Voice Dysfunction Research Articles

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

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

Voice dysfunction in dysarthria: application of the Multi-Dimensional Voice Program™

Phonatory dysfunction is a frequent component of dysarthria and often is a primary feature noted in clinical assessment. But the vocal impairment can be difficult to assess because (a) the analysis of voice disorder of any kind can be challenging, and (b) the voice disorder in dysarthria often occurs along with other impairments affecting articulation, resonance, and respiration. A promising assessment tool is multi-parameter acoustic analysis, such as the Multi-Dimensional Voice Program™ (MDVP). Part 1 of this paper recommends procedures and standards for the acoustic analysis of voice, including (1) selection of the sample to be analyzed, (2) signal quality requirements, (3) availability of normative data for both genders and different ages of speakers, (4) reliability of analysis, and (5) correlation of acoustic results with results from other methods of analysis. In Part 2, acoustic data are reviewed for the dysarthria associated with Parkinson disease (PD), cerebellar disease, amyotrophic lateral sclerosis (ALS), traumatic brain injury (TBI), unilateral hemispheric stroke, and essential tremor. Tentative profiles of voice disorder are described for these conditions. These profiles may serve as hypotheses for future research. Although several issues remain to be resolved in the acoustic analysis of voice disorder in dysarthria, steps can be taken now to promote the reliability, validity, and clinical utility of such analyses. Learning outcomes (1) As a result of this activity, the participant will be able to describe ways in which an optimal multi-dimensional analysis of voice can be performed with modern acoustic analysis systems. (2) As a result of this activity, the participant will be able to apply multi-dimensional acoustic analysis of voice to individuals who have a dysarthria-related voice disorder. (3) As a result of this activity, the participant will be able to identify major sources of normative data on the Multi-Dimensional Voice Program.

Software corrections of vocal disorders

We discuss how vocal disorders can be post-corrected via a simple nonlinear noise reduction scheme. This work is motivated by the need of a better understanding of voice dysfunctions. This would entail a 2-fold advantage for affected patients: Physicians can perform better surgical interventions and on the other hand researchers can try to build up devices that can help to improve voice quality, i.e. in a phone conversation, avoiding any surgical treatment. As a first step, a proper signal classification is performed, through the idea of geometric signal separation in a feature space. Then through the analysis of the different regions populated by the samples coming from healthy people and from patients affected by T1A glottis cancer, one is able to understand which kind of interventions are necessary in order to correct the illness, i.e. to move the corresponding feature vector from the sick region to the healthy one. We discuss such a filter and show its performance.

A Longitudinal Study of the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer Questionnaire in Patients Treated for Laryngeal Cancer

A prospective longitudinal study was performed to investigate the sensitivity to change over time of the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer questionnaire (S-SECEL), addressing communication dysfunction in patients with laryngeal cancer. Twenty-six consecutive patients attending a weekly tumour conference over a period of one year at Sahlgrenska University Hospital were included in the study prior to start of treatment. The patients answered four questionnaires repeatedly in the course of one year: the S-SECEL, the European Organization for Research and Treatment of Cancer (EORTC), the Core Quality of Life Core Questionnaire (QLQ-C30) supplemented by the Head and Neck cancer questionnaire module (QLQ-H&N35), and the Hospital Anxiety and Depression (HAD) scale. In addition, performance status was assessed. The S-SECEL questionnaire was well accepted by the patients, and compliance was satisfactory with a cumulative response rate of 88% at one year, supporting its feasibility in clinical settings. Repeated measures with the S-SECEL over one year demonstrated a significant decrease in voice and speech dysfunction. The correlation pattern over time between the S-SECEL and the EORTC and HAD questionnaires lent support to the construct validity of the S-SECEL and indicated that the questionnaire was sensitive to clinical change. The changes in S-SECEL correlated most strongly with changes in the EORTC QLQ-H&N35 speech scale, moderately with changes in the QLQ-C30 role and emotional functioning and global QoL scales, while the weakest correlations were with changes in physical functioning. The S-SECEL was sensitive to changes in communication dysfunction, with convergent and discriminant validity of longitudinal assessments, and with relevance for the quality of life of patients with laryngeal cancer receiving different treatment modalities.

Response of Asthma-Related Voice Dysfunction to Allergen Immunotherapy: A Case Report of Confirmation by Methacholine Challenge

Professional singers and other serious voice users are particularly susceptible to alterations in their vocal apparatus. As the support for vocalization, lung function is an essential element of the production of speech and song. Patients have been described who presented with voice complaints along with minimal or no abnormalities on spirometry, but responded to conventional bronchodilator and other asthma therapy. It was proposed that this represented an exercise-induced asthmalike condition, brought on by the hyperventilation associated with performing. The objective of this study was to establish whether improvement in vocalization while performing correlated with a decrease in nonspecific bronchial reactivity.We concluded that resolution of vocal complaints in conjunction with a decrease in methacholine reactivity supports the hypothesis that these patients do have an exercise-induced asthmalike condition brought on by airway drying. As with other patients with asthma, it appears to respond to allergy-directed therapy.

