Arytenoid adduction as an adjunct to type I thyroplasty for unilateral vocal cord paralysis

BACKGROUND

Surgical management of unilateral vocal cord paralysis has evolved over the last three decades. The recent use of type I thyroplasty has resulted in improvements in voice, swallowing, and respiration. The study was performed to evaluate our experience in 28 patients undergoing arytenoid adduction as part of their surgical rehabilitation of unilateral vocal cord paralysis.

METHODS

Patients undergoing arytenoid adduction with or without silastic medialization for unilateral vocal cord paralysis were entered into a prospective data base. Evaluation included symptomatic improvement in hoarseness, aspiration, dysphagia, dyspnea, and the radiographic documentation of pneumonia. Objective evaluation included mean phonatory air flow and acoustic analysis. Complications associated with surgery were recorded.

RESULTS

A satisfactory result was obtained in 27 of 28 (96%) patients. By symptom, improvement in hoarseness was evident in 96%, dyspnea 80%, dysphagia 94%, and aspiration 84%. Improvements in phonatory flow rate (p < .001), estimated mean laryngeal airway resistance (p < .001), and maximally prolonged phonation (p < .01) were identified. Complications occurred in 18% and consisted of local wound sepsis (n = 1), hematoma (n = 1), seroma (n = 1), and transient airway edema (n = 2). There were no episodes of airway obstruction requiring tracheostomy or implant extrusion.

CONCLUSIONS

Arytenoid adduction as part of type I thyroplasty is a safe and effective procedure. Subjective analysis confirms marked improvement in laryngeal function in the form of speech, swallowing, and respiration. Objective analysis confirms improvement in voice parameters. Future directions will focus on determination of those patients best served by arytenoid adduction.

Acoustic and physiologic characteristics of inspiratory phonation

Voice produced on inhaled air is a form of phonation that has received relatively little attention despite its apparent usefulness in the assessment of vocal function. This preliminary investigation was designed to describe the general characteristics of vocalization driven by an ingressive phonatory airflow. Vocal fundamental frequency (F0), electroglottographic (EGG), and airflow measures were examined in 16 normal men and women, who alternated between inspiratory and expiratory voice. Mean F0 routinely increased during inspiratory voice segments, shifting on average 5.1 semitones above the subjects' comfortable expiratory voice frequency. EGG data showed inspiratory voice to be associated with a more symmetrical pattern of vocal fold contact characterized by a prolonged interval of increasing contact. Both short-term F0 variability (jitter) and EGG amplitude perturbation were significantly higher during inspiratory voice. Stroboscopic examination of four of the subjects showed caudal displacement of the larynx and lengthened vocal folds associated with inspiratory phonation. The absolute airflow rate was significantly greater for inspiratory phonation, on average 48.5% higher than during normal expiratory voice. It was also found that both inspiratory pulse and falsetto vibratory patterns could be produced by at least some of the subjects, indicating some control over the mode and frequency of vocal fold vibration when driven by an ingressive airflow.

Vocal fundamental frequency measures as a reflection of tumor response to chemotherapy in patients with advanced laryngeal cancer

The fundamental frequency (F0) characteristics of 19 male patients with advanced laryngeal cancer, treated with cisplatin-based chemotherapy as part of a Larynx Preservation Protocol (LPP), were measured before each of three cycles of chemotherapy received before definitive radiotherapy (RT). In these select patients, for whom chemotherapy resulted in > or = 50% decrease in the tumor bulk, it was found that mean F0 was essentially unaffected by the disease and did not change over the course of chemotherapy, although the cycle of their treatment could be differentiated by both speaking F0 variability (pitch sigma) and F0 perturbation (jitter). Although these measures failed to distinguish between those patients showing a complete response (CR) (no measurable disease) versus a partial (PR) (residual) tumor response at the primary disease site, the significant changes observed in both groups indicate that frequency variation measures could prove valuable in the documentation of tumor response to nonsurgical therapeutic intervention if the voice is directly affected. Additional assessment of 15 age- and disease-matched patients who showed minimal or no primary response to the chemotherapy showed no significant change in any of the frequency measures after one chemotherapy cycle, suggesting that vocal improvement seen in the successful chemotherapy patients was not due to postbiopsy healing or other systemic influence unassociated with tumor reduction.

