Abnormal Vocal Fold Research Articles

Treatment of Recurrent Vocal Fold Hemorrhage in Ehlers‐Danlos Syndrome

Objectives: Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders. Generalized tissue and vascular fragility underlie many physical findings and resultant complications from the syndrome. We present a patient with vascular subtype of EDS with recurrent vocal fold hemorrhage who underwent successful treatment by microflap excision and CO2 laser ablation of true vocal fold microaneurysm. This is the first case report of a successful therapeutic laryngeal intervention for an EDS patient. Methods: Case report of one patient at a single institution. Results: A patient with hemorrhagic polyp after intubation underwent standard microscopic direct laryngoscopy and excision of a hemorrhagic polyp on her right true vocal fold. Hemorrhage recurred, and the patient underwent repeat microflap excision with identification of and CO2 laser ablation of a vocal fold microaneurysm. The patient experienced resolution of hemorrhage with resolution of dysphonia. Conclusions: This case report, the first documented therapeutic intervention for a vocal fold abnormality in EDS, highlights not only the care that should be taken when intubating patients with EDS but also the importance of considering additional measures needed to prevent recurrence of hemorrhage in patients with this connective tissue disorder.

Effect of Vocal Fold Injury Location on Vibratory Parameters in Excised Canine Larynges

To investigate the effect of vocal fold injury location on vibratory amplitude and lateral phase difference. Repeated measures with each excised canine larynx serving as own control. Basic science study conducted in university laboratory. Vocal fold vibration of excised canine larynges was recorded with a high-speed camera before and after inducing vocal fold injury at 1 of 5 locations: anterior, middle, posterior, medial, or superior. Medial and superior injuries were created within the middle third of the vocal fold. Five larynges were used for each of the 5 injury locations. Kymography was performed at the midpoint of the vocal folds for each video. Pre- and postinjury vibratory amplitude and lateral phase difference were compared for each location. The anterior and medial injuries produced consistent decreases in vibratory amplitude. Middle and posterior injuries might slightly decrease amplitude. Superior injuries seemed to have no effect on amplitude. Anterior and medial injuries induced phase asymmetry between the right and left vocal folds. Middle injuries appeared to affect phase difference slightly, whereas posterior and superior injuries had no effect. Injury to the anterior or medial portions of the vocal fold may be most likely to cause abnormal vocal fold vibration. Using caution in these locations during phonosurgery may favor superior postoperative vocal outcomes.

Paradoxical vocal fold motion: respiratory retraining to manage long-term symptoms

Paradoxical vocal fold motion (PVFM) is a laryngeal disorder characterized by abnormal adduction of the vocal folds during respiration. It is caused by a multitude of etiologies and their interactions. In the current study, a 24-year-old female patient with a 12-year complaint of shortness of breath was diagnosed with paradoxical vocal fold motion following nasal endoscopy, spirometry testing and detailed case history analysis. She had no history or indication of laryngopharyngeal reflux or chronic cough. She performed respiratory retraining exercises three to four times daily for a period of four weeks, and continued daily exercises for two additional months as needed. After four weeks of treatment, abnormal vocal fold adduction continued to be seen on endoscopy and the patient was mildly symptomatic. One month post-treatment, there was no abnormal vocal fold adduction and the patient reported rare shortness of breath. At three months post-treatment, there was no abnormal vocal fold adduction and the patient no longer reported shortness of breath. She reported normal breathing with no symptoms one year later. The results suggest that non-pulmonary related shortness of breath treated with respiratory retraining can effectively eliminate dyspnea in patients with long term breathing difficulties caused by paradoxical vocal fold motion. Resolution may require treatment over an extended period of time.

