6个月音质趋于稳定，主、客观声学评价及气流动力学参数较术前改善明显，17例（89．5％）患者音质改善明显，声带结构及黏膜振动接近正常，声门闭合明显改善；2例患者音质改善不明显，声带形态接近正常，声门闭合改善，但黏膜振动不良。声音嘶哑主观评分与术前比较改善明显（P值均〈0．05），总评分2例患者（10．5％）提高2个等级，15例患者（79．0％）提高1个等级，2例患者（10．5％）评级无明显改变。除基频外，嗓音声学参数及最大发音时间与术前比较差异均有统计学意义（P值均〈0．01），8例（42．0％）患者声学参数达到正常范围，17例患者（89．5％）最大发音时间达到正常范围。19例患者随诊均6个月-1年，未发现筋膜吸收，其中5例患者随诊满2年，音质稳定。结论筋膜移植填充声带沟的手术可在一定程度上矫正声带固有层缺陷，改善声门闭合不良，恢复声带振动特性。     

新生儿初发声门下狭窄再插管

新生儿声门下狭窄是气管插管后的主要并发症，传统的治疗方法包括环状软骨裂开、气管切开及喉气管重建手术。气管切开术有0～24％的致死率，并增加护理喂养难度，发音期幼儿失去发育。该文介绍了10例因首次插管引起声门下狭窄患儿（早产儿），体重0．6～s．skg，全部行经鼻再插管，s周内6例拔管成功。‘例不能拔管，行气管切开术，1例带管生存，1例死于与声门下狭窄无关疾病，2例拔除气管套管，无须行喉整复手术，呼吸通畅，发育正常。研究证明，新生儿初发声门下狭窄，在镇静条件下，经鼻再插管，可以压迫炎性肿胀组织，保持正常的气道，促…     

In vitro and in vivo comparison of the low-resistance Groningen and the Provox tracheosophageal voice prostheses

This study has been performed to evaluate and compare two frequently used indwelling tracheoesophageal voice prostheses, the low-resistance (LR) Groningen and the Provox voice prosthesis. The airflow resistance in vitro of the Provox prosthesis has been measured and compared to our reported results of the LR Groningen prosthesis. The in vivo study involved fifteen non-myotomized laryngectomees who randomly received one of the two prostheses. Measurements were performed of the intratracheal phonatory pressure and of voice parameters. The intelligibility of speech in noise was evaluated in eight patients. Patients preferences regarding the two prostheses were assessed. Aerodynamic measurements show the Provox voice prosthesis to have a lower airflow resistance. The median intratracheal phonatory pressure for phonation of 75 dB was significantly lower (2.1 kPa) in patients using the Provox voice prosthesis. Speech rate, maximal phonation time and maximal vocal intensity showed no significant difference. The intelligibility of speech in noise produced with the Provox was significantly better than the speech produced with the LR Groningen prosthesis. Subjectively, most patients preferred the Provox prosthesis because speech required less effort. Patients with a hypotonic pharyngoesophageal segment tended to prefer the LR Groningen prosthesis.     

The ultra-low resistance Groningen voice prosthesis: clinical experiences.

The performance of the ULR Groningen prosthesis was assessed in 21 laryngectomees. The intratracheal phonatory pressures (PITP), voice parameters (speech rate, maximal phonation time, maximal vocal intensity, dynamic vocal intensity range), device lifetime and patient's subjective acceptances were recorded and compared to identical parameters for other prostheses reported in the literature and to data obtained from an age-matched group of normal laryngeal speakers. The low airflow resistance of the ULR Groningen voice prosthesis objectively (PITP = 2.7 kPa) and subjectively leads to a low effort to phonate. Compared to "normals" maximal phonation time shows no significant difference, but speech rate, maximal vocal intensity and dynamic vocal intensity range show a significant worse outcome. The mean device lifetime of the ULR Groningen prosthesis is more than 13.6 weeks, which is comparable to other indwelling voice prostheses. In conclusion, the ULR Groningen voice prothesis enables easier tracheoesophageal phonation than the low-resistance Groningen type.     

Aerodynamic properties of the low-resistance Groningen button

Shunt tracheoesophageal speech is currently the most successful form of voice and speech rehabilitation in laryngectomees. Insertion of valve prostheses into the tracheoesophageal shunts has overcome drawbacks caused by stenosis of the shunt and aspiration. In 10 years of satisfactory results with the standard Groningen button valve prosthesis, the overall concept of this device has proved its value. The airflow resistance, however, is relatively high, so that a low-resistance device has been developed without changing the favorable characteristics of the standard device. The design of this low-resistance Groningen button is described. The airflow resistances of the standard and low-resistance Groningen buttons have been measured and compared. The airflow resistance of the low-resistance Groningen button is also compared with the reported airflow resistances of various other valve prostheses.     

