Vocal Fold Mass Research Articles

Impact of hydration on vocal loading using phonetogram measures

<p><strong>Background:</strong> Vocal loading is a phenomenon that affects the vocal folds and voice parameters. Prolonged vocal loading may cause vocal fatigue. Hydration is one of the easiest precautions to reduce the effect of vocal loading. Voice range profile is an analysis of a participant’s vocal intensity and fundamental frequency ranges. Speech range profile is a graphical display of frequency intensity interactions occurring during functional speech activity. Phonetogram software can analyse VRP and SRP.</p><p><strong>Methods:</strong> Total sixty normophonic participants (thirty male and thirty female) were included in this study. Phonetogram, version 4.40 by Tiger DRS, software used to measure the voice range profile and speech range profile. For VRP, participants were asked to produce vowel /a/ and a passage reading task was given for SRP measurement.</p><p><strong>Results:</strong> All sample recording were done at pre vocal loading task, VLT and after hydration. Parameter that were used to measure the effects were Fo-range, semitone, max-F, min-F, SPL range, max-I, min-I, area (dB). Result showed that after VLT all other parameters like Fo-range, semitone, max-F, min-F, SPL range, max-I, min-I, area (dB) in VRP and SRP were reduced except min-F VRP in male, min-I VRP and min-I SRP in both male and female participants. After hydration all other parameters were improved except max-F VRP and min-F VRP in female, max-I VRP, min-F VRP and area VRP.</p><p><strong>Conclusions:</strong> This study concluded that vocal loading has negative impact on vocal fold tissue and mass. </p>

Inflammatory Myofibroblastic Tumor of the Larynx: Report of a Case

PurposeInflammatory myofibroblastic tumor (IMT) is a rare tumor composed of mesenchymal myofibroblastic spindle cells enveloped by an inflammatory infiltrate. Historically, this tumor sparked debate regarding whether it was a true malignancy with metastatic potential or merely a locally destructive physiologic inflammatory response. Few reports of IMT exist in the recent literature, with the majority of cases occurring in the pediatric population and favoring the lungs. Here we present an exceedingly rare case of IMT involving the larynx of a 22-year-old female. ResultsA hemorrhagic and solid mass of the right true membranous vocal fold was excised and sent for histopathological assessment. Features of the surgical specimens were diagnostic for IMT. Intralesional steroid therapy was selected for additional treatment. Panendoscopy facilitated surveillance for any additional or recurrent lesions, of which there were none. At 11 months post-excision, follow-up MRI revealed symmetric vocal cords without evidence of any masses. ConclusionsAlthough rare, laryngeal IMT should be considered in any patient presenting with hoarseness due to a vocal fold mass. Based on the successful treatment of our patient, we suggest that our approach of surgical excision followed by intralesional corticosteroid injection may be an efficacious treatment approach for this rare tumor. However, more research is warranted to elucidate the most effective, safe, and cost-effective treatment approach.

Normative Speech Data in Professional Opera Singers- A Retrospective Study

The purpose of this study was to compare objective voice parameters for the professional opera singer population with KAYPENTAX CSL normative values. Medical records of students at an elite opera conservatory who came into the senior author's (RTS) office for a baseline evaluation were reviewed retrospectively. All subjects had no voice complaint and had not undergone voice surgery. Subjects with vocal fold mass and scar were excluded. All subjects had undergone objective voice measurements by one of three board certified speech-language pathologists using the KAYPENTAX CSL (computerized Speech Lab) protocol. Mean, standard deviation, median and range were compared with normative values provided by KAYPENTAX CSL. Twenty-seven elite opera conservatory students (11 females and 16 males, ages 21-29 years) were included in the study. There were significant differences between singers and normative values of KAYPENTAX CSL. Among men, the jitter, relative average perturbation and noise- to- harmonic ratio among singers were significantly lower than KAYPENTAX CSL normative values. Among the females, the shimmer percent of singers was significantly higher than KAYPENTAX CSL normative values. Our findings indicate that singers may have different normative voice parameters. However, further research is needed to confirm or refute these findings, and similar studies are needed for singers in other genres.