Organ preservation surgery for laryngeal squamous cell carcinoma: Low incidence of thyroid cartilage invasion

Determine the incidence and risk factors for thyroid cartilage invasion in early and midstage laryngeal cancer. Retrospective review. A retrospective review was carried out of tumors treated by open surgery with at least partial resection of thyroid cartilage from 1992 to 2008. Preoperative laser, radiation therapy, or chemotherapy were excluded. Tumor stage, anterior commissure involvement, vocal fold (VF) mobility, computed tomography (CT) scan, and pathological cartilage status were recorded. Three hundred fifty-eight patients were treated for tumors staged cT1 (32%), cT2 (53%), and cT3 (15%) by vertical (26%), supracricoid (62%), or supraglottic partial laryngectomy (12%). The thyroid cartilage was invaded in 8.9% of cases. Abnormal VF mobility was significantly related to thyroid cartilage invasion (Fisher exact test, P = .0002). Neither anterior commissure involvement nor CT scan were related to cartilage invasion. Thyroid cartilage invasion was rare but increased if VF mobility was impaired. This has implications for transoral resection, which unlike open surgery avoids unnecessary cartilage resection.

Incidence of structural vocal fold abnormalities associated with vocal fold polyps

SummaryPhonotrauma is considered the main cause of vocal fold polyps (VFP). However, the authors believe that an underlying anatomical deviation could render the vocal folds more susceptible to such trauma.AimTo prove this hypothesis a retrospective chart review was carried out to correlate the surgical findings of patients with VFP.Material and MethodsThe charts of thirty-three patients who underwent surgery for excision of VFP were reviewed: 21 had right VFP, 10 had left VFP and 2 had bilateral lesions.ResultsAssociated lesions were reported in 27 patients (14 lesions on the opposite VF and 13 on the ipsilateral VF): 10 opposite nodules, 12 sulcus vocalis, 3 cysts, and 2 capillary engorgement.Discussion and ConclusionsThe high incidence of associated anatomical lesions to the VF (63%) suggests that patients with these minor underlying anatomical deviations are more vulnerable to vocal abuse, probably because they present abnormal glottic closure and an irregular vibratory margin.

Preliminary Evaluation of Stroboscopy System Using Multiple Light Sources for Observation of Pathological Vocal Fold Oscillatory Pattern

Laryngostroboscopy is used to check the oscillatory patterns of the vocal folds. However, the use of one single flash timing cannot give a clear view of abnormal vocal fold oscillations that have multiple fundamental frequencies. Visualization of such complex vocal fold movements will be helpful in the diagnosis of diplophonia, a pathological condition in which the vocal folds produce multiple tones at the same time. We developed a new stroboscopy-based technique using multiple light-emitting diodes (LEDs) and image analysis. Specific flash timings for each LED, suitable for accurate visualization, were determined on a computer according to an algorithm based on frequency analysis. The image analysis extracted the necessary parts of the captured images to yield a clear slow-motion view of the oscillations. The series of visualization procedures took advantage of the narrow-spectrum light property of LEDs, thereby yielding a degradation-free picture. Feasibility tests using a mechanical vocal fold model demonstrated that this computer-assisted system allows observation of the pathological oscillatory patterns as one single video. They would not be clearly visualized by conventional stroboscopy. Because of its relatively simple use and inexpensive construction, the proposed technique can become one potential option for clinical assessment of pathological vocal fold oscillations.

Predictors of Laryngeal Complications in Patients Implanted with the Cyberonics Vagal Nerve Stimulator

