A new training method for velopharyngeal dysfunction: Self-inhalation for hypernasality

OBJECTIVE

There are various methods to treat velopharyngeal dysfunction including　surgery and rehabilitation therapy. Even if a rehabilitation program is effective, the evaluation of its efficacy remains subjective. In this paper, we propose a new method of rehabilitation training for velopharyngeal dysfunction focusing on the objective peak inspiratory flow (PIF) rate.

METHODS

Four patients, who were diagnosed with velopharyngeal dysfunction without cleft palate at ENT clinic of the National Hospital Organization, Tokyo Medical Center, participated in this study. All patients underwent our original rehabilitation program for velopharyngeal dysfunction, a method using the In-Check Dial, Turbohaler model. As a self-training rehabilitation program, we asked them to inhale forcefully 10 times daily at home using the In-Check Dial to increase the value of PIF rate for 3 months. We measured the patients' PIF rates with the In-Check Dial at the ENT clinic at the initial visit and after the 3-month training.

RESULTS

The PIF rates of the four patients without nasal clips were higher than the rates with nasal clips at the initial visit. After the training, PIF rate without a nasal clip of all patients increased than the rate at the initial visit, which represented significant difference (P < 0.05). Also, after 3 months, PIF rate without a nasal clip was higher or equal than the rates with a nasal clip at the initial visit except one case. Naso-pharyngo-laryngeal fiberscopy did not detect salivary pooling around larynx and mirror fogging test did not show nasal escape in the three of four patients after 3 months of training. All reported improvement in dysphagia and dysarthria.

CONCLUSION

This new method can be used not only to evaluate velopharyngeal function but also as an effective self-training treatment.

[Een rood en gezwollen gelaat na heffen van de armen]

An 82-year-old woman attended our outpatient clinic because of a swollen right arm and hoarseness. Upon raising both arms, the patient developed a red and swollen face (Pemberton's sign). An MRI of the thorax showed a large intrathoracic goitre, which compressed venous structures and limited blood flow even when she lowered her arms.

Respiratory Tract Infections and Voice Quality in 4-Year-old Children in the STEPS Study

OBJECTIVES

Health-related factors are part of the multifactorial background of dysphonia in children. Respiratory tract infections affect the same systems and structures that are used for voice production. The purpose of this study was to investigate if the number of respiratory tract infections or the viral etiology were significant predictors for a more hoarse voice quality.

METHODS

The participants were 4-year-old children who participated in the multidisciplinary STEPS study (Steps to the Healthy Development and Well-being of Children) where they were followed up from pregnancy or birth to 4 years of age. Data were collected through questionnaires and a health diary filled in by the parents. Some of the children were followed up more intensively for respiratory tract infections during the first 2 years of life, and nasal swab samples were taken at the onset of respiratory symptoms. Our participants were 489 of these children who had participated in the follow-up for at least 1 year and for whom data on respiratory tract infections and data on voice quality were available.

RESULTS

The number of hospitalizations due to respiratory tract infections was a significant predictor for a more hoarse voice quality. Neither the number of rhinovirus infections nor the number of respiratory syncytial virus infections was statistically significant predictors for a more hoarse voice quality.

CONCLUSIONS

Based on our results, we would suggest including questions on the presence of respiratory tract infections that have led to hospitalization in the pediatric voice anamnesis. Whether the viral etiology of respiratory tract infections is of importance or not requires further research.

Coexisting Vocal Fold Polyps and Sulcus Vocalis: Coincidence or Coexistence? Characteristics of 14 Patients

OBJECTIVE

The study aimed (1) to evaluate the prevalence of sulcus vocalis (SV) coexisting with vocal fold polyp (SV-VFP), and (2) to determine the effect of their coexistence on voice quality.

STUDY DESIGN

This is a retrospective cohort study in a tertiary referral center.

METHODS

The medical records of all patients who underwent micro direct laryngoscopy due to VFPs between January 2013 and April 2015 were reviewed. Patients with SV-VFP were identified and data of their demographics, medical history, habits, preoperative and intraoperative laryngeal findings, and pre- and postoperative GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) score, and compared with the data of patients with solitary VFPs (S-VFPs).

RESULTS

Eighty-nine patients were diagnosed with VFPs, 14 (15.7%) of whom were diagnosed with SV-VFPs. Patients with SV-VFPs had significantly lower incidence of concurrent leukoplakia (P = 0.01), higher incidence of contralateral vocal fold lesions (P = 0.04), increased voice roughness score postoperatively (P = 0.01) on the GRBAS score, and had a lower rate of cigarette smoking (P = 0.02) compared with patients with S-VFPs.

CONCLUSIONS

The possibility of a hidden SV should be considered when detecting VFPs, particularly in patients with contralateral vocal fold lesions and without cigarette smoking history. Because the group of patients with SV-VFP presented with unique features, we suspect that the coexistence of VFPs and SVs is not incidental and that SVs may contribute to the formation of VFPs, possibly by alternating glottic airflow.

Lessons Learned After 1000 Cases of Transcutaneous Laryngeal Ultrasound (TLUSG) with Laryngoscopic Validation: Is There a Role of TLUSG in Patients Indicated for Laryngoscopic Examination Before Thyroidectomy?

INTRODUCTION

Patients with hoarseness of voice, previous neck operation, or suspicion of malignancy are at high risk of having pre-thyroidectomy vocal cord (VCP) palsy. Therefore, vocal cord (VC) functions should be evaluated before surgery. This study aimed to evaluate the accuracy of hoarseness, a voice-related questionnaire (Voice Handicap Index [VHI]-30), and transcutaneous laryngeal ultrasound (TLUSG) in diagnosing VCP, as well as the role of TLUSG in the evaluation of high-risk patients.

