Phonatory Function Research Articles

Dynamic MRI of Larynx and Vocal Fold Vibrations in Normal Phonation

Dynamic magnetic resonance imaging (MRI) of the larynx and vocal folds during phonation was used for measuring the vertical laryngeal movements and the glottal angle of the vocal folds opening and closing in dynamic phase. The data used in this analysis were taken on 10 healthy volunteers during maximal inspiration and the prolonged phonation of the vowels [i] (as in key), [a] (as in car), [u] (as in loop), and the consonant [sh] (as in ship). The results of our MRI data have demonstrated the difference of the vocal folds movement in relation to the vowel and consonant sounds, with a large glottal opening for [sh] and a narrow opening for [i] and [u], and the difference of the laryngeal position in relation to the vowels, with [a] and [u] having a lower larynx position than [i]. Imaging the larynx's positions and the vocal folds' vibrations is possible using dynamic MRI. This technique permits measurements of laryngeal structures and glottal parameters in dynamic function with multiplanar high-resolution imaging. Analysis of laryngeal activity and vocal folds' vibration may be helpful for the evaluation of the phonation function and for the understanding of the physiology of vocal production and voice modulation.

Objective Analysis of Voice after Microlaryngoscopic Surgery in Patients with Vocal Polyps at Different Anatomical Sites

Background: Vocal polyps are a common, benign disorder of the larynx, which is most often treated by surgical excision. The aim of this study was to compare the postoperative changes in voice that correspond to the anatomical locations of vocal polyps. Methods: A retrospective study was conducted. Twenty-one patients were diagnosed with a polyp on the anterior third of the vocal fold (group Ⅰ) and 17 patients with a polyp on the middle third (group Ⅱ). Acoustic and phonatory function analyses were performed before surgery and six weeks thereafter. Results: Whereas postoperative jitter and shimmer decreased, the postoperative harmonic-to-noise ratio and maximal phonation time increased in all patients (P＜0.05). Jitter, harmonic-to-noise ratio, and maximal phonation time tended to improve more after surgery in group Ⅰ, whereas shimmer tended to decrease more in group Ⅱ. Only the increase in harmonic-to-noise ratio after surgery in group Ⅰ was significantly greater than that in group Ⅱ (P＜0.05). Conclusion: Surgery led to greater improvement in the harmonic-to-noise ratio in patients with a polyp on the anterior third than in those with a polyp on the middle third of the vocal fold. This implies that a polyp on the anterior third produces more disturbance in the harmonic component of the voice than does a polyp on the middle third of the vocal fold.

Autologous grafts for treatment of vocal sulcus and atrophy

To obtain complete glottal closure, and evaluate improvement of vocal fold vibration amplitude and vocal quality in patients with sulcus vocalis. Autogenous fat and/or fascia augmentation was used in 34 patients with sulcus vocalis. Mean follow-up time was 1 year. The perceptual acoustic and phonatory functions and videolaryngostroboscopic data were evaluated before and after the procedure. Most of the individuals reported an improvement of vocal quality, a complete glottal closure, an enhancement of mucosal wave excursion, and significant results of acoustic perceptual and phonatory functions after the surgery. Fat and fascia injections are effective autogenous implants and should be considered options in the treatment of patients with sulcus vocalis and vocal fold atrophy.

Phonatory function of the elderly determined by intensity-loading test: A comparison with the young

The goal was to test the hypothesis that the elderly have diminished laryngeal regulation capability, so we investigated phonatory function in the elderly and young using a sound pressure-loading test. In 36 healthy men (17 in their 20s, 19 in their 70s) and 45 healthy women (22 in their 20s, 23 in their 70s), fundamental frequency, sound pressure level, mean flow rate (MFR), and expiratory lung pressure (EP) were determined from phonatory function testing. Subjects phonated at a comfortable level and at high intensity, without changing vocal pitch. MFR, EP, and airway resistance increased with high-intensity phonation in the young; however, only MFR and EP increased in the elderly. The findings supported our hypothesis: with high-intensity phonation, the elderly undergo unchanged laryngeal regulation but a greater degree of expiratory regulation. The elderly are likely to become tired due to the effort required for phonation.