Since its approval by the US Food and Drug Administration in 1997 for management of medically refractory seizures, more than 35,000 patients have been implanted with the Cyberonics vagal nerve stimulator. Preliminary reports described transient vocal changes in the majority of subjects, which were thought to be short-term. However, these reports were for the most part based upon perceptual evaluations by the subjects themselves. Later reports described possibly more permanent recurrent laryngeal nerve injury and recommended measuring the nerve diameter to use the safest spiral cuff electrode. To date, no study has systematically evaluated vocal fold mobility in subjects before and after implantation. The objectives of this study were to determine the true incidence of both short- and long-term recurrent laryngeal nerve injuries and determine whether there are any potential indicators to predict in which patients long-term nerve deficits may develop. Thirteen subjects underwent preimplantation laryngeal electromyography, videolaryngoscopy, measurement of the maximum phonation time, Voice Handicap Index determination, and Consensus Auditory-Perceptual Evaluation of Voice. Two weeks after implantation, all subjects underwent videolaryngoscopy. Three months after implantation and activation of the device, all subjects were reevaluated. Six of the 13 subjects had significant vocal fold mobility abnormalities at 2 weeks. Significant electromyographic abnormalities were detected before implantation in 5 subjects. All 5 of these subjects, at 3 months after implantation, had prolonged left vocal fold paresis. The authors conclude that perioperative vocal fold paresis occurs in approximately 50% of subjects. Further, laryngeal electromyography performed before implantation of the vagal nerve stimulator is a statistically significant predictor (p < .05) of which patients may be at risk for extended vocal fold abnormalities. Possible explanations for this phenomenon are offered. Surgical modifications to limit vagal nerve injury are offered.

The Utility of Evaluating True Vocal Fold Motion Before Thyroid Surgery

The objective of this study was to evaluate the utility of screening laryngoscopic examination in evaluating vocal fold (VF) mobility before thyroid surgery. The authors conducted a retrospective chart review of 340 patients who have undergone thyroid surgery from January 1998 to June 2005 and had preoperative laryngoscopy by mirror, fiberoptic, or videostroboscopic examination. Reports of preoperative voice change or complaint and reports of preoperative VF examination, including the method of examination, were recorded. For patients with VF motion impairment, reports of the intraoperative condition of the recurrent laryngeal nerve (RLN), preoperative diagnosis based on fine needle aspiration, and final postoperative histopathologic examination results were recorded. Twenty-two patients were found to have preoperative VF motion impairment, of which seven (32%) patients were asymptomatic with no detectable subjective or objective voice problems. This differs significantly from the hypothesis that patients with VF motion impairment are always symptomatic (P=.009). Using voice symptoms as a screening test to predict VF motion impairment in 340 patients reveals that the sensitivity was 68%, specificity was 91%, positive predictive value (PPV) was 31%, and negative predictive value (NPV) was 98%. Among the 22 patients with preoperative VF motion impairment, five (72%) of the seven asymptomatic patients had benign, slowly progressive disease on their final histopathology reports. Six of these asymptomatic patients had their preoperative VF evaluation by fiberoptic examination, whereas one patient had indirect mirror laryngoscopy. Of 22 patients with preoperative VF motion impairment, five (22.5%) patients had abnormal VF mobility contralateral to the thyroid lesion on their preoperative evaluation, and only two of them had nerve injury reported after a previous thyroid surgery. This result differs significantly from the hypothesis that impaired mobility is ipsilateral to the side of the lesion (P=.05). Patients without voice complaints can have VF motion impairment. Patients can also have VF motion impairment contralateral to the thyroid lesion. Preoperative VF examination helps counsel patients appropriately about the risks of surgery and helps outline a plan for the extent of surgery while minimizing the medicolegal ramifications of iatrogenic RLN injury.

Voice Abnormality in Adults with Congenital and Adult-Acquired Growth Hormone Deficiency

Adult males with congenital, untreated, severe GH deficiency (GHD) due to genetic GHRH receptor deficiency exhibit distinctive, high-pitched, and raspy voice characteristics. To determine the physical underpinning of this phenomenon, we performed voice recordings, translarynx impedance measurements, spectral analysis, and estimates of spectral complexity [approximate entropy (ApEn)] in four affected men. Results were compared with those obtained in four men with untreated adult-onset GHD and a normal male population. Congenital GHD subjects had a high-pitched voice with a fundamental frequency typical of normal females (174-266 Hz). Their frequency spectra were characterized by abnormal harmonics, with reversal/interruption of the normal amplitude decay among higher-order harmonics, findings consistent with a creaky quality of the voice. Patients with adult-onset GHD, acquired at ages 31, 38, and 40 yr, had a normal male pitch (fundamental frequency, 117-154 Hz) but pathologically low ApEn values, corresponding to a breathy quality of the voice and suggesting abnormal vocal fold function. A fourth patient who acquired GHD at age 22 yr had a pitch intermediate between male and female, high ApEn, and a spectral pattern similar to the congenital GHD patients. This study demonstrates an effect of GH on laryngeal size and vocal fold compliance that results in a high pitch and disordered spectral quality. The time of onset of GHD determines which type of abnormality predominates.