METHODS

A total of 1000 patients undergoing thyroidectomy or other endocrine-related neck procedures were prospectively included. Symptoms of hoarseness, the VHI-30 score, and TLUSG were evaluated. Validation laryngoscopies were performed by a separate endoscopist after performing TLUSG. All the assessments were performed one to seven days before surgery. The findings of hoarseness, the VHI-30 score, and TLUSG were correlated with laryngoscopic findings to evaluate the diagnostic accuracy.

RESULTS

Of 1000 patients, nine preoperative VCP were diagnosed with laryngoscopy. Sensitivity in detecting VCP by hoarseness, the VHI-30 score, and TLUSG were 33.3%, 62.5%, and 88.9%, respectively. A total of 342 patients were considered as high risk, and eight preoperative VCP were confirmed with laryngoscopy. Despite it not being possible to visualize the VCs in 26 (7.7%) patients, TLUSG had a higher accuracy in detecting VCP than the VHI-30 did (96.8% vs. 74.2%; p < 0.001). If patients had been selected who were unassessable or who had had VCP on assessment for confirmatory laryngoscopy, TLUSG saved more patients from laryngoscopic examinations than the VHI-30 did (87.7% vs. 71.3%; p < 0.001). A history of neck operation and suspicion of malignancy did not affect the assessment by TLUSG (p > 0.05).

CONCLUSION

TLUSG is a feasible, non-invasive, and sensitive tool in detecting VCP in high-risk patients. It has safely precluded 87.7% high-risk patients from laryngoscopy. TLUSG should be incorporated as a part of the ultrasound examination of the thyroid.

Adverse Reaction to Hyaluronic Acid Injection Laryngoplasty: A Case Report

INTRODUCTION

Injection laryngoplasty using hyaluronic acid is a safe procedure commonly performed on patients with glottic insufficiency.

STUDY DESIGN

This is a descriptive study of a case of adverse reaction to hyaluronic acid in a patient who underwent injection laryngoplasty for the treatment of unilateral vocal cord paralysis.

DISCUSSION

The patient was treated with antibiotics and corticosteroids and had a full recovery. The authors recommend close observation following injection laryngoplasty using hyaluronic acid and diligent investigation of persistent postoperative laryngopharyngeal symptoms.

[Clinical study of the influence of laryngopharyngeal reflux on quality of life in patients with dysphonia]

OBJECTIVE

To explore the morbidity of laryngopharyngeal reflux in patients with dysphonic diseases and to investigate the influence of LPR on the patients.

METHODS

One hundred and twenty-seven patients with dysphonic diseases were encountered in Peking University of the People Hospital. Under the agreement, the patients were asked to fill in the scales of RSI, RFS, VHI and SF-36.24-hour ambulatory double pH monitoring was applied to diagnose LPR definitely. 2643 volunteers were recruited to fill in the RSI scale through physical examination, outpatient, the ward and web survey.

RESULTS

46.46% (59/127) patients were diagnosed with LPR definitely. 1241 of 2643 volunteer, who filled in the RSI, score more than zero in the first entry of hoarseness or dysphonia, 65.0% (807/1241) of them, scoring 13 points or higher, were diagnosed with clinically suspected LPR. Based on the 24-hour ambulatory double pH monitoring, VHI total scores and subscores in the emotional domains were higher in positive group than in negative group. There was no statistical difference (P>0.05) in functional and physical domains. The SF-36 scale was used to evaluate the quality of life of the patients. The difference of 6 dimensionality, scores had statistical significance (P<0.05), including role-physical, general health, validity, social function, role-emotional and mental health. There was no statistical difference in dimensionalities of role-physical and bodily pain.

CONCLUSIONS

The volunteers who were diagnosed with hoarseness or dysphonia had the higher morbidity rate of LPR. At the time of treatment, more attention should be paid to the quality of life.

Classroom Noise and Teachers' Voice Production

PURPOSE

The aim of this study was to research the associations between noise (ambient and activity noise) and objective metrics of teachers' voices in real working environments (i.e., classrooms).

METHOD

Thirty-two female and 8 male teachers from 14 elementary schools were randomly selected for the study. Ambient noise was measured during breaks in unoccupied classrooms and, likewise, the noise caused by pupils' activity during lessons. Voice samples were recorded before and after a working day. Voice variables measured were sound pressure level (voice SPL), fundamental frequency, jitter, shimmer, and the tilt of the sound spectrum slope (alpha ratio).

RESULTS

The ambient noise correlated most often with the fundamental frequency of men and voice SPL, whereas activity noise correlated with the alpha ratio and perturbation values. Teachers working in louder ambient noise spoke more loudly before work than those working in lower noise levels. Voice variables generally changed less during work among teachers working in loud activity noise than among those working in lower noise levels.

CONCLUSIONS

Ambient and activity noises affect teachers' voice use. Under loud ambient noise teachers seem to speak habitually loudly, and under loud activity noise teachers' ability to react to loading deteriorates.

Dysphagia, hoarseness, and globus in a postoperative patient

Sore throat, hoarseness, and dysphagia are known and recognized postoperative complications of laryngeal mask airway use during operative procedures. The patient's symptoms, present immediately after surgery, are thought related to airway manipulation. Airway foreign bodies, although low on the differential, can cause similar symptoms. We present a case of a single patient who presented to a tertiary care center after an elective outpatient procedure with postoperative sore throat, hoarseness, and dysphagia. A foreign body was found lodged in the patient's hypopharynx. The differential diagnosis of sore throat, hoarseness, and dysphagia in the postoperative patient is explored in further detail.

Genetic and environmental effects on vocal symptoms and their intercorrelations

PURPOSE

Recently, Simberg et al. (2009) found genetic effects on a composite variable consisting of 6 vocal symptom items measuring dysphonia. The purpose of the present study was to determine genetic and environmental effects on the individual vocal symptoms in a population-based sample of Finnish twins.

