Glottal Closure Insufficiency Research Articles

Concept for diagnosis and therapy of unilateral recurrent laryngeal nerve paralysis following thoracic surgery.

Injury to the recurrent laryngeal nerve is a potential complication in thoracic surgery, and may lead to postoperative dysfunction due to the resulting insufficient glottal closure. The aim of this study was, first, to develop an interdisciplinary concept of early diagnosis and adequate therapy of recurrent laryngeal nerve paralysis (RLNP), and second, to investigate efficiency of this approach. 120 patients (77 male, 43 female) aged between 15 and 85 years (mean 57 years) were examined otolaryngologically before and after thoracic surgery. Individual therapeutic modalities were chosen according to established criteria. In 18 patients (15 %), RLNP was found (16 left, 2 right). Five had already been diagnosed preoperatively. Functional voice therapy, stimulation-current therapy or external vocal fold medialization was performed depending on the prognostic criteria. RLNP following thoracic surgery requires immediate diagnosis and therapeutic strategy to minimize postoperative complications and to overcome impairments in the voice, swallowing, and coughing. The interdisciplinary concept presented in this study is especially advisable in high-risk RLNP procedures.

Influence of glottal closure configuration on vocal efficacy in young normal-speaking women

Summary Posterior closure insufficiency of the glottis is often mentioned in connection with permanent voice disorders. Recently published studies have revealed that an incomplete closure of the glottis can be found also in normal-speaking voices, especially in women. However, the effect of glottal closure configuration on vocal efficacy is not sufficiently clarified. The purpose of this study was to determine the effect of glottal closure configuration on singing and speaking voice characteristics. Overall, 520 young female normal-speaking subjects were examined by videostroboscopy for different phonation conditions in the combination of soft, loud, low, and/or high phonation and by voice range profile measurements. According to the videostroboscopic analysis, the subjects were subdivided into four groups: complete closure of the vocal folds already in soft phonation (group 1), closure of the vocal fold with increasing intensity (group 2), persistent closure insufficiencies despite increasing intensity (group 3), and hourglass-shaped closure in subjects with vocal nodules (group 4). Subjects in which the glottal closure could not be evaluated sufficiently were subclassified into group 5 (missing values). Selected criteria of the singing and speaking voice were evaluated and statistically processed according to the mentioned subclassification. Group 1 reached significantly the highest sound pressure levels (SPL max) for the singing voice as well as for the shouting voice. Group 3 showed a limited capacity to increase the intensity of the singing and speaking voice. The results gathered in this study objectify the relationship of insufficient glottal closure and reduced vocal capabilities. As long as no conclusive data on long-term consequences of insufficient glottal closure are available, a prophylactic improvement of the laryngeal situation especially in female professional voice users by voice therapy should be recommended.

Aerodynamic Measurements in Medialization Thyroplasty

Objective --External vocal fold medialization thyroplasty is a standard technique for improving voice, swallowing and breathing impairments due to insufficient glottal closure caused by either unilateral vocal fold paralysis or deficit of vocal fold tissue (i.e. as a result of cordectomy, scarring processes or sulcus glottidis). However, only scant information is available concerning the effect of the medialization thyroplasty on aerodynamic parameters. The aim of this study was to investigate the effect of vocal fold medialization thyroplasty on the degree of laryngeal stenosis using selected aerodynamic parameters. Material and Methods --Thirty patients (12 female, 18 male) underwent external vocal fold medialization with a titanium vocal fold medialization implant under local anesthesia supplemented by i.v. sedation. Pulmonary function tests were performed pre- and postoperatively and selected parameters were analyzed statistically. Results --All patients reported improved self-control of breathing during speaking, laughing, coughing and physical activity. The postoperative values of the parameters tested showed no significant alteration in comparison to the preoperative data. Conclusions --The analysis of the aerodynamic findings indicated that the medialization procedure using an implant did not cause an increase in the laryngeal resistance.

Functional results after external vocal fold medialization thyroplasty with the titanium vocal fold medialization implant.

