Mucosal Wave Propagation Research Articles

Hyperplastic epithelial lesions of the vocal folds: combined use of exfoliative cytology and laryngostroboscopy in differential diagnosis

The mainstay of successful tumor therapy is early detection of neoplastic tissue. Although exfoliative cytology has proven to be a reliable tool, its importance is still underestimated. Laryngostroboscopy is the most important tool for functional investigation in laryngological and phoniatric diagnosis. Stroboscopic evaluation allows early detection of infiltrative processes of the vocal folds. Aim of our study was to demonstrate that combination of both, exfoliative cytology and stroboscopy, provides a highly sensitive and easy to perform method in differential diagnosis of epithelial hyperplastic lesions of the vocal folds. In 130 patients with varying degrees of vocal fold keratosis up to glottic cancer, preoperative layngostroboscopy was performed. Stroboscopy was classified pathological in case of reduced or abolished amplitude of vocal fold vibration and/or reduced or abolished mucosal wave propagation. Under general anaesthesia histology with corresponding cytological specimens were obtained. The latter were classified in three groups reaching from normal (I), dysplastic (II), up to malignant (III) cytology. Invasive carcinoma was diagnosed in 32 cases by histology, corresponding malignant cytology was found in 21 specimens (sensitivity: 74%). By certain combination of cytology with pathological stroboscopy, a sensitivity of more than 97% can be achieved. Combination of cytology and stroboscopy allows detection of glottic cancer with a sensitivity of 97%, in contrast to 74% as found by cytology alone. This combination can be used as preliminary or sorting procedure and gives the opportunity of early detection, as well as for follow-up examinations. For repeated biopsies can cause scars with consecutive voice impairment, this procedure is very smooth but nevertheless reliable method.

Valoración estroboscópica de laringitis crónicas

IntroductionThe laryngostroboscopy allows analysis of the vocal fold vibrations during phonation. Disruption of normal viscoelastic properties of the superficial lamina propria results in aberrant vocal fold vibration and mucosal wave propagation. Therefore, an investigation was performed to relate the stroboscopic results with the anatomopathologic results of chronic laryngitis and glottic cancer. Material y methodsWe performed a retrospective study, which included 30 direct laryngoscopies with biopsy of 25 patients and their corresponding laryngostroboscopies. Results60% of the cases of “absence of mucosal wave” displayed severe dysplasia or carcinoma. 20% of the cases of “limited or present mucosal wave” were carcinoma. ConclusionsThe probability of finding severe dysplasia or carcinoma is significantly greater when we find absence of mucosal wave. The presence of mucosal wave does not exclude the possibility of malignant lesion of the vocal fold.

The influence of the position of the laryngeal endoscope laryngeal on videokymography

Resumo/SummaryVideokymography is a new high-speed imaging technique to investigate vocal fold vibration. The system has been considered useful in the analysis of irregular signals, making it possible to observe left-right asymmetries, open quotient, propagation of mucosal waves, and movement of the upper and lower margins. The aim of the present study was to verify the correspondence of the videokymographic images with larynx exposition angle variation. Three Brazilian adult female subjects, with no vocal complains, were evaluated. Videokymographic images were obtained with the laryngeal endoscope 90o positioned on the measuring line, perpendicular to the glottal axis - zero degree, during a sustained “ae” vowel, using habitual frequency and intensity. The procedure was repeated twice and adjusted by rotating the camera in fifteen degrees from the perpendicular line to the right and to the left. The results showed clear differences depending on the position of the endoscope, suggesting the standardization of laryngeal exposition to interpretate videokymographic images correctly.

Laryngeal findings in users of combination corticosteroid and bronchodilator therapy.