Nonsurgical Management of Pediatric Vocal Fold Nodules

Pediatric vocal fold nodules are challenging to diagnose and treat. Making an accurate diagnosis in the office usually requires fiberoptic laryngoscopy in awake patients, which is not tolerated by all patients (or parents!). There is a lack of firm agreement about what constitutes a vocal fold abnormality in a child because a pediatric larynx normally looks different than an adult one. Evenwhenaccurately identified, there is not a common classification scale for the extent or severity of pediatric vocal fold nodules or their impact on communication. To compound the difficulties of studying this entity, many clinicians believe that vocal fold nodules are self-limiting, resolving at puberty, so that earlier investigationor intervention is considered“unnecessary.” In this article, I describe the basic pathologic features of vocal fold nodules, the options for diagnosis and management, and then discuss the pros and cons of the hypothesis that they are best managed without surgery.

Severe obstructive airway disorders and diseases: vocal fold dysfunction.

Vocal Fold Dysfunction is a syndrome characterized by abnormal adduction of the focal folds during inspiration and is the cause of a wide spectrum of clinical manifestations ranging from mild inspiratory stridor to an inability to move any air. Patients present with varying degrees of intermittent respiratory difficulty, the most severe caused by intense laryngospasm. Distinguishing Vocal Fold Dysfunction from Refractory Asthma is important to avoid unnecessary pharmacotherapy and intubation. The diagnosis of Vocal Fold Dysfunction can only be made with certainty by flexible fiberoptic laryngoscopy while the patient is symptomatic. Pulmonary function studies and a lack of response to bronchodilators may provide clues to the diagnosis. Most patients with the condition can be managed by speech therapy and the use of breathing strategies that eliminate the abnormal vocal fold movement. Chronic laryngeal irritation may be a trigger for Vocal Fold Dysfunction and conditions such as laryngopharyngeal reflux disease should be aggressively managed in this patient population.

Integrated analyzer and classifier of glottographic signals.

Electroglottography (EGG) and photoglottography (PGG) are two plausible methods to study voice production for monitoring the patterns of laryngeal vibrations. It has been suggested that measures such as open quotient and speed quotient calculated from glottographic signals can provide useful information regarding pathological phonation. In this paper, an integrated analyzer and classifier of glottographic signals was implemented. The system makes it possible to calculate the measures from digitized EGG and PGG signals automatically in order to examine vocal fold abnormality. The system developed several techniques to extract features from glottographic signals and proposed a statistical classification method that can possibly aid the diagnosis process. To check the reliability of the system, a training set and a test set of glottographic signals from normal people and patients with recurrent/superior laryngeal paralysis were analyzed and classified by the system. The results showed that the system is a useful tool for quantitative study of phonatory pathophysiology and can be used by the examiner who is interested in the clinical examination of glottographic signals. Moreover, glottographic techniques may have some clinical applications in the quantitative documentation of phonatory function in patients with voice disorders but requires further evaluation before clinical application.

Altered laryngeal function following thyroidectomy.

The laryngograph was used to record and compare the voice changes in 11 thyroidectomy patients and 14 controls. The frequency histogram was studied and the change in its spread following surgery used to identify abnormal vocal fold movements due to recurrent laryngeal nerve damage. It also demonstrated changes which occur in thyroidectomy patients and not in patients having other operations. The possible causes include external laryngeal nerve damage.