Wyniki czynnościowe po leczeniu zmian zwężających światło krtani

Six subjects before and after surgery because of the laryngeal stenosis were presented. In 3 cases laryngeal web was recognised which arises after endoscopical removal of infant papilloma. The scar after laser chordectomy due to carcinoma of the larynx occurred in remaining 3 patients. All presented patients simultaneously were undergoing removal of the lesion endoscopically and insertion of silastic separator. Respiratory and phonatory function assessment in patients who were operated because of the laryngeal stenosis was the aim of this study. Treatment effectiveness was estimate on the basis of pre- and postoperative spirometry with flow--volume loop and postoperative phoniatric examination. Ventilatory function was analysis on the basis of the following parameters: PIF, FEV1, FIV1, PEF, FVC. Phoniatric examination was performed after 2 months of outpatient observation and rehabilitation. It consisted of subjective voice assessment using GRBAS scale, videolaryngostroboscopy and assessment of the phonation time. Some of the analysed parameters especially in patients with posterior stenosis were significantly better after surgery. Phoniatric rehabilitation after surgery caused improvement of voice quality and phonatory function of the larynx. Thanks to insertion of silastic separator good phoniatric function and ventilation efficiency are possible.

What Should Be the Working Relationship between Otolaryngologists and Speech Language Pathologists?

What should be the working relationship between laryngologists and speech language pathologists?An explosion in diagnosis and treatment options in laryngology, logopedics and phoniatrics has become available. In part this is due to technology, but an even greater contribution has been due to application of multidisciplinary approach to the patient with voice and swallows complaints. The multi-disciplinary clinic approach to patients with voice and swallowing disorders brings in contributions from basic scientists, speech language pathologists and laryngologists. In their own right each specialty brings contributions based on professional training and clinical pathways to care for voice and swallow disorders. In aggregate, the contribution to team care of the patient is greater than the separate parts. We will explore in this paper some of the added benefits to care of professional and non-professional voice users by such a team approach.While the physician (phonosurgeons or phoniatricians) is primarily the medical specialist invested with the authority and responsibility for medical care of the patient with voice and swallow complaints, they also carry the mandate from society for co-ordination of care once the medical issues are no longer relevant. In this regard, management of functional deficits in voice and swallow are to be championed primarily by someone with medical training (i.e., physician) . A physician must be involved in the therapy and rehabilitation of voice and swallow to provide a comprehensive approach to achieve optimum results. The model used in laryngology and voice care specialty is modeled after other established relationships between disciplines such as orthopedic surgery and physical therapy and pulmonary medicine and respiratory therapy. Speech language patholo-gists interested in providing voice therapy should achieve: a) defined professional stan-dards, b) understand their scope of practice, and c) demonstrated area of clinical expertise. Patient safety, increased efficiency, and value to patient care must be demonstrated. Training must be based on systems practice using didactic and clinical patient based teaching.In our voice center we use speech language therapists extensively in a variety of ways in counseling and direct care. Our clinicians are primarily responsible for a) objective and perceptual evaluation of promontory function before and after interventional treatment, b) pre-operative counseling in pre and post operative voice use surrounding phono-surgery, management of functionally based benign lesions of the larynx (nodules, contact granuloma, muscle tension dysphonia, presbyphonia, puberphonia, and voice enhancement), c) evaluation and management of functional voice disorders such as psychogenic dysphonia, dysphonia for secondary gain and conversion voice disorders and d) optimizing the power, source, and filter system to improve phonatory function by voice rehabilitation. The swallow therapists' primary role is to do functional assessment of swallow, assist in performing fiberoptic evaluation of swallow function, administer modified barium swallow, perform swallow therapy and alaryngeal speech, and evaluate for electro stimulation. The physician is the primary diagnostician, medical and surgical treatment specialist and co-coordinator of overall care while the therapist functions as specialists in rehabilitation, diagnosis of functional deficit, and treatment of functional loss.The optimum model of care for patients with voice and swallow disorders is a multi-disciplinary approach that addresses both functional and medical aspects of care.