Post-thyroidectomy superior laryngeal nerve injury.

Voice dysfunction after thyroidectomy may be caused by damage to laryngeal nerves or lesions to strap muscles with laryngo-tracheal movement impairment. Injury to an external branch of the superior laryngeal nerve (EBSLN) is sometimes difficult to recognize clinically and its electromyographic incidence ranges from 0% to 58%. In this study we evaluated, 12-18 months postoperatively, 45 patients who had undergone thyroid surgery (6 total lobectomy, 5 subtotal thyroidectomy, and 34 total thyroidectomy), using a subjective interview, laryngeal videostroboscopy and spectrographic analysis with a multidimensional voice program. Vocal parameters included fundamental frequency, jitter, shimmer, noise-to-harmonic-ratio (NHR) and degree of sub-harmonics. Laryngeal electromyography (LEMG) of the cricothyroid (CT) muscles was performed in 21 subjects with voice problems (35 EBSLNs) using a modified method for the CT recording. In 3 patients of this group (14%) LEMG documented a unilateral EBSLN injury. Easy voice fatigue and decreased pitch range were the most common symptoms after surgery. Average values of vocal parameters pre- and postoperatively in patients without neural damage (n = 42) were: jitter 0.64% and 0.78%, shimmer 3.25% and 3.54%, and NHR 0.12% and 0.13%, respectively (P > 0.05). Acoustic analysis revealed altered patterns in some patients with no objective evidence of damage to EBSLNs, suggesting an extralaryngeal cause of vocal dysfunction, such as laryngo-tracheal fixation or lesions to strap muscles. We conclude that laryngeal videostroboscopy and spectrographic analysis are very useful to assess voice problems after thyroidectomy, including in patients without LEMG-proven neural lesions, in order to suggest early speech rehabilitation, especially in professional voice users.

IMPAIRMENT, DISABILITY, AND OTHER MEDICAL-LEGAL ASPECTS OF DYSPHONIA

As awareness of the importance of the human voice has grown, so too have legal issues surrounding voice dysfunction. Otolaryngologists must be familiar with principles of impairment and disability and with appropriate medical-legal management for voice patients.

Arytenoid adduction combined with Gore-Tex medialization thyroplasty.

To describe the technique of combined Gore-Tex medialization thyroplasty with arytenoid adduction and to determine the long-term vocal outcome of patients treated for unilateral vocal cord paralysis with this procedure. A retrospective chart review and patient reevaluation for patients treated at The University of Iowa Hospitals and Clinics between May 1995 and June 1999. The review addressed patient demographics, perioperative and long-term complications, and voice outcomes. Details of the surgical technique are provided within the manuscript. Seventy-two Gore-Tex medialization procedures were completed. Arytenoid adduction was included in 22 of these procedures. This subset of patients was compared with the patients treated with Gore-Tex alone. No major postoperative complications occurred in either group. Preoperative and postoperative voice and videostroboscopy data were available for 19 arytenoid adduction patients and 25 Gore-Tex alone patients. On a seven-point scale (6 [severely abnormal] --> 0 [normal voice]), the average patient rating of voice dysfunction improved from 4.2 to 1.6 (arytenoid adduction) and 4.5 to 2.8 (Gore-Tex alone). Maximum phonation time improved from 6.9 seconds to 16.7 seconds in the arytenoid adduction group. Subjective voice assessment employing the four-point GRBAS scale (3 [severely abnormal] --> 0 [normal]) identified average improvement from an overall grade of 2.1 to 0.8 arytenoid adduction and 2.2 to 1.5 in the Gore-Tex alone group. Improvement was identified in the vocal quality of breathiness from 1.9 to 0.2 (arytenoid adduction) and 1.9 to 0.9 (Gore-Tex alone). The combined technique of Gore-Tex medialization thyroplasty and arytenoid adduction provide functional results that appear to exceed the improvement attained with medialization alone.

DYSPHONIA RELATED TO MEDICAL THERAPY

It is essential for laryngologists, speech and language pathologists, and others caring for professional voice users to be familiar with the potential vocal effects of any substance ingested by a professional voice patient. This article reviews pharmacologic agents that may have laryngeal side effects. Essentially, any ingested substance is suspect as a cause for voice dysfunction. It is also necessary for laryngologists to educate voice professionals about the consequences of drugs on the voice and the potential problems associated with properly prescribed medication.

Aerodynamic measurements of patients with Parkinson's disease.