Presbylarynx: Is It a Sign of the Health Status of the Elderly?

Only a full understanding of how different diseases affect the same or different anatomical/functional entities, may provide a clue on how comorbidity should be taken into consideration. The aim of this study was to evaluate the chronic medical illnesses of an elderly population, in order to analyze potential correlation of specific comorbidities with presbylarynx. This case-control, prospective, observational, and cross-sectional study was carried out on consecutive subjects observed by otorhinolaryngology, in a tertiary center, from January to September 2020. The inclusion criteria were ability to report an accurate medical history and ≥65 years of age. The exclusion criteria were neurologic diagnoses, autoimmune disease, history of thoracic or head and neck surgery, cancer, radiotherapy, thyroid pathology, vocal fold mass lesions, acute laryngitis, or vocal fold paralysis. Based on videostroboscopy of the larynx, the patients were subdivided into two main groups: presbylarynx versus no presbylarynx. Health status was assessed by evaluation of chronic medical illnesses (individual diagnoses of chronic conditions plus Charlson comorbidity index [CCI]), functional status (Katz index of independence in activities of daily living and functional Ambulation ambulation classification), and emotional status (Geriatric Depression Scale). A total of 174 subjects (60 males; 114 females) were included (mean age=73.99 years; range 65-95 years). Presbylarynx was identified in 71 patients (41%). A statistically significant difference was found concerning diabetes mellitus type 2 (T2DM); P< 0.001), asthma or chronic obstructive pulmonary disease (COPD; P< 0.001), and psychiatric disorder (P< 0.001). The mean score of CCI between "presbylarynx" and "no presbylarynx" groups was statistically different (P= 0.021). Results showed an association between some functional dependence (P< 0.001), and mild or severe depression (P< 0.001) and the presence of presbylarynx. Presbylarynx may be considered a sign of the health status of the elderly. Based on CCI, It was found that patients with higher probability of 10-year mortality exhibit more endoscopic signs of presbylarynx. It was also found that patients with better scores in functionality scales exhibited less endoscopic findings compatible with presbylarynx. Among chronic medical illnesses, T2DM, asthma, or COPD may be considered risk factors for noticeable endoscopic signs of presbylarynx.

Impact of Instructed Laryngeal Manipulation on Acoustic Measures of Voice–Preliminary Results

Control of laryngeal muscles is required to manipulate pitch, volume, and voice quality. False vocal fold activity (FVFA) refers to the constriction and release of constriction of the false vocal folds. True vocal fold mass (TVFM) represents the cross-sectional thickness of the vocal folds. Larynx height (LH) refers to the vertical position of the larynx in the neck. To date, studies of voice control have examined the effects of these parameters separately. No study has investigated the impact of instructed systematic manipulation of these parameters on acoustic voice measures in vocally healthy trained subjects. This study examined the effects of systematically manipulating FVFA, TVFM, and LH on several acoustic voice measures. Twelve vocally trained speakers were instructed to use specific techniques to achieve experimental conditions of constriction and release of constriction of FVFA, thicker and thinner TVFM, and normal and low LH. Each condition was implemented in combination with manipulating the other parameters. Voice recordings of sustained vowel /a/ and Rainbow Passage were obtained for all laryngeal manipulation conditions and underwent acoustic analyses for fundamental frequency (F0), signal typing, harmonics-to-noise ratio (HNR), cepstral peak prominence (CPP), and vocal relative intensity. Constricted FVFA caused more aperiodicity in the signals, lower CPP, and lower vocal relative intensity than release of constriction. Thicker TVFM resulted in significantly higher CPP and vocal relative intensity than thinner TVFM. Modifying TVFM did not affect F0 and HNR. Low LH had significantly lower F0 but did not impact on HNR, CPP, and intensity. The effects of systematic manipulation of each laryngeal parameter resulted in independent acoustic effects without measurable interaction. Release of constriction of FVFA, thicker TVFM, and low LH were configurations that resulted in more optimal acoustic signals.