Metody badania czynności fonacyjnej krtani w Klinice Otolaryngologicznej Uniwersytetu Poznańskiego w latach 1922–1939

Indirect laryngoscopy development and progress initiated in 1854 by the autolaryngoscopy of the famous singing voice teacher Manuel Garcia in ENT speciality is connected with the names of L. Tuerck and J.N. Czermak, the last one being called the father of laryngoscopy. In 1878 M. Oertel used for the first time stroboscopic light in indirect laryngoscopy. The perception of stroboscopic picture is based on the Talbot principle. Two apparatuses used for the evaluation of larynx function in the Poznań ENT Department before the II World War are presented:--Polylaryngoscop enabling evaluation the indirect laryngoscopy simultaneously by several individuals.--Mechanical stroboscop of Oertel type with perforated disc moved by electrical engine. For 130 years laryngostroboscopy belongs to the basic examination methods of larynx phonatory function.

An Exploration of Skin Acceleration Level as a Measure of Phonatory Function in Singing

Two kinds of fluctuations are observed in phonetogram recordings of singing. Sound pressure level (SPL) can vary due to vibrato and also due to the effect of open and closed vowels. Since vowel variation is mostly a consequence of vocal tract modification and is not directly related to phonatory function, it could be helpful to suppress such variation when studying phonation. Skin acceleration level (SAL), measured at the jugular notch and on the sternum, might be less influenced by effects of the vocal tract. It is explored in this study as an alternative measure to SPL. Five female singers sang vowel series on selected pitches and in different tasks. Recorded data were used to investigate two null hypotheses: (1) SPL and SAL are equally influenced by vowel variation and (2) SPL and SAL are equally correlated to subglottal pressure (P(S)). Interestingly, the vowel variation effect was small in both SPL and SAL. Furthermore, in comparison to SPL, SAL correlated weakly to P(S). SAL exhibited practically no dependence on fundamental frequency, rather, its major determinant was the musical dynamic. This results in a non-sloping, square-like phonetogram contour. These outcomes show that SAL potentially can facilitate phonetographic analysis of the singing voice.

Immediate Recurrent Laryngeal Nerve Reconstruction and Vocal Outcome

The objective of this prospective study was to assess the long-term effects of immediate reconstruction of the recurrent laryngeal nerve (RLN) during thyroid cancer extirpation on postoperative phonatory function. The subjects were 22 patients with advanced thyroid cancer who underwent resection of the primary lesion and involved RLN. RLN paralysis was seen in 12 patients preoperatively and involvement of the RLN was noted intraoperatively in 10. Immediate reconstruction of the RLN was performed on eight patients using the great auricular nerve and one underwent direct anastomosis of the RLN stumps (group I). Nine patients opted not to have phonosurgical procedures (group II). The remaining four had arytenoid adduction immediately after cancer extirpation (group III). Phonatory function (stroboscopy, maximum phonation time [MPT], mean airflow rate [MFR], harmonics-to-noise ratio [HNR], jitter, and shimmer) was followed for at least 9 months. Minimal or no glottal gap during phonation was observed in six patients in group I, whereas the patients in group II had a large gap along the entire fold. HNR, MPT, and MFR were significantly better in group I (17.7 +/- 3.6 dB, 15.1 +/- 6.3 s, and 100 +/- 32 mL/s, respectively) than in group II (12.1 +/- 2.9 dB, 5.4 +/- 3.1 s, and 430 +/- 207 mL/s, respectively). Patients in group III had a gap of varying degrees along the membranous fold. Although HNR, shimmer, and MPT in group III were comparable to group I, the other parameters were less favorable than in group I. Immediate RLN reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function.

P053 Proper Capsular Incision Can Avoid Hoarseness After Enucleation of Schwannoma From the Cervical Vagus Nerve

Objective: Postoperative hoarseness is the major complication after enucleation of vagus nerve schwannoma. To improve the function of phonation, we compared the incidents of hoarseness after 2 different incisions of the tumor capsule after enucleation of schwannoma of the cervical vagus nerve.