At the conclusion of this article, the readers should be able to 1) describe the laryngeal findings in patients who use combination therapy for asthma, 2) discuss the mechanism of laryngeal irritation from the use of inhalers, and 3) describe possible mechanisms for reducing laryngeal irritation and secondary dysphonia from the use of inhalers. To describe voice changes and laryngeal findings in patients who are started on combination corticosteroid and bronchodilator therapy in the form of a dry powder inhaler (DPI). Retrospective, single-subject design. Retrospective review of 10 consecutive patients meeting inclusion criteria, who presented at the voice center with more than 4 weeks of dysphonia after being started on a combination form of asthma medication for control and maintenance therapy. All patients were nonsmokers and without history of previous identification or excision of vocal pathology. All patients were treated previously with a proton pump inhibitor for gastroesophageal reflux. Laryngeal videostroboscopic evaluations were performed on all patients. Patients were asked to complete a questionnaire regarding their perceived voice change and history of medical maintenance therapy for asthma. Dysphonia was present in the patients selected for greater than 4 weeks. Patients had been switched to combination therapy after previously using traditional two-drug asthma regimens. In eight of nine patients, the vocal folds demonstrated areas of hyperemia, with plaque-like changes on the surface mucosa. Reduced amplitude of vibration and a reduction in mucosal wave propagation were present on videostroboscopy. Questionnaires revealed that all patients were initiated on combination DPI treatment within the last 6 months. Dysphonia caused by a change in the surface mucosa is a side effect from the use of DPI therapy for asthma. The high-impact force during inhalation of the medication and carrier leads to deposition of particles in the upper airway. We believe the extent of mucosal irritation can be minimized by patient education in the proper delivery of DPI. In some cases, however, return of the two medications delivered separately was necessary. The irritation of the laryngeal mucosa and return of normal vibratory parameters occurred in all patients.

Aerodynamics, voice quality, and laryngeal image analysis of normal and pathologic voices.

The purpose of this review is to describe examinations of phonatory function and their relation to image analysis of the unilaterally immobile larynx. Special emphasis was placed on image analysis using three-dimensional endoscopic images produced from CT scans. Developments in modern image processing technique have led to the quantification of various aspects of vocal fold vibration. Stroboscopic images of the vocal fold were digitized and, subsequently, the glottal gap area, amplitude, and degree of bowing were analyzed quantitatively in relation to phonatory function. Vocal fold vibration was observed with the aid of videokymography, during which images from a single transverse line can be recorded. Successive line images were shown in real time on a monitor, with the time dimension displayed in the vertical direction. This system enabled the assessment of left-right asymmetries, open quotient, propagation of mucosal waves, and forth. Three-dimensional endoscopic images derived from multislice CT scans provided a novel method for evaluating morphologic characteristics of the laryngeal lumen in relation to phonatory function. The combination of three-dimensional endoscopy and coronal reconstructed images supplemented stroboscopic findings exemplified by differences in vertical position and thickness between the vocal folds. Depth information about the vocal fold as well as the presence of paradoxic movement of the affected vocal fold and overadduction of the healthy vocal fold during phonation should be taken into account when surgical intervention to improve hoarseness resulting from unilateral vocal fold immobility is performed. Phonatory function tests, videostroboscopy, and laryngeal image analysis are prerequisites to achieving this goal.

Examination of models of mucosal wave propagation

Over the years, many models have been proposed to capture mucosal wave propagation along the medial surface of the vocal folds. However, historically, little quantitative data have existed with which to evaluate such models. Indeed, standard methods of laryngeal examination have imaged the medial surface vibrations of the vocal folds very poorly. However, new methods of imaging the medial surface dynamics of the vocal folds have recently been reported [D. A. Berry, D. W. Montequin, and N. Tayama, J. Acoust. Soc. Am. 110, 2539–2547 (2001)]. These data are used to evaluate a variety of models of mucosal wave propagation. [Work supported by NIDCD Grant No. R01 DC03072.]

A high-speed methodology for comparing phonosurgical outcomes in an excised larynx model

Many phonosurgical techniques have been used to treat hoarseness resulting from vocal disease, such as unilateral vocal fold paralysis. However, because of difficulty in documenting changes in mucosal wave propagation, comparing the outcomes of different phonosurgical techniques presents a formidable challenge. The purpose of this investigation is to compare two phonosurgical treatments of unilateral vocal fold paralysis, thyroplasty type 1 and arytenoid adduction, in terms of their impact on the mucosal wave. For thyroplasty type 1, the pushing force was systematically varied. For arytenoid adduction, the pulling forces were systematically varied. Across all experiments, systematic changes were also made in the subglottal pressure, glottal airflow, pre-phonatory posturing, and in the size of the glottal chink. Because stroboscopic methods could not image properly the aperiodic vibrations associated with paralysis, a digital high-speed imaging system was utilized (the Kodak EktaPro 4540). Using this system, the 3-D vibrations of the mucosal wave were imaged across all experimental conditions. In this presentation, we focus on the methodology employed to collect these measurements.

Stroboscopic assessment of vocal fold keratosis and glottic cancer.