METHOD

The sample comprised 1,728 twins (125 monozygotic and 108 dizygotic twin pairs) born between 1961 and 1989, who completed a questionnaire concerning 6 vocal symptoms. Values for additive genetic, dominant genetic, shared environmental, and nonshared environmental components were computed separately for all symptoms. Multivariate analyses to determine genetic and environmental associations between the vocal symptoms were also performed.

RESULTS

Variance was explained by significant additive genetic effects (27%) in only one of the vocal symptoms, namely, voice gets low or hoarse, whereas the variance of one of the vocal symptoms, voice gets strained or tires, could be explained by nonshared environmental influence alone. Multivariate analyses showed that the correlations for most of the symptom combinations were significant.

CONCLUSIONS

Both genetic and environmental components influence vocal symptoms. Genetic and environmental influences seem to be differently balanced in different vocal symptoms. Genetic effects are moderate, whereas environmental effects seem to be the most important factor contributing to the presence of vocal symptoms.

Diagnostic evaluation and management of hoarseness

Hoarseness is a common symptom that can result from a wide spectrum of underlying causes ranging from the common cold to a malignancy. A framework for diagnostic evaluation is presented based on categorizing the myriad of causes by how they interfere with the voice production mechanism. Triaging of cases by necessity or urgency of laryngoscopy is assisted by forming a global index of suspicion based on targeted history taking. Laryngoscopy is required in most cases to obtain a diagnosis for the hoarseness. Treatments commonly prescribed for hoarseness are critically examined in this article. To listen to audio clips of patients with different types of hoarseness, please visit our website, www.medical.theclinics.com.

Overall voice and strain level analysis in rock singers

BACKGROUND

overall voice and strain level analysis in rock singers.

AIM

to analyze the voice o rock singers according to two specific parameters: overall level of vocal deviation (OLVD) and strain level (SL); to compare these parameters in three different music samples.

METHOD

participants were 26 male rock singers, ranging in age from 17 to 46 years (mean = 29.8 years). All of the participants answered a questionnaire for sample characterization and were submitted to the recording of three voice samples: Brazilian National Anthem (BNA), Satisfaction and self-selected repertoire song (RS). Voice samples were analyzed by five speech-language pathologists according to OLVD and SL. Statistical analysis was done using the software SPSS, version 13.0.

RESULTS

statistically significant differences were observed for the mean values of OLVD and SL during the performance of Satisfaction (OLVD = 32.8 and SL = 0.024 / p=0.024) and during the RS performance (OLVD = 38.4 and SL = 55.8 / p=0.010). The values of OLVD and SL are directly proportional to the samples of the BNA* and RS**, i.e. the higher the strain the higher the OLVD (p,0.001*; p=0.010**). When individually analyzing the three song samples, it is observed that the OLVD does not vary significantly among them. However, the mean values present a trend to increase from non-rock to rock performances (24.0 BNA / 32.8 Satisfaction / 38.4 RS). The level of strain found during the BNA performance presents statistically significant difference when compared to the rock performances (Satisfaction and RS, p=0.008 and p=0.001).

CONCLUSION

the obtained data suggest that rock style is related to the greater use of vocal strain and that this strain does not necessarily impose a negative impression to the voice, but corresponds to a common interpretative factor related to this style of music.

[Hoarseness patterns in children]

The objective of the present work was to study the structure of voice disorders in children depending on the methods chosen to diagnose dysphonia. Medical histories of 1,451 children at the age varying from 2 months to 16 years were analysed. All of them were patients hospitalized for the first time between 1997 and 2007 to treat hoarseness caused by vocal cord nodules, functional or mutational dysphonia, chronic laryngitis, vocal cord paresis/palsy, recurring respiratory papillomatosis, vocal cord cystitis, and cicatrical laryngeal stenosis. It was shown that vocal cord nodules and functional dysphonia diagnosed in 53.1% and 12.2% of the children were the main causes of voice disturbances. The former condition was especially common in boys aged from 7 to 12 years engaged in intense sports activities while the latter prevailed in 5 to 12 year-old girls studying singing. It is concluded that measures are needed to increase awareness of both parents and teachers of psycho-emotionally labile children about causes of hoarseness and methods of its diagnosis. The use of the fibrolaryngoscopic technique makes it possible to elucidate the cause of dysphonia in children of any age starting from the first days of postnatal life.

Voice quality of psychological origin

Variations in voice quality are essentially related to modifications of the glottal source parameters, such as: F0, jitter, and shimmer. Voice quality is affected by prosody, emotional state, and vocal pathologies. Psychogenic vocal pathology is particularly interesting. In the present case study, the speaker naturally presented a ventricular band voice whereas in a controlled production he was able to use a more normal phonation process. A small corpus was recorded which included sustained vowels and short sentences in both registers. A normal speaker was also recorded in similar tasks. Annotation and extraction of parameters were made using Praat's voice report function. Application of the Hoarseness Diagram to sustained productions situates this case in the pseudo-glottic phonation region. Analysis of several different parameters related to F0, jitter, shimmer, and harmonicity revealed that the speaker with psychogenic voice was capable of controlling certain parameters (e.g. F0 maximum) but was unable to correct others such as shimmer.

Hoarseness - what is the voice trying to tell you?

BACKGROUND

Most episodes of hoarseness are benign and self limiting.

METHODS

This article describes the causes and management of hoarseness in adults, outlines the features of common causes of voice disturbance in adults, and highlights a number of red flags that should trigger urgent referral.

DISCUSSION

Patients with hoarseness lasting more than 3 weeks require specialist assessment to visualise the larynx.