Laryngology Education in Otolaryngology Residency Programs – A Pilot Study

To evaluate resident exposure to laryngology during otolaryngology residency. An anonymous, web-based, multiple choice, electronic questionnaire was sent to all 125 accredited otolaryngology training programs in the United States to distribute to otolaryngology senior residents (postgraduate year [PGY]-4, PGY-5). Sixty-four residents (33 PGY-4 and 31 PGY-5) responded to the survey. 85.9% had had training in strobovideolaryngoscopy. Only 7.8% of residents had had training in performing or interpreting objective voice measurements, and 26.6% had had training in performing or interpreting laryngeal electromyography. 42.2% of residents had participated in a laryngeal surgical laboratory. Only 19.4% of residents had attended a national laryngology meeting during the preceding 12 months. 92.2% of residents reported that their program had a laryngologist attending, 95.3% had a speech-language pathologist in their department, and 21.9% had a laryngology fellow. 87.5% of residents reported that they do not have to transfer any laryngeal cases to another facility. Exposure to microdirect laryngoscopy, vocal fold mass excision with microflap technique, type I thyroplasty, and subglottic stenosis repair was (100%, 92.2%, 84.4%, and 96.9%, respectively). 54.7% of residents were exposed to arytenoidectomy, and 14.1% of residents were exposed to reduction of arytenoid dislocation/subluxation. 45.3% of residents reported that they had an interest in music, 25% had an interest in singing, 14.1% had an interest in acting. More comprehensive laryngeal education could be achieved during otolaryngology residency by increasing exposure to objective voice measurements, laryngeal electromyography, and laryngeal surgery, especially arytenoid procedures including dislocation/subluxation reduction and arytenoidectomy.

Lung volume affects the decay of oscillations at the end of a vocal emission

At the end of a vocal emission, when the voicing is not interrupted by a laryngeal closure, a damped oscillatory motion of each vocal fold can be observed after the last contact phase of the two fold edges on the midline. It can be precisely analysed using a measure of transglottal light intensity (photoglottography). Actually, during modal phonation, the vocal oscillator mainly comprises two components: the vocal folds themselves and the vibrating air mass. A simple calculation suggests that the internal air mass set into vibration is larger than the vocal fold mass. In order to investigate the effect of the vibrating air mass, a voicing protocol was elaborated for validly measuring and comparing damping characteristics in two conditions: at high and at low lung volume, ceteris paribus. Glottal area, intraoral pressure, electroglottogram and sound were recorded simultaneously. Elaborated voicing protocol consisted in series of fast repetitions (3–4 s−1) of the vowel /ε/, each vocalization being followed by an abrupt bilabial occlusion with complete airflow interruption. The average difference in lung volume between the two conditions is approximately 2410 mL. The results show that the decay of vocal fold oscillation is influenced by the amount of lung air that is set into oscillation. A reduction of the air volume leads to a significant increase in the rate of decay, thus voicing at low lung volume requires more energy, which is of importance for voice hygiene.

Immediate effects of water resistance therapy on patients with vocal fold mass lesions

IntroductionSemi-occluded vocal tract exercises, such as water resistance therapy (WRT), are widely used in voice therapy. However, the potential positive effects of such a therapy on vocal fold oscillation patterns in patients indicating a need for phonomicrosurgery have not yet been explored. The presented study aims to analyze the effect of WRT in patients suffering from vocal fold mass lesions.Materials and methodsEight participants with vocal fold mass lesions were asked to sustain a phonation on the vowel /i/ at a comfortable loudness and a fundamental frequency of 250 Hz (females) or 125 Hz (males). During phonation the subjects were simultaneously recorded with transnasal high-speed videoendoscopy (HSV, 20.000 fps), electroglottography, and audio signals. These subjects then performed a WRT (phonation in a silicone tube of 30 cm length, 5 cm below the water surface) for 10 min. Repeated measurements of sustained phonation were performed 0, 10, and 30 min after exercising. From the HSV data the glottal area waveform (GAW) was segmented and GAW parameters were computed.ResultsDuring WRT there was an increase of the GAW related open quotient and closing quotient. Immediately after WRT, there was a drop of both values followed by a rise of these parameters up to 30 min after the intervention. Furthermore, there was no correlation between GAW and electroglottographical open quotients.ConclusionsThe effects observed after a single session of WRT on participants with vocal fold mass lesions showed a similar pattern to vocal fatigue.