A persistent insufficiency of glottal closure is mostly a consequence of a unilateral vocal fold movement impairment. It can also be caused by vocal fold atrophy or scarring processes with regular bilateral respiratory vocal fold function. Because of consequential voice, breathing, and swallowing impairments, a functional surgical treatment is required. The goal of the study was to outline the functional results after medialization thyroplasty with the titanium vocal fold medialization implant according to Friedrich. In the period of 1999 to 2001, an external vocal fold medialization using the titanium implant was performed on 28 patients (12 women and 16 men). The patients were in the age range of 19 to 84 years. Twenty-two patients had a paralysis of the left-side vocal fold, and six patients, of the right-side vocal fold. Detailed functional examinations were executed on all patients before and after the surgery: perceptive voice sound analysis according to the "roughness, breathiness, and hoarseness" method, judgment of the s/z ratio and voice dysfunction index, voice range profile measurements, videostroboscopy, and pulmonary function tests. In case of dysphagia/aspiration, videofluoroscopy of swallowing was also performed. The respective data were statistically analyzed (paired t test, Wilcoxon-test). All patients reported on improvement of voice, swallowing, and breathing functions postoperatively. Videostroboscopy revealed an almost complete glottal closure after surgery in all of the patients. All voice-related parameters showed a significant improvement. An increase of the laryngeal resistance by the medialization procedure could be excluded by analysis of the pulmonary function test. The results confirm the external medialization of the vocal folds as an adequate method in the therapy of voice, swallowing, and breathing impairment attributable to an insufficient glottal closure. The titanium implant offers, apart from good tissue tolerability, the advantage of an easy, time-saving, and individually adjustable application during the operation.

External vocal fold medialization in patients with recurrent nerve paralysis following cardiothoracic surgery.

Recurrent laryngeal nerve injury is a possible complication following cardiothoracic surgery. Due to insufficient glottal closure, dysphonia and dysphagia with aspiration may occur. The purpose of the study was to outline the effect of vocal fold medialization thyroplasty on voice, swallowing and breathing impairments. Between 1999 and 2001, medialization thyroplasty using the titanium implant (TVFMI) according to Friedrich was performed in 14 patients with postoperative left-sided recurrent nerve paralysis (five female and nine male patients, mean age 64 years) by an external approach. Previous surgical procedures comprised six lobectomies (combined with resection and replacement of the subclavian artery in one case), two pneumonectomies, one resection of a schwannoma in the aortopulmonary window, two replacements of the descending aorta, one aortocoronary bypass procedure (with LIMA), and two esophageal resections using Akiyama technique, respectively. Before and after thyroplasty, the patients underwent an otolaryngological/phoniatric examination including videostroboscopy, voice sound analysis, voice range profile measurement, pulmonary function testing, and in selected cases videofluoroscopy of swallowing. Following thyroplasty, all patients reported on subjective improvement of voice, swallowing and breathing functions. Videostroboscopy revealed an improved glottal closure (six complete, six with posterior gap). All voice related parameters (e.g. roughness, breathiness, hoarseness, maximum sound pressure levels of the singing and shouting voices) were significantly improved. Due to potential risk of recurrent nerve alteration in left-sided intrathoracic procedures, a preoperative and postoperative laryngoscopic examination is recommended. The external medialization of the vocal folds can be regarded as an excellent method for improvement of voice, swallowing and breathing, in particular, when the quality of life is impaired due to persistent recurrent nerve paralysis.

Vertical partial laryngectomy

A total of 98 patients with early glottic squamous carcinomas (61 patients in Tla, 6 in T1b and 31 in T2) received vertical partial laryngectomy (VPL) from 1979 to 1998. All over 5-year survival rate, cause-specific survival rate and laryngeal preservation rate were 90%, 95% and 89%, respectively. There were no differences in those rates between the following three groups VPL for salvage after failure of irradiation on 47 patients, VPL as initial treatment on 35, and VPL as salvage surgery on 16 with previous irradiation in other hospitals. Consequently radiotherapy is better than VPL as initial treatment for early glottic carcinomas with taking account of quality of voice, and VPL is suitable for salvage after failure of irradiation. By means of questionnaires as to aspiration, no patients suffered from aspiration pneumonia, even if, with insufficient glottal closure for a long postoperative period.