P073: Phonatory Functions of the Elderly

P073: Phonatory Functions of the Elderly

Autologous Fat Augmentation for Voice and Swallow Improvement after Cordectomy

Surgery for the treatment of early-stage glottic carcinoma still remains a valid option. In most patients, newly formed neocord tissue preserves glottic functions, but in some patients an important glottic gap leading to glottic insufficiency may occur. In our study, 11 patients who had serious glottic insufficiency after endoscopic laser and laryngofissure cordectomy were treated with autologous fat injection (AFI) into the neocord tissue for voice and swallowing rehabilitation. One patient did not attend the first control visit and was excluded from the study. The remaining 10 patients were evaluated in the preoperative and postoperative periods for phonatory functions and efficacy of AFI by videolaryngostroboscopy and computerized acoustic analysis. Phonatory functions showed statistically significant improvement in the shimmer, noise-to-harmonic ratio, maximum phonation time and fundamental frequency. Perceptual ratings (GRBAS scale) also showed statistically significant improvement in all 5 parameters. Despite improvement in glottic closure, the mucosal wave deteriorated. Due to recurrence of symptoms of glottic insufficiency, AFI was repeated in 2 patients at the third and fifth months, respectively. One year later, the AFI resulted in successful rehabilitation of swallowing in all patients. The probability of resorption of autologous fat and the deterioration of the mucosal wave after AFI remain a problem, but re-injection can be done easily. As AFI is an easy, safe and cheap method, we concluded that it is a promising alternative procedure for managing voice problems after laser or laryngofissure cordectomy defects.

Lidocaine Block of the Recurrent Laryngeal Nerve in Adductor Spasmodic Dysphonia: A Multidimensional Assessment

Lidocaine block of the recurrent laryngeal nerve (RLN) has been reported as a procedure for surgical selection of patients with adductor spasmodic dysphonia (ADSD). However, its effects on phonation have not been rigorously assessed in a prospective fashion using strict entry criteria and multiple measures of phonatory function. This investigation assessed the phonatory effects of RLN lidocaine block in ADSD to explore its potential as a diagnostic tool. Single group, pre/postexperimental trial. Twenty-one consecutive patients with suspected ADSD underwent unilateral RLN block, causing temporary ipsilateral vocal fold paralysis. Voices were recorded before and during the block. Patients completed self-ratings of overall level of dysphonia severity, vocal effort, and laryngeal tightness. Blinded listeners completed auditory-perceptual ratings, and the frequency of phonatory breaks was acoustically analyzed. During the block, patients reported significant reductions on overall severity (P = .045), vocal effort (P < .001), and laryngeal tightness (P = .002). Listeners rated the voices during the block as significantly more breathy (P < .001), less strained (P < .001), and less severe (P = .059). Acoustic analysis confirmed significantly fewer phonatory breaks during the block (P < .001). Patient-based ratings of improvement were more consistent than listener ratings, and reduction in overall severity correlated with perceived breathiness. Although individuals varied in their outcomes, group results suggest that response to RLN lidocaine block warrants further study as a possible diagnostic tool in ADSD.

Photocoagulation of Microvascular and Hemorrhagic Lesions of the Vocal Fold with the KTP Laser

Ectasias and varices of the vocal fold are microvascular lesions that are often due to chronic abuse of the voice, and are occasionally encountered in association with other disorders such as polyps, Reinke's edema, and hematoma. The KTP laser can be used for photocoagulation of small vascular lesions, because the laser beam is well absorbed by hemoglobin, and damage to the epithelium is minimal. The present pilot study examined how the KTP laser could be used for microvascular lesions and their associated lesions. Twelve patients who had undergone phonomicrosurgery were enrolled in the present study. The microvascular lesions were treated by photocoagulation with the laser set at a low power of 1.5 W in the continuous mode, while preserving the epithelium, and associated lesions were then treated by microdissection with cold instruments. The postoperative phonatory function was assessed by maximum phonation time, a perceptual test rating (GRBAS scale), and stroboscopy. The procedures were completed successfully in all cases. An exceptional case of a small hemorrhagic polyp allowed treatment with the laser only. The postoperative stroboscopic findings, maximum phonation time, and perceptual test rating all showed significant improvement compared with the preoperative state. No adverse effects, such as scarring or reduction of the mucosal wave, were observed in the current series. KTP laser photocoagulation is a relatively simple and safe procedure for treating microvascular lesions of the vocal fold. It is not recommended for photocoagulation of hemorrhagic polyps or hematomas, because such lesions have little blood flow inside and thus photocoagulation is usually impossible or requires too much laser energy. However, photocoagulation of perimeter or feeding vessels of such disorders may facilitate the following procedure by avoiding unnecessary bleeding, as well as preventing recurrence of hemorrhagic lesions.