Voice abnormalities and their relation with motor dysfunction in Parkinson's disease

OBJECTIVE

To evaluate changes in perceptual and several acoustic parameters of voice in patients with Parkinson's disease (PD) and to find out any relation with these parameters and motor components of Unified Parkinson's Disease Rating Scale (UPDRS) in this patient group.

MATERIALS AND METHODS

Twenty patients with PD (12 male and 8 female) were given objective and subjective voice tests and results were compared with those of 20 age- and sex-matched controls. Patient's perceptual voice analysis was assessed using GRBAS scale including Grade of Dysphonia, Roughness, Breathiness, Asthenia and Strain items. Measurements for objective voice analysis, acoustic assessment tests including frequency perturbation [jitter (jitt)%], intensity perturbation [shimmer (shim)%], noise to harmonic ratio (NHR), fundamental frequency (F0), variability of fundamental frequency (vF0), diadochokinetic rate (DDK) and maximum phonation time (MPT) were used. An assessment of disability caused by voice disorders was scored according to the Voice Handicap Index (VHI) by the patient. All subjects also underwent videolaryngostroboscopic (VLS) examination. Motor components of UPDRS and acoustic parameters of voice were investigated for any correlations.

RESULTS

Compared with controls, roughness (P = 0.15), breathiness (P = 0.004) and asthenia (P = 0.031) values of males and breathiness (P = 0.043) and asthenia (P = 0.023) values of females were higher in patients with PD. Mean VHI scores of patients with PD were higher for both male and female patients (P = 0.0001 for male, P = 0.002 for female). The mean values for MPT (P = 0.02) and DDK (P = 0.025) were shorter in patients with PD. Jitt%, shim% and mean F0 values were similar among the two groups. But mean vF0 values were significantly higher in male patients with PD (P = 0.05). On VLS examination, non-closure glottic pattern was found to be more frequent in the PD group.

CONCLUSION

Although it is well known that pathophysiological changes in PD affect the voice, the present study found only few significant correlations between motor component of UPDRS and voice parameters.

Hoarseness in children: the role of laryngopharyngeal reflux

OBJECTIVE

The role of laryngopharyngeal reflux (LPR) in hoarseness in children is not well studied. The purpose of this study was to determine the prevalence of LPR in hoarse children.

METHODS

Retrospective chart review identified 337 children with hoarseness over a 3-year period.

DATA COLLECTED

mode of presentation, associated symptoms, endoscopic findings, laboratory testing, and therapeutic interventions and their outcomes.

RESULTS

Mean age at presentation was 7.2+/-4.3 years with a male:female ratio of 1.7:1. Of the 295/337 (88%) children who underwent endoscopy, 107/295 (36%) had LPR changes alone, 86/295 (29%) had vocal fold nodules, 63/295 (20%) had both LPR and vocal fold nodules; and 22/295 (7%) had a finding other than LPR or nodules. Of the children diagnosed with LPR by endoscopy (with or without nodules), 93/170 (55%) underwent at least one additional test for reflux with 69/93 (74%) having a positive test. Of the children diagnosed with LPR by endoscopy, neither cough nor throat clearing was identified in 82/170 (48%) of children. At the first follow-up visit, an average of 3 months from initial presentation, 50% of 169 children who were treated for reflux had improved or resolved. By the second follow-up visit, 4.5 months later, 68% of those children had improved or resolved.

CONCLUSIONS

LPR appears to be a very common cause of hoarseness in children, and is an increasingly important symptom in identifying children with LPR. Treatment of LPR often results in improvement of hoarseness.

Vocal fold immobility following burn intensive care

OBJECTIVE

To evaluate factors associated with the development of vocal fold immobility in patients surviving burn intensive care.

STUDY DESIGN AND SETTING

A retrospective review of patients referred to Department of Speech Pathology by the Burn Intensive Care Unit between June 2002 and November 2004. Patients underwent videostroboscopic examination, and associations of vocal fold immobility with factors related to patient management were examined by using logistic regression.

RESULTS

Vocal fold immobility was diagnosed in 25 (48%) of the 52 patients evaluated. A significant association with a history of intubation during overseas aeromedical evacuation (odds ratio 4.5, P = 0.026) was observed. Multivariate modeling demonstrated an increased risk of 3% for each % total body surface area (TBSA) of burn.

CONCLUSION

High-altitude transport of intubated patients was a significant risk factor in the development of laryngeal injury.

SIGNIFICANCE

This study magnifies the role that endotracheal tube cuff pressure may play in recurrent laryngeal nerve injury.

Presbyphonia: a review

Recent research has led to greater understanding of the physiologic and cellular factors involved in the aging of laryngeal tissues, and concurrent advances in treatment promise improvements in clinical outcomes. This article reviews the current medical literature with respect to the age-related clinical and pathological changes in the larynx leading to presbyphonia.

Pharyngeal and laryngeal symptoms and signs related to extraesophageal reflux in patients with heartburn in gastroenterology practice: a prospective study

OBJECTIVES

To describe pharyngeal and laryngeal symptoms and findings in correlation to extraesophageal reflux (EER) in patients with heartburn.

DESIGN

A prospective study.

SETTING

Patients referred to Department of Gastroenterology, Karolinska University Hospital Huddinge.

PARTICIPANTS

Forty-three patients with chronic heartburn as the primary symptom, subdivided on the basis of oesophageal manometry to have gastro-oesophageal reflux disease (GORD) (n = 25) or not (n = 18).

MAIN OUTCOME MEASURES

Laryngeal video recordings of 43 patients were examined off-line. The occurrence of symptoms and laryngeal pathology were correlated to the results of 24-h double-probe pH monitoring.