Vocal fold oscillation pattern changes related to loudness in patients with vocal fold mass lesions

IntroductionVocal fold mass lesions can affect vocal fold oscillation patterns and therefore voice production. It has been previously observed that perturbation values from audio signals were lower with increased loudness. However, how much the oscillation patterns change with gradual alteration of loudness is not yet fully understood.Material and methodsEight patients with vocal fold mass lesions were asked to perform a glide from minimum to maximum loudness on the vowel /i/, ƒo of 125 Hz for male or 250 Hz for female voices. During phonation the subjects were simultaneously recorded with transnasal high speed videoendoscopy (HSV, 20,000 fps), electroglottography (EGG), and an audio recording. Based on the HSV material the Glottal Area Waveform (GAW) was segmented and GAW parameters were computed.ResultsThe greatest vocal fold irregularities were observed at different values between minimum and maximum sound pressure level. There was a relevant discrepancy between the HSV and EGG derived open quotients. Furthermore, the EGG derived sample entropy and GAW values also evidenced different behavior.ConclusionsThe amount of vocal fold irregularity changes with varying loudness. Therefore, any evaluation of the voice should be performed under different loudness conditions. The discrepancy between EGG and GAW values appears to be much stronger in patients with vocal fold mass lesions than those with normal physiological conditions.Level of evidence4.

Vocal fold scars: a common classification proposal by the American Laryngological Association and European Laryngological Society.

Vocal fold scar is one the most challenging benign laryngeal pathologies. The purpose of this paper is to propose a classification that will allow for a common description of this entity between laryngologists, prevent discrepancies in interpretation, allow for comparison of related studies, and offer a training tool for young laryngologists. Based on the depth and laterality of scarring, we propose 4 types: type I, characterized by atrophy of lamina propria with/without affected epithelium; type II, where the epithelium, lamina propria, and muscle are affected; type III, where the scar is located on the anterior commissure; type IV, which includes extended scar formation in both anteroposterior and rostro-caudal axis with significant loss of vocal fold mass. We believe that our proposal is comprehensive and encompasses all existing iatrogenic and non-iatrogenic etiologies in a simple and concise manner. It also serves its purpose as a descriptive, comparative, and training tool.

Efficacy of Videostroboscopy and High-Speed Videoendoscopy to Obtain Functional Outcomes From Perioperative Ratings in Patients With Vocal Fold Mass Lesions

A major limitation of comparing the efficacy of videostroboscopy (VS) and high-speed videoendoscopy (HSV) is the lack of an objective reference by which to compare the functional assessment ratings of the two techniques. For patients with vocal fold mass lesions, intraoperative measures of lesion size and depth may serve as this objective reference. This study compared the relationships between the pre- to postoperative change in VS and HSV visual-perceptual ratings to intraoperative measures of lesion size and depth. Prospective visual-perceptual study with intraoperative measures of lesion size and depth. VS and HSV samples were obtained preoperatively and postoperatively from 28 patients with vocal fold lesions and from 17 vocally healthy controls. Two experienced clinicians rated amplitude, mucosal wave, vertical phase difference, left-right phase asymmetry, and vocal fold edge on a visual-analog scale using both imaging techniques. The change in perioperative ratings from VS and HSV was compared between groups and correlated to intraoperative measures of lesion size and depth. HSV was as reliable as VS for ratings of amplitude and edge, and substantially more reliable for ratings of mucosal wave and left-right phase asymmetry. Both VS and HSV had mild-moderate correlations between change in perioperative ratings and intraoperative measures of lesion area. Change in function could be obtained in more patients and for more parameters using HSV than VS. Group differences were noted for postoperative ratings of amplitude and edge; however, these differences were within one level of the visual-perceptual rating scale. The presence of asynchronicity in VS recordings renders vibratory features either uninterpretable or potentially distorted and thus should not be rated. Amplitude and edge are robust vibratory measures for perioperative functional assessment, regardless of imaging modality. HSV is indicated for evaluation of subepithelial lesions or if asynchronicity is present in the VS image sequence.