Aerodynamic characteristics of the Nijdam voice prosthesis in relation to tracheo-esophageal wall thickness

Tracheo-esophageal speech using various prostheses is currently the most successful form of voice and speech rehabilitation for laryngectomees. Main inter-device differences are durability and trans-device pressure loss during speech. The valveless indwelling Nijdam voice prosthesis is a new voice prosthesis. A barrier mechanism is created by a combination of the esophageal mucosa and the umbrella-like “hat” of the prosthesis that covers the esophageal side of the tracheo-esophageal fistula. The Nijdam prosthesis can be used clinically for longer periods of time when compared to such other indwelling voice prostheses as the Provox prosthesis and the low-resistance Groningen prosthesis. However, trans-device pressure loss during speech has been unknown. Adjustment of the shaft length of the Nijdam voice prosthesis to tracheo-esophageal wall thickness was expected to affect trans-device pressure loss during speech. We report the results of in vitro tests to quantify the effect of tracheo-esophageal wall thickness on trans-device pressure loss. In the present study pressure loss was measured at different air flow rates in relation to tracheo-esophageal wall thickness. Findings demonstrated that when shaft length of the Nijdam prosthesis corresponded exactly to tracheo-esophageal wall thickness, trans-device pressure loss was comparable to that of the Provox prosthesis. If a relatively shorter Nijdam prosthesis was chosen to prevent aspiration from occurring, the pressure loss across the prosthesis increased to that of the low-resistance Groningen prosthesis.     

Alternative voice after laryngectomy using a sound-producing voice prosthesis

OBJECTIVE: To improve the voice quality of female laryngectomees and/or laryngectomees with a hypotonic pharyngoesophageal (PE) segment by means of a pneumatic artificial source of voice incorporated in a regular tracheoesophageal (TE) shunt valve. STUDY DESIGN: Experimental, randomized, crossover trial. METHODS: The new sound source consists of a single silicone lip, which performs an oscillatory movement driven by expired pulmonary air flowing along the outward-striking lip through the TE shunt valve. A prototype of this pneumatic sound source is evaluated in vitro and in six laryngectomees. In vivo evaluation includes speech rate, maximal phonation time, perceptual voice evaluation of read-aloud prose by an expert listener, speech intelligibility measurements with 12 listeners, and self-assessment by the patients. Moreover, extensive acoustical and aerodynamic in vivo registrations are performed using a newly developed data acquisition system. RESULTS: The current prototype seems beneficial in female laryngectomees with a hypotonic PE segment only. For them the sound-producing voice prosthesis improves voice quality and increases the average pitch of voice, without decreasing intelligibility or necessitating other pressure and airflow rates than regular TE shunt speech. Pitch regulation of this prosthetic voice is possible, yet limited. CONCLUSIONS: The mechanism is feasible and does not result in unacceptable airflow resistance. For this new mechanism of alaryngeal voice to become an established technique for postlaryngectomy voice restoration, a voice suitably pitched for male laryngectomees has to be generated and a large part of the melodic and dynamic range of the sound source has to be attainable within physiological airflow rates.     

Aerodynamic and sound intensity measurements in tracheoesophageal voice

BACKGROUND: In laryngectomized patients, tracheoesophageal voice generally provides a better voice quality than esophageal voice. Understanding the aerodynamics of voice production in patients with a voice prosthesis is important for optimizing prosthetic designs and successful voice rehabilitation. OBJECTIVES: To measure the aerodynamics and sound intensity in tracheoesophageal voice production. STUDY DESIGN AND METHODS: We built a special setup, which consisted of a Pentium 200 MHz computer with an AD-DA interface card and Labview 4.01 software. In an oral/nasal mask we constructed several mass flow sensors and a microphone. This measured both the oral airflow and the level of sound. For the measurement of endotracheal pressure, which is the driving force behind the airflow, we used a transducer which was connected to the tracheostoma. The endoesophageal pressure was measured at the level of the prosthesis in the esophagus by a Mikrotip transducer. Using this we could determine how much the voice prosthesis contributes to the overall pressure drop of the phonatory tract. Furthermore, the average airflow rate as a function of the sound pressure levels could be determined. RESULTS: In our population, 6 out of 7 patients showed a positive relationship between trans-source airflow and generated sound intensity. We compared our prosthesis pressure drop values with in vitro data and found that there are some differences, possibly due to difference in age of the prosthesis and physiological circumstances in vivo. The overall contribution of the voice prosthesis to the airway resistance depends on the level of phonation and the type of device. In our patient group it is apparent that the pharyngoesophageal (PE) segment has the greatest share of the total pressure drop, especially at higher airflow rates. We measured a 27% pressure drop in airflow over the voice prosthesis. Different tracheostoma occlusion methods did not have any effect on the aerodynamics and sound intensity. One patient that had had a jejunal graft for reconstruction showed, not unexpectedly, extremely different aerodynamic values. We were unable to define optimal airflow rates or optimal resistance values for sound production in the PE segment. CONCLUSION: The aerodynamic characteristics of voice production in laryngectomized patients with voice prostheses are determined by both prosthetic factors and PE segment tissue factors. In our patient group the PE segment is responsible for the greatest pressure drop. We found no significant difference in pressure drop and sound intensity for different tracheostoma occlusion methods.     