RESULTS

Pharyngeal or laryngeal symptoms occurred often or quite often in 72% (18 of 25) of the GORD patients and 61% (11 of 18) of the patients without GORD. EER occurred in 73% (16 of 22) of the GORD patients with laryngeal symptoms and in 38% (6 of 16) of those without GORD but with laryngeal symptoms (P = 0.047). In the multivariate analysis the odds for hoarseness was 17 times higher if the patient had heartburn more than five times a day, compared with patients with heartburn less than once a day (OR 17.8, CI 1.7-405.9; P = 0.01). Cohen's kappa for intrarater reliability was 0.851 (P = 0.001). Laryngeal pathology was found in 56% of the GORD patients and 44% patients without GORD. There was no significant difference in the occurrence of any specific symptom or finding between the patients with and without GORD, nor with and without EER.

CONCLUSIONS

Although GORD together with laryngeal symptoms seem to be predictive of EER, there are no specific pharyngeal and laryngeal symptoms or findings that would help distinguishing patients with EER from those without. However, the more frequent the heartburn to the more frequent is hoarseness.

An asymmetric smooth contour two-mass model for recurrent laryngeal nerve paralysis

Irregular vocal fold vibrations are assumed to be a major cause of hoarseness. A common clinical condition presenting with hoarseness is a unilateral recurrent laryngeal nerve paralysis (RLNP). In order to explain high-speed video recordings of clinical RLNP, RLNP-type vocal fold vibrations are simulated by extending the well known two-mass model (2MM) to an asymmetric smooth-contour two-mass model (SC2MM). Polynomial interpolations form a smooth surface over the lumped elements of the 2MM. Laryngeal asymmetry is accounted for by introduction of an asymmetry coefficient and an anterior commissure angle which models a variable glottal closure insufficiency. Compared to the 2MM, the SC2MM yields a smaller glottal volume flow and is more stable in critical parameter constellations of RLNP-like conditions. It is able to model the vocal fold dynamics during a glottal closure insufficiency.

Musculoskeletal patterns in patients with voice disorders

This study correlated the ear, nose, and throat (ENT) and physiotherapy input on 26 patients who presented with voice problems and were found by the ENT surgeon to have a degree of musculoskeletal issues. It also looked for patterns of musculoskeletal findings. Although all patients referred were found by the physiotherapist to have musculoskeletal abnormalities, the correlation proved to be excellent among the subgroup of performers, but only fair-to-good among the other voice professionals. Certain patterns of musculoskeletal abnormalities were frequently encountered, including a high held larynx, a shortening or contraction of the stylohyoid and sternocleidomastoid muscles, and a weak deep flexor mechanism. In this small group, most patients seemed to improve, although it must be noted that management was not limited to physiotherapy. In summary, physiotherapy input proved helpful in the evaluation and management of this group of patients presenting with voice problems.

Predicting mutational change in the speaking voice of boys

SUMMARY

The authors investigated whether acoustic speaking voice analyses can be used to predict the beginning of mutation in 21 male members of a professional boys' choir. Over a period of 3 years before mutation, children were examined every 3 months by ear, nose, and throat (ENT) and phoniatric specialists. At the same time, the voice was evaluated acoustically using analysis features of the Goettingen Hoarseness Diagram (GHD). Irregularity component and noise component, jitter, shimmer, mean waveform correlation coefficient, and fundamental frequency were determined from recordings of the speaking voice. Significant changes of acoustic features appeared 7 and 5 months before mutation onset, which indicates that vocal function is already restricted 6 months before mutation onset. This acoustic voice analysis is therefore suitable to support the care of the professional singing voice.

Stereotactic radiosurgery for recurrent pleomorphic adenoma invading the skull base--case report--

A 38-year-old man presented with a recurrent pleomorphic adenoma in the parapharyngeal space invading the skull base 19 years after the first operation for a parotid gland tumor. Stereotactic radiotherapy was performed to control the tumor growth using a marginal dose of 8 Gy and maximum dose of 18 Gy with care taken to minimize the dose to nearby structures. The symptoms were reduced within a few months. Magnetic resonance imaging over 5 years showed that the tumor was controlled with no regrowth. Stereotactic radiotherapy is a therapeutic option for the treatment of pleomorphic adenomas.

Correlates of Varying Vocal Fold Adduction Deficiencies in Perception and Production: Methodological and Practical Considerations

In this study the voice characteristics of normal male and female speakers are compared to those of two groups of patients with unilateral vocal fold paralysis. In order to enhance phonation, the patients in the first group compensate for the adduction deficiency which results from paralysis. The patients in the second group do not use compensatory strategies. Sustained vowels [i:, a:, u:] were produced by the speakers and scored for roughness, breathiness and hoarseness (RBH) by 8 raters. Although interrater agreement for RBH scores is only moderate on average, these percepts make consistent distinctions between the three speaker groups. Consistent but different distinctions are made between the three speaker groups for male and female speakers. The results show that male and female speakers should not be pooled in experimental studies of the pathological voice. Our results also indicate that female patients with a compensated unilateral vocal fold paralysis cannot be clinically evaluated solely on the basis of perception, because their voices cannot be distinguished from normal, healthy female speakers, despite their physiological impairment. The group distinctions made on the basis of RBH scores are supported by differences in the acoustic parameters which are derived by automatic analysis of the sustained vowels. Despite identical group distinctions for RBH scores and acoustic parameters, the acoustic basis of the percepts is not straightforward. Different acoustic predictors of the percepts were found for male compared to female speakers. Additionally, interrater differences point towards the presence of perceptual trading relations.