Clinical analysis of vocal fold firbrous mass

To explore the character of laryngoscopy finding, voice, and therapy of vocal fold fibrous mass. Clinical data, morphology, voice character, surgery and pathology of 15 cases with vocal fold fibrous mass were analyzed. The morbidity of vocal fold fibrous mass might be related to overuse of voice and laryngopharyngeal reflex. Laryngoscopy revealed shuttle line appearance, smoothness and decreased mucosal wave of vocal fold. These patients were invalid for voice training and might be improved by surgery, but recovery is slow. The morbidity of vocal fold fibrous mass might be related to overuse of voice and laryngopharyngeal reflex. Conservative treatment is ineffective for this disease, and surgery might improve.

Biomechanical Description of Phonation in Children Affected by Williams Syndrome

The voice of persons with Williams syndrome (WS) is described as hoarse with a deep and unstable fundamental frequency (f0). These observations may be justified by the deficit of elastin due to a haplo-insufficiency in the ELN gene characteristic of the syndrome. In view of the possible relationship between elastin deficit and dysphonia, a study of the dynamic function of WS phonation was conducted by means of biomechanical analysis. In order to assess the presence of dysphonic symptoms and their degree of severity, the biomechanical description of WS phonation has been evaluated in terms of dynamic mass and viscoelasticity estimates. Glottal biomechanical features such as vocal fold dynamic mass, stiffness, unbalances, and laryngeal tremor of 12 children with WS aged 3 to 8 years (five girls and seven boys) have been estimated and compared with the normative phonation of 97 children with typical development (53 girls and 44 boys). The results show that WS children show differences in f0, vocal fold mass and stiffness, phonation stability, glottal contact defects, and laryngeal tremor. The conclusions may help to make a more complete view of the connection between WS and dysphonia based on objective assessments.

Dynamics of the Driving Force During the Normal Vocal Fold Vibration Cycle

Intraglottal pressure is the driving force of vocal fold vibration. Theoretically, simultaneous quantification of glottal area and transglottal airflow allows the calculation of the intraglottal pressure waveform during a single vibration cycle. In this study, we show that, by combining photoglottography (transglottal light transmission) and airflow (Rothenberg mask) measurements during sustained vocal emissions in vivo, the intraglottal pressure wave can be approximated in a way similar to what has been done in models. The results confirm in vivo that the intraglottal pressure is systematically larger during the opening phase than during the closing phase, so that over one whole cycle, the driving force performs net positive work, accounting for sustained vocal fold motion. A component of this driving force asymmetry is related to vocal tract inertance, which also accounts for the skewing of the airflow waveform compared with the area waveform. Furthermore, the intraglottal pressure ratio (opening:closing) increases with voicing intensity, reaches a maximum around 76 dB, and significantly decreases at higher intensities. This rise and fall suggests that there is a range of intensity values in which, mechanically, a maximum of the driving force is imparted to the vocal fold mass. This finding could have implications for voice economy in professional speakers.