Clinical experience with the low-resistance Groningen button

Summary Since its introduction in 1980, the standard Groningen button prosthesis has been of proven value for post-laryngectomy voice rehabilitation. Its relatively high airflow resistance has, however, been the cause of failure in achieving good post-laryngectomy tracheoesophageal shunt speech in some patients. The low-resistance Groningen button (LRGB) was therefore designed, thus reducing airflow resistance by 50% when compared to the standard device. The clinical performance of the LRGB, and the effect of prophylactic amphotericin, was assessed in 32 patients. The device lifetime, intratracheal phonatory pressures and patients' subjective acceptances of the prosthesis were recorded. Present findings showed that the majority of the patients preferred the LRGB as it required less effort to operate than the standard device. The intra-tracheal phonatory pressure was found to increase with time, but this change was prevented with the prophylactic use of amphotericin to inhibit concurrent colonization by Candida spp, which also helped to prolong the prosthesis lifetime.This study was performed in the ENT Department, University Hospital, Groningen, The Netherlands     

The ultra-low resistance Groningen voice prosthesis: aerodynamic properties

Post-laryngectomy voice rehabilitation using the low resistance (LR) Groningen voice prosthesis has over the past years provided good voice and speech results. The valve part of the prosthesis is largely responsible for the airflow resistance of the prosthesis. This study was performed to evaluate if by modifying the valve part of the LR Groningen prosthesis a lower airflow resistance in vitro could be achieved. Several prototypes with modified valves were tested. Based on the aerodynamic measurements the prosthesis with a single slit of 200 degrees in the 'hat' of the esophageal flange was selected for further evaluation and named the ultra-low resistance (ULR) Groningen voice prosthesis. Aerodynamic measurements were performed and showed the airflow resistance of the ULR Groningen voice prosthesis to be significantly lower than the resistance of the LR Groningen and the Provox voice prostheses.     

Differences in aerodynamic characteristics of new and dysfunctional Provox®2 voice prostheses in vivo

Tracheoesophageal voice prostheses need to be replaced due to increased airflow resistance or retrograde leakage of fluid into the trachea as a consequence of biofilm formation. Previous in vitro studies show a change of aerodynamic features of biofilm covered voice prostheses after removal of the prostheses out of the patient. To assess these changes in an in situ situation, aerodynamic characteristics were measured within 45 patients at the beginning and at the end of the wearing process of the Provox 2 voice prosthesis. As a consequence, the influence of biofilm formation on aerodynamic characteristics can be evaluated. In the majority of cases, leakage through the prosthesis was the reason for replacement. No differences were found in the total flow, volume range and intratracheal pressure (ITP) of the voice prostheses measured. The airflow resistance of biofilm covered prostheses was significantly reduced compared to new clean prostheses. However, no correlation was found between the extent of biofilm and the different aerodynamic features measured. Biofilm formation on the Provox 2 is responsible for both reduction in airflow resistance and leakage through the prosthesis by deterioration of the silicone rubber material.     

Pharyngoesophageal myotomy for vocal rehabilitation of laryngectomees

Pharyngoesophageal myotomy, performed in 16 laryngectomees to improve vocal rehabilitation, proved to have some negative side effects. Although no failures of speech rehabilitation using a button were consequently found, a considerable number of button assisted esophageal speakers had a breathy voice. Also, the number of poor injection-esophageal speakers was much higher than in the group of nonmyotomized laryngectomees. A "normal" pseudoglottis could only rarely be identified by fluoroscopy in the myotomized group. A significantly lower intratracheal pressure appeared to be required for tracheo-esophageal phonation after myotomy. To improve the slightly disappointing voice rehabilitation results of the myotomized laryngectomees, a modified myotomy is proposed.