Tracking outcomes after phonosurgery for sulcus vocalis: a case report

Outcomes data after a surgical or behavioral intervention should be tracked until stability is reached. Often it is unclear how long patients should be followed and at what point an outcome can be considered stable. These issues have implications for treatment decision making, efficacy measurement, and the design of research studies. Vocal function data were collected 24 hours before and at 1, 6, and 12 months after phonosurgery for sulcus vocalis. One data series was collected daily during the first month after surgery, providing a unique opportunity to study voice changes in the immediate postoperative period. The different vocal function indices (acoustic, perceptual, videostroboscopic, aerodynamic, psychosocial) demonstrated a general pattern of improvement after intervention; however, they appeared to reach stability at different times. This report reinforces the value of following patients until complete outcome stability.

Vocal fold deposits in autoimmune disease--an unusual cause of hoarseness

The objective of this study was to evaluate the symptoms and clinical characteristics in patients with autoimmune vocal fold deposits. Fourteen patients underwent videolaryngostroboscopic examination and voice recording. Eleven of the 14 patients underwent rheumatological examination. In all cases, endoscopic examination showed transverse white-yellow band lesions in the middle of the membranous portion of the vocal folds. In most cases, the lesions were bilateral but not exactly opposing each other. The most common voice characteristics were instability and intermittent aphonia. Inflammatory disease was present in 10 patients; five of these had rheumatoid arthritis (RA). No immunological signs common for all patients could be found. The histological examination was consistent with rheumatoid nodules. Vocal fold deposits, occurring most often in patients with RA, is an uncommon cause of hoarseness. Because the patients may have hoarseness as their primary symptom, it is important for otolaryngologists to be familiar with this disorder.

[Measurement and interpretation of irregular vocal cord fold vibrations]

BACKGROUND

Irregular vibrations of the vocal folds are regarded as a main reason for the common symptom of hoarseness. With real time resolution, they can only be observed using high speed recording techniques (up to 10,000 images/s).

METHOD

During the last years, we have developed a recording device and image processing software dedicated to the extraction of vocal fold motion curves from the image series. Irregular vibrations can be understood by using Hirano's "body-cover-model": one vocal fold is assumed to act as a system of two coupled oscillators (the vocal muscle and the epithelium, coupled by the connective tissue of Reinke's space).

RESULTS

By applying this biomechanical two-mass model and inversely solving Bernoulli's equation, the driving parameters of the vibration were computed from the high speed image series in selected cases. These parameters, like the subglottal pressure und the bilateral tension of the vocal muscle cannot, in general, be measured directly.

DISCUSSION

From the model, it can be supposed that laryngeal asymmetry (either in mass or tension) is the primary reason causing irregularity. The consequence of asymmetry in the medio-lateral direction are different fundamental frequencies on each side, while asymmetry in the anterior-posterior direction leads to ap-mode vibrations.

[Vowel selection effects on the parameters of acoustic analysis]

OBJECTIVE

To investigate if there is difference about the parameters of acoustic analysis with the different vowel |a|, |i|, |ae| and decide which vowels is best fitted to the acoustic analysis.

METHOD

40 normal and 130 pathologic voice patients accepted acoustic analysis. Each acoustic parameters such as jitter, shimmer, NNE, SDF0, SNR were compared with different vowels.

RESULT

Jitter, shimmer, NNE with |i| were much lower than that with |a| and |ae| in normal cases and light hoarseness group. While the acoustic parameters with |i| were much higher than that with |a| and |ae| in moderate and heavy hoarseness group.

CONCLUSION

|a| and |ae| were the preferred vowels for normal and light hoarseness group, while the |i| could supply some useful suggestion for the moderate and heavy hoarse patients.

Objective assessment of hoarseness by measuring jitter

The objective measurement of hoarseness by measuring 'jitter' (the average percentage pitch-period variation between consecutive pitch-cycles) using an inverse filtering technique is described. Twenty-five patients with a variety of causes of hoarseness were studied, together with five individuals who had mild hoarseness induced by histamine challenge and 12 normal individuals. The mean severity of jitter in the patient group (9.8%) was significantly different from the normals. (1.04%) In addition, there was a significant correlation (R2 = 0.53; P < 0.0001) between jitter and subjective assessment of hoarseness. The mean values of jitter with histamine challenge before and after recovery (1.03%, and 1.18%) were significantly different (P < 0.0001) to the mean maximum value during the challenge (2.64%). These data suggest that jitter is an objective and repeatable measurement of hoarseness-even small changes in hoarseness in individual patients. It is likely to prove most effective for monitoring treatment response.

Dual-probe pH monitoring for the assessment of gastroesophageal reflux in the course of chronic hoarseness in children

The purpose of our study was to assess gastroesophageal reflux (GER) by dual-probe pH monitoring in children suffering from chronic hoarseness for more than six months. Seventeen children (aged between 2 and 12 years, 10 boys and 7 girls) were enrolled. All children underwent a laryngoscopy and a 24-hour dual-probe pH monitoring. At both sensor, distal and proximal esophageal, a pathological GER was defined as the presence of episodes of acid reflux with pH < 4 during a fraction of the total recording time greater than 5.2 percent. The computer considered the child was supine when asleep and upright when awake. Laryngoscopy revealed interarytenoid erythema and/or edema with vocal cord nodules or granulomas in 13 cases (76.4%), isolated vocal nodules or granulomas in three cases (17.6%) and a normal appearance in one case (5.8%). At both sensors, the majority of refluxes occurred when the child was upright, as analyzed by the percentage of time the intra-esophageal pH was below four (% time pH < 4), number of refluxes, reflux episodes/hour and longest reflux episode, p < 0.05 between upright and supine for each parameter. The median total % time pH < 4 on the proximal and distal probes was respectively 1.62 percent (95% CI 1.50-3.79) and 11.49 percent (95% CI 8.81-27.17), p < 0.0003. Among the 17 hoarse children, a pathological GER was observed in 12 (70.5%) at the distal sensor and in three (17.5%) at both sensors. Among the 16 hoarse children with abnormal findings on laryngoscopy, two (12.5%) had diagnosed pathological GER at the proximal and 11 (68.7%) at the distal sensor. The only child with normal findings on laryngoscopy exhibited a pathological GER at both sensors. Our results suggest that chronic hoarseness is associated with a pathological GER. The majority of these documented refluxes occurred when the child was awake.