Pitch Strength as an Outcome Measure for Treatment of Dysphonia

Measurement of treatment outcomes is critical for the spectrum of voice treatments (ie, surgical, behavioral, or pharmacological). Outcome measures typically include visual (eg, stroboscopic data), auditory (eg, Consensus Auditory-Perceptual Evaluation of Voice; Grade, Roughness, Breathiness, Asthenia, Strain), and objective correlates of vocal fold vibratory characteristics, such as acoustic signals (eg, harmonics-to-noise ratio, cepstral peak prominence) or patient self-reported questionnaires (eg, Voice Handicap Index, Voice-Related Quality of Life). Subjective measures often show high variability, whereas most acoustic measures of voice are only valid for signals where some degree of periodicity can be assumed. However, this assumption is often invalid for dysphonic voices where signal periodicity is suspect. Furthermore, many of these measures are not useful in isolation for diagnostic purposes. We evaluated a recently developed algorithm (Auditory Sawtooth Waveform Inspired Pitch Estimator-Prime [Auditory-SWIPE']) for estimating pitch and pitch strength for dysphonic voices. Whereas fundamental frequency is a physical attribute of a signal, pitch is its psychophysical correlate. As such, the perception of pitch can extend to most signals irrespective of their periodicity. Post hoc analyses were conducted for three groups of patients evaluated and treated for voice problems at a major voice center: (1) muscle tension dysphonia/functional dysphonia, (2) vocal fold mass(es), and (3) presbyphonia. All patients were recorded before and after surgical/behavioral treatment for voice disorders. Pitch and pitch strength for each speaker were computed with the Auditory-SWIPE' algorithm. Comparison of pre- and posttreatment data provides support for pitch strength as a measure of treatment outcomes for dysphonic voices.

Are Instructions to Manipulate Specific Parameters of Laryngeal Function Associated with Auditory-Perceptual Ratings of Voice Quality in Nondisordered Speakers?

This preliminary study investigated whether auditory-perceptual judgments of voice quality by experienced speech language pathologists were associated with instructions given to speakers to manipulate specific laryngeal postures. Experimental, within-subject design. Nine speakers were instructed and trained to manipulate three vocal parameters implicated in functional voice disorders-false vocal fold constriction, vocal fold mass, and larynx height-while reading a standard passage. Experienced judges rated these standard passages in terms of the widely used perceptual voice qualities breathiness, roughness, vocal strain, glottal fry, tone onset, tone color, loudness, and pitch. Between-subject factorial analysis of variance, controlling for judge unreliability, revealed some evidence that perceptual judgments are strongly associated with underlying laryngeal muscle activity that can then serve clinical planning of goals for intervention. Eta2 effect sizes were large for all dependent measures, ranging from 0.39 for pitch to 0.77 for strained. Although these results are encouraging, they were obtained under ideal conditions. Further research is warranted.

Comparison of Videostroboscopy to Stroboscopy Derived From High-Speed Videoendoscopy for Evaluating Patients With Vocal Fold Mass Lesions.

Videostroboscopy (VS) uses an indirect physiological signal to predict the phase of the vocal fold vibratory cycle for sampling. Simulated stroboscopy (SS) extracts the phase of the glottal cycle directly from the changing glottal area in the high-speed videoendoscopy (HSV) image sequence. The purpose of this study is to determine the reliability of SS relative to VS for clinical assessment of vocal fold vibratory function in patients with mass lesions. VS and SS recordings were obtained from 28 patients with vocal fold mass lesions before and after phonomicrosurgery and 17 controls who were vocally healthy. Two clinicians rated clinically relevant vocal fold vibratory features using both imaging techniques, indicated their internal level of confidence in the accuracy of their ratings, and provided reasons for low or no confidence. SS had fewer asynchronous image sequences than VS. Vibratory outcomes were able to be computed for more patients using SS. In addition, raters demonstrated better interrater reliability and reported equal or higher levels of confidence using SS than VS. Stroboscopic techniques on the basis of extracting the phase directly from the HSV image sequence are more reliable than acoustic-based VS. Findings suggest that SS derived from high-speed videoendoscopy is a promising improvement over current VS systems.

The influence of vocal fold mass lesions on the passaggio region of professional singers.