Vocal cord medialization for unilateral paralysis associated with intrathoracic malignancies

Patients with unilateral vocal cord paralysis from intrathoracic malignancies may have significant dysfunctions of speech, swallowing, ventilation, and effective coughing as a result of inadequate compensation of the nonparalyzed cord. In patients with already compromised pulmonary function, aspiration can be a life-threatening event. Sixty-three patients with intrathoracic malignancies required surgical correction of vocal cord paralysis. Primary pathology included lung cancer (49), esophageal cancer (nine), and miscellaneous tumors (five). Symptoms included hoarseness (62), dyspnea (21), aspiration (26), weight loss (19), dysphagia (14), and pneumonia (14). The surgical procedures included medial displacement of the vocal cord with silicone elastomer (48), temporary Gelfoam injection (seven), and Teflon (polytetrafluoroethylene) injection (eight) to move the affected cord to a medial position. In 11 patients, the operation was performed in the acute postoperative setting to improve pulmonary toilet. Symptomatic improvement was noted in the following proportions of affected patients: hoarseness, 92%; dyspnea, 90%; dysphagia, 93%; aspiration, 92%; pneumonia, 93%; and weight loss, 47%. Overall success rate of the intervention was 57 of 63 patients (90%). All 11 patients treated in the acute setting had immediate improvement. A variety of complications occurred in 17% of patients. Surgical management of vocal cord paralysis in patients with intrathoracic malignancies prevents life-threatening pulmonary complications in the acute postoperative setting. In chronic situations, it provides patients with improved speech, swallowing, and pulmonary function, resulting in improved quality of life, even for patients not cured of their disease.

Vocal stability and vocal tract configuration: an acoustic and electroglottographic investigation

Previous studies have reported differences in vocal fundamental frequency perturbation (jitter) and amplitude perturbation (shimmer) measures as a function of vowel type. However, it is not clear from those studies whether these effects derive from modifications in the shape of the vocal tract or from intrinsic vowel differences in mean fundamental frequency and vocal amplitude. The present study sought to address this issue using simultaneously obtained acoustic and electroglottographic (EGG) signals. Ten normal adult men and 10 normal adult women prolonged three maximally stable productions of the vowels [symbol: see text]. Vocal sound pressure level was maintained at 74 +/- 4 dB, while mean fundamental frequency was maintained at 110 and 220 Hz +/- 0.5 st for the male and female subjects, respectively. Results indicated that when vocal frequency and intensity are controlled, acoustic and EGG measures of mean jitter and shimmer do not show a significant vowel effect.

Speaker race identification from acoustic cues in the vocal signal

One-second acoustic samples were extracted from the mid-portion of sustained /a/ vowels produced by 50 black and 50 white adult males. Each vowel sample from a black subject was randomly paired with a sample from a white subject. From the tape-recorded samples alone, both expert and naive listeners could determine the race of the speaker with 60% accuracy. The accuracy of race identification was independent of the listener's own race, sex, or listening experience. An acoustic analysis of the samples revealed that, although within ranges reported by previous studies of normal voices, the black speakers had greater frequency perturbation, significantly greater amplitude perturbation, and a significantly lower harmonics-to-noise ratio than did the white speakers. The listeners were most successful in distinguishing voice pairs when the differences in vocal perturbation and additive noise were greatest and were least successful when such differences were minimal or absent. Because there were no significant differences in the mean fundamental frequency or formant structure of the voice samples, it is likely that the listeners relied on differences in spectral noise to discriminate the black and white speakers.