Disruption of the normal viscoelastic properties of the superficial lamina propria (SLP) results in aberrant vocal fold vibration and mucosal wave propagation. Therefore, an investigation was performed to determine whether stroboscopy is a reliable method for 1) differentiating invasive glottic carcinoma from intraepithelial atypia or 2) determining the depth of cancer invasion. An analysis was done on the preoperative vocal fold vibration characteristics of 62 keratotic (intraepithelial, 45; cancer, 17) lesions that were subsequently resected by means of microlaryngoscopy. Histopathology and intraoperative mapping were used to specify the depth of invasion. A panel of 4 blinded judges was used to assess the amplitude of vocal fold vibration and the magnitude of mucosal wave activity in the region of the lesion from videostroboscopic recordings. The final comparative data set comprised only those ratings that achieved at least 75% interjudge agreement. Of the 28 intraepithelial lesions that could be reliably evaluated for amplitude of vocal fold vibration, only 2 were normal, with the amplitude reduced in 24 and absent in 2. Of the 30 intraepithelial lesions in which mucosal wave activity could be reliably assessed, only 2 were normal, with the wave reduced in 24 and absent in 4. Furthermore, amplitude of vocal fold vibration and magnitude of mucosal wave propagation were absent in 2 of 4 carcinomas in which the depth of microinvasion did not reach the vocal ligament. According to the findings herein, reduced amplitude of vocal fold vibration and/or mucosal wave propagation associated with keratosis did not reliably predict the presence of cancer or the depth of cancer invasion into the laminae propriae. However, the presence of a flexible mucosal wave probably indicates that there is not extensive vocal ligament invasion. Reductions in the amplitude of vocal fold vibration and in mucosal wave magnitude were usually noted in intraepithelial atypia, despite the fact that there was no invasion into the SLP. The reduced epithelial pliability could be due to bulky keratosis and/or alteration of the SLP occurring as a result of inflammation or fibrovascular scarring.

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.

Effect of vocal tract inertance on phonation threshold pressure: theory and measurements

In a previous analytical study [Titze, J. Acoust. Soc. Am. 83, 1536–1552 (1988)], it was shown that vocal fold oscillation is facilitated by the presence of a vocal tract, i.e., phonation threshold pressure is lowered by an inertive acoustic impedance of the vocal tract. Results of a recent simulation study [Titze and Story, J. Acoust. Soc. Am. 101, 2234–2243 (1997)] support the theory and show that a narrow ‘‘epilarynx tube’’ (area <1.0 cm2) in the lower vocal tract provides impedance-matching and gives the biggest facilitative effect. This small-amplitude oscillation theory was revised in the present study to simultaneously account for vocal fold mucosal wave propagation and vocal tract inertance, as energy transfer mechanisms for flow-induced oscillation. Analytical expressions of phonation threshold pressure were derived showing the relative contributions of the two mechanisms. Empirical data on the effect of vocal tract on phonation threshold pressure were also obtained in a physical model of the vocal fold mucosa [Titze et al., J. Acoust. Soc. Am. 97, 3080–3084 (1995)]. Both analytical and experimental results show that the facilitative effects of vocal tract on the ‘‘ease’’ of phonation are the most prominent under specific glottal geometry and biomechanical conditions. [Supported by NIH Grant No. P60-DC00976.]

Quantitative evaluation of the effects of thyroarytenoid muscle activity upon pliability of vocal fold mucosa in an in vivo canine model.

Stiffness of the vocal fold is a significant factor in determining mucosal wave propagation and in the control of the fundamental frequency of phonation. We measured pliability of the vocal fold mucosa in an in vivo canine model as an index of stiffness while the histological layer-by-layer structure of the vocal fold was not disrupted. The point 1 mm below the free edge showed a maximal pliability that gradually diminished toward the tracheal side and reached a minimum. When the thyroarytenoid (TA) muscle contracted, pliability of the mucosa was significantly increased (P < 0.001). Mucosal pliability of the excised larynx was significantly increased compared with that in vivo (P < 0.001). The point of minimal pliability in the absence of TA muscle contraction did not shift after excision of the larynx, while TA muscle contraction caused a downward shift of the point of minimal pliability. Mucosal pliability can thus be used to quantitatively assess the effects of TA muscle contraction on stiffness of the vocal fold mucosa.