Gastropharyngeal and gastroesophageal reflux in globus and hoarseness

BACKGROUND

The role of gastropharyngeal reflux in patients with globus pharyngeus and hoarseness remains unclear.

OBJECTIVE

To evaluate patients with complaints of globus, hoarseness, or globus and hoarseness combined for the presence of gastropharyngeal and gastroesophageal reflux.

DESIGN

Prospective clinical cohort study of 3 groups of patients undergoing ambulatory 24-hour double-probe pH monitoring. In patients with pathologic gastroesophageal reflux, an upper gastrointestinal endoscopy was also performed.

SETTING

Tertiary care, outpatient clinic.

PATIENTS

Twenty-seven patients with globus alone, 20 patients with hoarseness alone, and 25 patients with globus and hoarseness combined.

RESULTS

Patients with well-defined pathologic reflux (ie, gastroesophageal reflux with or without gastropharyngeal reflux) were present mainly in the group of patients with globus combined with hoarseness: 18 (72%) of 25 patients, compared with 7 (35%) of 20 patients with hoarseness alone and 8 (30%) of 27 with globus alone. Seven (10%) of all 72 patients had prolonged acid exposure at the laryngopharyngeal junction in the presence of a normal gastroesophageal pH registration. Abnormal findings in the esophagus were found at endoscopy in 17 (65%) of 26 patients with pathologic gastroesophageal reflux (with or without gastropharyngeal reflux).

CONCLUSIONS

We found a high prevalence of pathologic reflux in patients with both globus and hoarseness. Based on these findings, we strongly advise upper gastrointestinal endoscopy for symptomatic otolaryngological patients with pathologic gastroesophageal reflux.

Acoustic voice analysis by means of the hoarseness diagram

The hoarseness diagram (Michaelis, Fröhlich, & Strube, 1998a) has been proposed as a new approach to describe different acoustic properties of voices. To test its performance in the analysis of pathologically disturbed and normal voices five requirements are suggested that should be met by any acoustic voice-analysis protocol to be used in voice research and clinical practice. The hoarseness diagram is then tested with regard to these requirements. Individual voices are found to show a satisfactory localization in the diagram. Aspects of stationarity are discussed in the context of four case studies. The different cases illustrate that changes in the acoustic analysis results are observed if the voice-generation conditions change, whereas results are stationary if phonation conditions do not change. Different pathological voice groups defined on grounds of the specific phonation mechanism are found to map to specific regions of the hoarseness diagram, with differences between group locations being significant. All results can be interpreted without exceptions if the two hoarseness diagram coordinates are taken to reflect the vibrational irregularity of the voice-generation mechanisms on the one side and the degree of closure of the vibrating structures on the other side. The hoarseness diagram and its underlying algorithms are thus shown to constitute a useful approach to acoustic voice analysis in research and clinical practice. The tests themselves demonstrate several application possibilities, including the quantitative monitoring of individual voices.

Phonomicrosurgical management of vocal fold polyps: the subepithelial microflap resection technique

Vocal fold polyps are typically caused by acute and chronic trauma to the microvasculature of the superficial lamina propria (SLP). Shearing stresses that are induced by hyperfunctional glottal sound production lead to bleeding into the SLP and malformed neo-vascularized masses. Because the primary process does not involve the epithelium, the authors designed a technique to resect hemorrhagic polyps by epithelial cordotomy with partial or complete preservation of the vocal fold epithelium. This approach is different from the traditional microsurgical resection of hemorrhagic polyps by amputation with or without the carbon dioxide laser. Forty patients who underwent microlaryngoscopic resection of hemorrhagic polyps from 1996 through 1998 were reviewed retrospectively. Thirty-six of the 40 procedures were by epithelial cordotomy and subepithelial removal of the polyp contents. Sixteen of 36 were assisted by a subepithelial infusion of saline and epinephrine, and all were 3 mm to 6 mm. Four of 40 polyps were amputated; all of these were less than 3 mm and were pedicled on a narrow base. Cold instruments were used exclusively in all 40 patients. Postoperative laryngeal stroboscopy within 2 weeks revealed improved mucosal wave propagation and improved glottal closure in all 33 patients in whom postoperative strobovideolaryngoscopy was available. The epithelial cordotomy technique was introduced to minimize disturbance of normal SLP and epithelium. Despite the hemorrhagic nature of these lesions, cold instruments could be used exclusively with facility due to careful microdissection between the polyp and the residual normal SLP and the enhanced hemostasis provided by the subepithelial infusion of saline and epinephrine. The rapid return to improved glottal function is the result of this ultra tissue-sparing technique.

Vocal mechanics as the basis for phonosurgery

OBJECTIVE

A number of modifications in laryngoplastic phonosurgery have recently been proposed. This report is intended to clarify the concept on which the surgery should be based, vocal mechanics, for further rational development of the surgery.

STUDY DESIGN

The results of various previous surgeries were compared. In an attempt to elucidate what makes the difference in the results, simulation of voice production was conducted with the use of excised larynges.

METHODS

Excised larynges were mounted on a tube so as to be blown from below. Experimental variables in the model included the glottal area initially set, stiffness of the vocal folds, and subglottal pressure. The conditions under which the voice became hoarse were examined.