誤えんに対するシリコン声帯注射の効果

Since 1983 intrafold silicone injection has been performed for unilateral recurrent laryngeal nerve paralysis in our department. It was previously reported that this technique is effective for improving voice. In this study, the effect of this technique on chronic aspiration was retrospectively examined.One hundred and five patients with chronic aspiration, who had undergone intrafold silicone injection for unilateral vocal fold paralysis, were examined as for the improvement of aspiration. It was found that this technique was effective for aspiration in more than ninty-five per cent of these patients. Therefore intrafold silicone injection should be performed as the first choice for patients with aspiration caused by glottal closure insufficiency. However, this technique was of no effect in patients with large glottal gap and/or impaired mobility of the tongue and larynx. It follows that another method is definitely required for these patients.

Spectral pattern recognition of improved voice quality

The self-organizing map (a neural network) was applied to the spectral pattern recognition of voice quality in 34 subjects: 15 patients operated on because of insufficient glottal closure and 19 subjects not treated for voice disorders. The voice samples, segments of sustained /a/, were perceptually rated by six experts. A self-organized acoustic feature map was first computed from tokens of /a/ and then used for the analysis of the samples. The locations of the samples on the map were determined and the distances from a normal reference were compared with the perceptual ratings. The map locations corresponded to the degree of audible disorder: the samples judged as normal were overlapping or close to the normal reference, whereas the samples judged as dysphonic were located further away from it. The comparison of pre- and postoperative samples of the patients showed that the perceived improvement of voice quality was also detected by the map.

Displacement of the ventricular fold following cordectomy

For early carcinoma of the vocal fold, three different therapeutic methods are mainly employed in daily clinic, radiotherapy, endoscopic laser surgery and cordectomy through laryngofissure. Each therapy has advantage and disadvantage by itself. However, if the indication is precisely and exactly drawn up, each therapy is thought to be an efficient treatment to some exent even today. The cordectomy is the most recommendable because an entire resection of the vocal fold can be performed with saf ty margin. On the other hand, insufficient glottal closure will happen after the cordectomy, resulting in breathy husky voice. Hence, we have newly designed a reconstructive surgery in order to avoid insufficient glottal closure even after cordectomy. A graft is made using the ipsilateral ventricular fold and this graft is displaced to the site of glottis. By a new glottis with the healthy vocal fold and the displaced ventricular fold, complete glottal closure is obtained. A patient can phonates one week later after the surgery. The ventricular fold has the same physical property as the vocal fold. Therefore, it is reasonable to use the ventricular fold to replace the vocal fold from the viewpoint of phonatory mechanism, especially vibratory wave motion.

Ｖｏｃａｌ Ｒｅｈａｂｉｌｉｔａｔｉｏｎとししての声帯内アテロコラーゲン注入術

Voice disorders to which intracordal injection for vocal rehabilitation can be applied have been expanded by the introdution of collagen. Attention has been focused on intracodal injection as an effective method for rehabilitation. This method is applicable not only to unilateral vocal paralysis, but also cases of insufficient glottal closure, such as sulcus vocalis and vocal atrophy.Injection of 3% atelocollagen was conducted in 9 cases of sulcus vocalis and one case of postoperative vocal fold scaring. These voice disorders show insufficient glottal closure and problem of vocal fold flexibility.Following results have been obtained with the study of 10 cases of such disorders: (1) In 80% of cases, vocal fold vibration, hoarseness and tiredness during phonation were improved. (2) In cases where the symptoms improved, the maximum sustained phonation time was prolonged. However the mean flow rate decreased in some cases and increased somewhat in others. (3) In cases where the symptoms were aggravated, the injection of DMPS had been carried out within one year previous to the operation.