Assessment of Phonatory Function by the Airway Interruption Method: Age-Related Changes

In order to ascertain age-related changes in phonatory function, an aerodynamic phonatory function test based on the airway interruption method was conducted. Subjects were 142 men and 144 women aged between 20 and 79 years. No subjects demonstrated abnormalities of sound quality. The test was conducted using the Nagashima PS77E phonatory function analyzer. Subjects were instructed to phonate at the most comfortable pitch and intensity, and fundamental frequency (F0), sound pressure level (SPL), mean flow rate (MFR), expiratory lung pressure (EP), and airway resistance were determined. F0 was lower among women aged > or =50 years. EP was lower for women aged > or =70 years than for those in other age groups. For both genders, airway resistance was lower for those aged > or =70 years when compared to other age groups. Among women, F0 was lower aged > or =50 years. In advanced age, EP and airway pressure decreased among women and airway resistance decreased among men. C-4.

Assessment of Swallowing Function of Patients with Free Ileocolic Flap Reconstruction after Total Pharyngolaryngectomy

Functions for swallowing and phonation are the major concerns for patients after total pharyngolaryngectomy. The possibility of rapid restoration of swallowing and phonation function would be an important motivating factor for surgery for these patients. From January 2003 to December 2004, 12 consecutive patients, all male, aged from 33 to 69 years old (average 51.9), received free ileocolic flap reconstruction after total pharyngolaryngectomy. The swallowing function was evaluated by esophagogram and feeding patterns before and after concurrent combined chemo-radiotherapy (CCRT). Four cases died of tumor recurrence, metastasis or suicide in the 2 years follow up. All flaps survive well in early post-operative period, but one late flap failure due to damage of vascular pedicle 7 months after the initial operation. One case showed inferior junction stricture by esophagogram, and one presented pharyngocutaneous fistula. Choking was noted in three cases, but none developed aspiration pneumonia. One case was noted to be prolonged dysphagia and was dependent upon tube feeding. Others got good swallowing function after the operation. The rate in successful restoration of swallowing function of this procedure is 92%. Free ileocolic flap is an ideal flap for swallowing function restoration for the patients after total pharyngolaryngectomy. Simultaneous reconstruction of phonation will not interfere with the patients' swallowing.

Traumatic laryngotracheal stenosis—An alternative surgical technique

Reconstruction of combined laryngotracheal stenosis requires complex techniques including resection and incorporation of grafts and stents that can be performed as single or multistaged procedure. A complicated case of traumatic laryngotracheal stenosis was managed by us, surgical technique is discussed. A 16-year-old male presented with Stage-3 laryngotracheal stenosis of grade-3 to 4 (>70% of the complete obstruction of tracheal lumen) of 5 cm segment of the larynx and trachea. Restoration of the critical functions of respiration and phonation was achieved in this patient by resection anastomosis of the trachea and with subglottic remodeling. Resection of 5 cm long segment of trachea and primary anastomosis in this case would have created tension at the site of anastomosis. So we did tracheal resection of 3 cm segment of trachea along with subglottic remodeling instead of removing the 5 cm segment of stenosed laryngotracheal region and doing thyrotracheal anastomosis. In complicated long segment, laryngotracheal stenosis, tracheal resection and subglottic remodeling with primary anastomosis can be an alternative approach. Fibrin glue can be used to support free bone/cartilage grafts in laryngotracheal reconstructions.