RESULTS

The voice became hoarse under the following major conditions: 1) the initial glottal area exceeded a certain value, 2) stiffness was too high, and 3) the glottis was too tightly closed. Clinical representation for each condition was made, particularly for excessively tight glottal closure such as in spasmodic dysphonia. A new type of surgical treatment for spasmodic dysphonia, lateralization thyroplasty, was briefly reported, which restored the voice to normal without recurrence for 1 year at the time of this writing.

CONCLUSIONS

A potential new type of laryngoplastic phonosurgery should be conformed to the mechanics of voice production. In treating dysphonia, it is often necessary to switch from etiologic or radical treatment, if infertile, to symptomatic treatment instead, at the level of mechanics.

Retrosternal goiter: a six-year institutional review

Retrosternal goiter is defined as any goiter in which at least 50 per cent of the thyroid resides below the level of the thoracic inlet. The incidence of retrosternal goiter varies from 3 to 20 per cent with respect to thyroidectomy patients. A retrospective chart review from June 1991 to December 1997 found 232 thyroidectomies performed at our institution. Sixteen patients were found to have retrosternal goiters (6.9%). The mean age was 57.8 years (range, 34-92). All were of benign pathology. Symptoms included shortness of breath (68.8%), hoarseness (37.5%), dysphagia (31.3%), and superior vena cava obstruction (6.25%). Thirteen patients were female (81.3%). Fifteen patients had surgical intervention (93.8%). Total thyroidectomy was performed in nine cases (60%), whereas lobectomy was performed in six cases (40%). All treated patients had complete resolution of symptoms. A cervical incision alone was used in 13 cases (86.7%). Complications consisted of one postoperative pleural effusion and in one case a traumatic C5 nerve root compression occurred. There were no instances of long-term vocal cord paralysis or hypoparathyroidism. There was no perioperative mortality. In the majority of patients with retrosternal goiter, surgery can be done expeditiously through a cervical incision with minimal morbidity and mortality.

[Hoarseness resulting from post-intubation arytenoid cartilage subluxation in an 11-year-old girl]

There has been described a case of the right arytenoid cartilage subluxation in a 11-year-old girl who underwent several intubations and bronchoscopies as a newborn and an infant. The voice has gone hoarse owing to those interventions. Videolaryngoscopy revealed anterior and medial dislocation of the right arytenoid cartilage accompanied by the immobility in the cricoarytenoid joint, right vocal movement being preserved. Voice therapy was not successful as the parents lost their interest, considering the present child's voice to be normal.

[The application of frequency-domain harmonics-to-noise ratio in the acoustic analysis of the normal voice and the abnormal voice]

The frequency-domain relative harmonics-to-noise ratios were analysed in 36 normal women and 30 patients who had suffered from abnormal voice. The result indicated: the frequency-domain relative harmonics-to-noise ratios of the normal voice were distributed stably and the relative harmonics-to-noise ratios of the diseased voice differed obviously from that of the normal one above 1,700 Hz (P < 0.01). The frequency-domain relative harmonics-to-noise ratio was considered as a valuable parameter in distinguishing normal voice and diseased voice.

[Functional voice quality assessment in curative microsurgery of laryngeal malignancies. Postoperative voice rehabilitation based on the "laryngeal double valve function"]

According to Negus and Pressman the sphincter systems of the vocal folds and the ventricular folds form a respiratory "laryngeal double valve function". Correspondingly, we found a physiological phonation system of the glottis and a pathological-compensatory one of the supraglottis. They appear to be regulated through an automatic phonatory control system with the glottal phonatory function evidently acting as sensor level. In order to confirm this hypothesis, objective voice analyses with glottal-relevant parameters of 26 voice-rehabilitated patients after minimally invasive laser surgery of glottal carcinomas are presented and integrated into a "hoarseness diagram" with the coordinates roughness and breathiness. Using statistically deliminated acoustic dusters, our data show a qualitative hierarchy of different postoperative phonation mechanisms. They demonstrate the influence of the vibratory capacity of glottal and supraglottal structures on the quality of the vibratory closure. Both functional parameters evidently determine the resulting voice quality in the sense of our hypothesis.

[An overview of the symptoms and signs of voice disorders and the pathophysiology of hoarseness]

Voice disorders are due to organic and functional disturbances of the voice generator, activator and resonator. They appear as a consequence of different factors which lead to the development of hoarseness, and may as well be the result of disturbed phonatory patterns. Phonatory patterns refer primarily to the muscular activity of the vocal system, which is delicately balanced within the voice generator, activator and resonator. PATHOPHYSIOLOGY OF HOARSENESS: Basic causes of hoarseness are insufficient glottic closure during phonation (glottal gap), changes in the vocal fold stiffness and imbalance in mechanical properties between the two folds. Glottal gap leads to the excessive air leakage during phonalion and insufficient conversion of the expiratory air into pulses. Turbulence of the expiratory air particles is increased, leading to the development of noise. Excessively stiff or tax vocal folds, both disturb the vibration process and lead to the development of noise and hoarseness. Imbalance in tension between the two folds, and especially in their mass, may lead to the glottal gap, with the consecutive noise and hoarseness. PHONATORY PATTERNS: Phonatory patterns refer to habitual movements of the vocal organs during phonation and speech, which are acquired during the process of learning phonation and speech. This is primarily the muscular activity of generator, activator and resonator of the voice, which is so balanced to produce the optimal voice quality with the least effort and fatigue. The activity of the phonatory organs is not well balanced in cases of voice disorders. That is the primary cause of functional voice disorders, and a very frequent consequence of organic voice disturbances. Hyperkinetic dysphonia is the most common type of disturbed phonatory patterns, characterized by excessive vocal effort, while hypokinetic dysphonia is rarely seen. The third type of functional disorders of the phonatory patterns is an incorrect placement of the voice (imposlatio falsa), which is characterized by an imbalanced muscular activity of the vocal organs, but within the normal limits concerning the overall amount of activity.