Videokymography: research and clinical issues

Stroboscopy is based on the assumption that the vibration is stable and regular. Irregular vibrations, as is often the case in voice pathology, cannot easily be studied by stroboscopy. Videokymography overcomes this drawback. Videokymography, using a modified CCD video camera, makes it possible to observe all kinds of regular and irregular vocal fold vibrations, including those leading to pathological voice productions, It easily visualises small left-right asymmetries, open and closed phases of the selected part of the glottis, lateral propagation of mucosal waves, movements of the upper margin and, in the closing phase, the lower margin of the vocal folds. This is advantageous for a more accurate diagnosis of voice disorders. Also other fields which study mechanical vibrations, like strings of musical instruments, may benefit from videokymography.

A qualitative study of mechanisms of jitter-induced shimmer in the voice

Measurements of jitter and shimmer are typically applied to microphone signals to discern the level of perturbations in the oscillatory behavior of the vocal folds. Shimmer, the average cycle-to-cycle change in amplitude, is known to linearly increase as the extent of amplitude modulation of tissue displacement increases. Behavior under frequency modulation (FM), however, is nonlinear. This nonlinearity is often attributed to time aliasing, the superposition of jittered impulse responses (assuming the source-filter model of phonation). As a consequence, whenever jitter is present, any measurement of shimmer cannot be solely attributed to amplitude modulation of the vocal fold tissue. The present study attempts to characterize other sources of FM-induced shimmer by examining points earlier in the voice production process. An interactive computer simulation of the vocal fold and vocal tract system is used under conditions of FM1/2 subharmonic modulation of the tissue displacement. It appears that, in addition to time aliasing, shimmer may be generated from FM-induced perturbations in mucosal wave propagation and tissue displacement. The paper qualitatively describes and illustrates these jitter-induced shimmer mechanisms.

Voice simulation with a body-cover model of the vocal folds.

A simple, low-dimensional model of the body-cover vocal-fold structure is proposed as a research tool to study both normal and pathological vocal-fold vibration. It maintains the simplicity of a two-mass model but allows for physiologically relevant adjustments and separate vibration of the body and the cover. The classic two-mass model of the vocal folds [K. Ishizaka and J. L. Flanagan, Bell Syst. Tech. J. 51, 1233-1268 (1972)] has been extended to a three-mass model in order to more realistically represent the body-cover vocal-fold structure [M. Hirano, Folia Phoniar. 26, 89-94 (1974)]. The model consists of two "cover" masses coupled laterally to a "body" mass by nonlinear springs and viscous damping elements. The body mass, which represents muscle tissue, is further coupled laterally to a rigid wall (assumed to represent the thyroid cartilage) by a nonlinear spring and a damping element. The two cover springs are intended to represent the elastic properties of the epithelium and the lamina propria while the body spring simulates the tension produced by contraction of the thyroarytenoid muscle. Thus contractions of the cricothyroid and thyroarytenoid muscles are incorporated in the values used for the stiffness parameters of the body and cover springs. Additionally, the two cover masses are coupled to each other through a linear spring which can represent vertical mucosal wave propagation. Simulations show reasonable similarity to observed vocal-fold motion, measured vertical phase difference, and mucosal wave velocity, as well as experimentally obtained intraglottal pressure.

Measurement of Mucosal Wave Propagation and Vertical Phase Difference in Vocal Fold Vibration

Examination of the surface wave properties of the vocal fold mucosa is becoming an important part of assessment of vocal function. A key wave property is propagation velocity, which determines the phase delay between the upper and lower margins of the vocal folds. Excised canine larynges were used to measure this phase delay, and therewith propagation velocity. The motion of two flesh points was tracked stroboscopically. Differential displacements between the flesh points were matched to displacements of a model. A least-squared fit of the data to the model provided the numeric values of propagation velocity, which varied from 0.5 m/s to about 2.0 m/s, depending on fundamental frequency. The corresponding phase delay along the medial surface of the vocal folds varied from about 60 degrees/mm to 30 degrees/mm.

Measurements of mucosal wave propagation and vertical phase difference in vocal fold vibration.

Examination of surface wave properties in the vocal fold mucosa is becoming an important part of assessment of vocal function. A key wave property is propagation velocity, which determines the phase delay between upper and lower margins of the vocal folds. Excised canine larynges were used in this study to measure this phase delay, and therewith propagation velocity. The motion of two fleshpoints was tracked stroboscopically. Differential displacements between the fleshpoints were matched to displacements of a model. A least-squared fit of the data to the model provided the numerical values of propagation velocity, which varied from 0.5 m/s to about 2.0 m/s, depending on fundamental frequency. The corresponding phase delay along the medial surface of the vocal folds varied from about 60°/mm to 30°/mm. [Work supported by NIDCD, Grant No. P60-DC0976.]