The role of adjustment of expiratory effort in the control of vocal intensity: Clinical assessment of phonatory function

To determine the role of the adjustment of expiratory effort in the control of vocal intensity. An intensity-loading test was performed by using the airway interruption method. Three groups of subjects were used: a control group thought to resemble normal vocal fold closure, a group of patients with Reinke's edema thought to represent increased mass at the level of the vocal folds, and a group with vocal fold paralysis that was thought to represent a group with lack of adequate vocal fold closure. In the control group, expiratory lung pressure and airway resistance slightly increased. In the patients with Reinke's edema, expiratory lung pressure, and airway resistance significantly increased. In this group, the voice intensity was controlled by laryngeal adjustment, but a greater expiratory effort was needed because of a greater increase in glottal resistance. In the patients with vocal cord paralysis, airway resistance did not increase even with a high-intensity voice. Vocal intensity was controlled by expiratory effort. If there is sufficient ability for laryngeal adjustment, vocal intensity is controlled primarily by laryngeal adjustment and by expiratory adjustment in response to increased glottal resistance. However, vocal intensity is controlled by expiratory effort when laryngeal adjustment ability is poor.

Vocal Fold Polyp in a Professional Brass/Wind Instrumentalist and Singer

Wind instrumentalists, especially brass players, and singers share common factors, including vocal tract shape, function and pressure, vocal fold opening and closure, breath vector of force and air flow rates. To understand the mechanism and function of the vocal folds with a pathological lesion, it is necessary to visualize the differing interactions of the vocal tract during wind and brass instrument playing and in singing. A school band director, singer, wind and brass instrumentalist, was referred by musician colleagues with intermittent dysphonia, aphonia, and inability to sing high notes. Simultaneous videolaryngoscopy, with and without stroboscopy, and external video examination were documented. An hourglass glottis with a sessile, cystic polyp of the left vocal fold were recorded and studied during phonation and the playing of 3 instruments. The techniques of glottic opening, closure, configuration and function varied with the type of instrument and phonatory function. Singing was adversely affected by the vocal fold polyp but no harmful interaction occurred during wind/brass instrument playing. Down-stream loading in singers is at the laryngeal level and in wind/brass instrumentalists is at the embouchure. Preoperative voice therapy, phonomicrosurgery, and postoperative voice rest followed by voice therapy, succeeded in restoring her combined wind/brass instrumental and singing career.

Vestibular fold flap for post-cordectomy laryngeal reconstruction

The development of techniques causing fewer sequelae without compromising oncologic control has led to better phonation, breathing, and postoperative swallowing in patients submitted to cordectomy. The objective of the present study was to describe post-cordectomy laryngeal reconstruction with a vestibular fold flap and to analyze the resulting laryngeal functions. Prospective study. Ten patients, 9 males and 1 female, aged 45 to 75 years (mean, 64.5 years), were evaluated. The patients had squamous cell carcinomas in the glottic region and were treated surgically by laryngofissure and cordectomy with the use of a vestibular fold flap for laryngeal reconstruction. The patients were followed up for functional laryngeal analysis that consisted of videolaryngostroboscopy, endoscopic evaluation of swallowing, and voice recording for perceptive auditory analysis, and for computing purposes. No patients depended on tracheostomy during the late postoperative period. No stenosis, anterior synechia, granuloma, or laryngocele were detected, although 1 patient developed immobility in the median position of the operated hemilarynx, which, however, was not sufficient to impair the respiratory function. No alterations in the pharyngeal phase of swallowing were observed by endoscopic evaluation. Using the GRBAS scale, we observed moderate (30%) and severe (20%) dysphonia in 50% of the patients and grade 1 dysphonia (40%) or normal (10%) dysphonia in the remaining ones. Computing analysis revealed the following mean values: fundamental frequency of 177.5 Hz, jitter 1.11%, and shimmer 7.04%. We conclude that reconstruction with a vestibular fold flap permitted the maintenance of the laryngeal functions of breathing and airway protection during swallowing, as well as the maintenance of phonation function, providing perfect voice emission according to perceptive auditory or acoustic analysis in 1 patient and moderate or severe dysphonia in one half of the cases when technical faults occurred.