In professional classical singing, an even voice quality throughout the entire singing voice range is essential. Transitions between vocal registers (passaggio) are the technically most challenging aspects in classical singing. It is hypothesized that they are most affected by vocal fold mass lesions (VFML). Cohort study. In this study, the effect of VFML on vocal fold vibration in the passaggio regions was analyzed in four female and three male singers suffering from organic dysphonia. The singers were asked to sing an ascending glissando through the passaggio regions, before and after treatment. The vocal fold vibration was documented with transnasal endoscopic high-speed imaging recordings at 20,000 frames per second, supplemented by synchronized acoustic and electroglottographic recordings. Major irregularities were found in the passaggio region of four singers before treatment, whereas the respective phonations below the passaggio were almost regular. In two female singers only the upper, but not the lower passaggio was affected. In all four of these participants, the passaggio region was more regular after treatment. In the remaining three participants, the VFML showed no effect on the passaggio region. However, the singers' ability to reach higher pitches was impaired, but was resolved after treatment. The data in this case study strongly suggest that the passaggio region could be affected by VFML, even if phonation outside the passaggio regions is unimpaired. When planning surgical procedures for professional singers, clinical examination protocols should therefore include phonatory tests across the passaggio regions. 4 Laryngoscope, 127:1392-1401, 2017.

Gender differences in onabotulinum toxin A dosing for adductor spasmodic dysphonia.

The objective of this study was to determine the influence of gender on onabotulinum toxin A dosing for the treatment of adductor spasmodic dysphonia symptoms. Retrospective review. A chart review of the senior author's database of botulinum toxin injections was performed. Patients diagnosed with adductor spasmodic dysphonia who received onabotulinum toxin A (BoNTA) injections to the thyroarytenoid muscle for at least 5 years were included for study. Patients who received alternate formulations of botulinum toxin (Myobloc, Dysport, or Xeomin) and patients with alternate diagnoses, such as abductor spasmodic dysphonia, tremor, and oromandibular dystonia, were excluded. The average BoNTA dose was calculated for each patient and statistical analysis was performed comparing the male and female groups. A total of 201 patients (52 males and 149 females) met inclusion criteria. The average follow-up times for the male and female groups were 10.2 ± 3.6 and 11.1 ± 4 years, respectively. The average BoNTA doses for the male and female groups were 0.6 ± 0.42 U and 1.3 ± 1.1 U, respectively. Statistical analysis was performed using an independent samples two-tailed t test yielding a P value of .0000000002. A large effect size was noted with Cohen's d = 0.85. The data from this retrospective chart review reveal a statistically and clinically significant correlation between female gender and higher average BoNTA dose for symptom control in adductor spasmodic dysphonia. Explanations for this observation are speculative and include a possible inverse relationship between optimal BoNTA dose and vocal fold mass and possibly greater neutralizing antibody formation among female patients. 4. Laryngoscope, 127:1131-1134, 2017.

The use of narrow band imaging for the detection of benign lesions of the larynx.

In the cases of uncertainty, even if the patient has no complaints about his voice quality, sometimes, benign vocal fold mass lesions are removed to exclude malignancy with the risk of resultant dysphonia. Narrow Band Imaging (NBI) enables a specific visualization of vessel structures in the superficial tissue. Benign lesions of the larynx are frequently characterized by abnormal vessel configuration or an absence of vessels in the area of the lesion. It was hypothesized that, in the primary diagnosis of patients with these benign lesions, the combination of white light and NBI endoscopy enables a better detection compared with white light endoscopy alone. Twenty-nine patients (eight patients with a cyst on a vocal fold, eight with a polyp, seven with a Reinke´s edema, two with a leukoplakia, one with a carcinoma, one with a granuloma, and two without any pathologic finding) were examined with normal white light and NBI endoscopy. 87 video sequences (29 white, 29 NBI, and 29 white/NBI) were generated and randomized and presented to 20 otolaryngologists who rated the videos in terms of the suspected diagnosis. Results were compared with the histopathologic findings of microlaryngoscopy. The probability of detecting benign lesions of the vocal folds was higher using NBI in combination with white light endoscopy compared with white light endoscopy alone. For vocal fold cysts, this difference was statistically significant. NBI endoscopy in combination with normal white light endoscopy improves the detection rate of benign lesions of the larynx, especially of vocal fold cysts.