Physics of vibrations in living tissues.

ArticlePhysics of Vibrations in Living TissuesHenning E. von Gierke, Hans L. Oestreicher, Ernst K. Franke, Horace O. Parrack, and Wolf W. von WitternHenning E. von GierkeFrom the Aero Medical Laboratory, Air Development Center, Wright-Patterson Air Force Base, Dayton, Ohio, Hans L. OestreicherFrom the Aero Medical Laboratory, Air Development Center, Wright-Patterson Air Force Base, Dayton, Ohio, Ernst K. FrankeFrom the Aero Medical Laboratory, Air Development Center, Wright-Patterson Air Force Base, Dayton, Ohio, Horace O. ParrackFrom the Aero Medical Laboratory, Air Development Center, Wright-Patterson Air Force Base, Dayton, Ohio, and Wolf W. von WitternFrom the Aero Medical Laboratory, Air Development Center, Wright-Patterson Air Force Base, Dayton, OhioPublished Online:01 Jun 1952https://doi.org/10.1152/jappl.1952.4.12.886MoreSectionsPDF (2 MB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations ShareShare onFacebookTwitterLinkedInWeChat Previous Back to Top Next Download PDF FiguresReferencesRelatedInformation Cited ByComparison of five viscoelastic models for estimating viscoelastic parameters using ultrasound shear wave elastographyJournal of the Mechanical Behavior of Biomedical Materials, Vol. 85Wideband optical elastography of in vivo human skin using geometrically focused surface wavesSurface response of a viscoelastic medium to subsurface acoustic sources with application to medical diagnosisThe Journal of the Acoustical Society of America, Vol. 113, No. 2Measurement of Mucosal Wave Propagation and Vertical Phase Difference in Vocal Fold Vibration28 June 2016 | Annals of Otology, Rhinology & Laryngology, Vol. 102, No. 1Mechanical pulse wave propagation in gel, normal and oedematous tissuesJournal of Biomechanics, Vol. 25, No. 10Resonance of the Pregnant Sheep Uterus1 August 2016 | Journal of Low Frequency Noise, Vibration and Active Control, Vol. 11, No. 1Three Dimensional Sound and Vibration Frequency Responses of the Sheep Abdomen1 August 2016 | Journal of Low Frequency Noise, Vibration and Active Control, Vol. 10, No. 4Vibration of the Abdomen in Non-Pregnant Sheep: Effect of Dynamic Force and Surface Area of Vibrator1 August 2016 | Journal of Low Frequency Noise, Vibration and Active Control, Vol. 10, No. 3Physiological characteristics of responses of wide dynamic range spinal neurones to cutaneously applied vibration in the catBrain Research, Vol. 507, No. 1Changes with Age in the Moisture Content of Human SkinJournal of Investigative Dermatology, Vol. 82, No. 1The dynamic mechanical properties of human skin in vivoJournal of Biomechanics, Vol. 16, No. 6Effect of Low Frequency Vibration on the Arterial WallCirculation Research, Vol. 29, No. 2Vibrotactile palpation instrument for use in minimal invasive surgeryThe absolute sensitivity characteristics of lung-sound transducers coupled to chest wallPortable system for measuring biomechanical propertiesInvestigation of significant interface parameters involved in the electromechanical transfer of tactile informationMeasurement and modeling of the acoustic impedance of the maternal abdomenTactile display using elastic wavesDynamic mechanical properties of human brain tissueJournal of Biomechanics, Vol. 2, No. 3Iatromathematics to Biomechanics4 November 2016 | Proceedings of the Institution of Mechanical Engineers, Vol. 181, No. 1Ultrasonic Absorption and Reflection by Lung Tissue5 August 2002 | Physics in Medicine and Biology, Vol. 5, No. 4I. MechanismsCirculation, Vol. 16, No. 2 More from this issue > Volume 4Issue 12June 1952Pages 886-900 Copyright & Permissions© 1952, by the American Physiological Societyhttps://doi.org/10.1152/jappl.1952.4.12.886PubMed14946086History Received 8 November 1951 Published online 1 June 1952 Published in print 1 June 1952 Metrics