Patients with Parkinson's disease commonly complain of voice dysfunction. Most of these complaints can be attributed to the known muscular control disorders that occur with Parkinson's disease. However, the manifestations of Parkinson's disease muscular dysfunction on parameters of phonation such as airflow, laryngeal resistance, and subglottal pressure necessary to sustain phonation have not been reported. The purpose of this study was to examine the aerodynamic characteristics of flow, laryngeal resistance, and phonation pressure threshold in a heterogeneous population of patients with Parkinson's disease who had varying voice complaints and to compare the data to similar studies for human subjects who have no voice complaints. The studies used a noninvasive method of detecting flow and acoustic signal from the lips, oral cavity and nose during phonation and used an external flow interruption technique to estimate subglottal pressure and phonation threshold pressure. About one third of the patients could not produce phonation at regular and loud intensities that were comfortable for normal subjects. The mean subglottal pressure (SGP) of patients with Parkinson disease who could produce 3 levels of intensity comparable to normal subjects was significantly higher than the mean SGPs for normal subjects for the same intensities of vocal production. The mean flow rates measured from patients with Parkinson's disease at the same 3 intensities of phonation was not significantly greater than in normal subjects. This indicated that the mean laryngeal resistance calculated for patients with Parkinson's disease was notably and significantly greater than mean laryngeal resistance calculated for normal subjects at the same intensity levels. The mean vocal efficiency (VE) for normal subjects was not significantly different than the mean VE for patients with Parkinson's disease, because greater pressure was used to generate similar flow and acoustic energy. These findings correlate with the perception of patients with Parkinson's disease that they are working harder to produce phonation. The observation of notably greater laryngeal resistance and phonation threshold pressure in patients with Parkinson's disease suggests that further studies of the glottic aperture in patients with Parkinson' disease may be useful for understanding how this common motor disorder disturbs phonation.

Titanium vocal fold medializing implant: introducing a novel implant system for external vocal fold medialization.

With the increasing worldwide spread of the Isshiki technique for external vocal fold medialization, some disadvantages and limitations have also emerged. and an increasing demand for a ready-made and standardized implant system can be observed. For this reason. I started experimental and clinical investigations with the goal of replacing the silicone with a safer material, and also simplifying and standardizing the surgical procedure. In particular, the danger of implant dislocation should be excluded with greater certainty. As a result, I have developed an implant made of medical-grade titanium. My surgical experiences in 20 patients with this newly developed titanium vocal fold medializing implant revealed that vocal fold medialization could be performed easily and that no perioperative complications occurred in any case. The major advantage was a significant reduction of operative time due to the preformed implant. This is not only more convenient for both the surgeon and the patient, but is also critical for obtaining optimal results due to the reduced intralaryngeal swelling and hematoma. The reduction of the glottic gap by the operation was statistically significant. Significant improvement of all voice parameters was achieved and demonstrated by a statistically significant reduction of the voice dysfunction index. Compared to the current techniques and implant systems, I see the following additional advantages: 1) titanium is a relatively safe implant material with excellent biocompatibility: 2) the design of the implant ensures optimal fixation and stabilization: 3) the implantation technique and handling is simple and time-saving; 4) the titanium sheet is easy to shape and adapt to the individual situation: and 5) only 2 sizes of implants, and no expensive instruments, are required.

External vocal cord medialization: functional outcome

Comprehensive evaluation of voice function is the precondition for indication and quality control of every phonosurgical procedure. In 53 patients presenting with glottic insufficiencies of different etiologies an external vocal fold medialisation was performed. Functional voice results obtained with this operation are presented and discussed. The following voice parameters were measured preoperatively and postoperatively, and statistical comparison was performed: mean fundamental frequency and sound pressure level, frequency and intensity range (voice range profile), perceptual evaluation of hoarseness, and maximum phonation time. The impairment of vocal communication skills was rated on a newly developed 7-point scale. A combined parameter called "Voice Dysfunction Index" was introduced for global assessment of vocal abilities in particular for long term observations. Statistically significant improvement of all voice parameters was demonstrated. Interestingly, in nearly all measurements male patients yielded significantly better results than females. Glottic insufficiencies due to scarring produced poorer functional results but without statistical significance. A statistically significant correlation between the preoperative and postoperative Voice Dysfunction Index could be observed. This score was also significantly correlated with the degree of glottal gap. No significant correlation between voice results and preoperative delay or follow-up period were observed. Voice therapy was performed in 81% of the patients. Correlation of duration of voice therapy and voice results was statistically significant and negative. Analysis of this surprising result showed that it was caused by some patients with vocal fold scarring in whom outcome was poor despite a long period of voice therapy. Significant improvement of vocal function can be obtained by external vocal fold medialization in patients with glottic insufficiencies. Glottal gaps caused by vocal fold scarring and/or atrophy can be treated with this method, too. However, results are not as good as in paralysis and require additional long term voice therapy. Satisfying results can be expected in patients with a long history of disturbances, and in older patients. Due to the reversibility of the operation, external vocal fold medialization can be performed even in cases of palsy prior to the spontaneous recovery period. The degree of glottic gap determines the functional disturbance. The degree of the preoperative impairment correlates with the outcome. Results are stable with respect to the follow-up period (mean 66 weeks).

Phonatory characteristics of patients undergoing thyroidectomy without laryngeal nerve injury

Complications that arise after thyroid surgery may be associated with infection, hemorrhage, hormonal problems, and laryngeal nerve injury. Voice alteration after thyroidectomy is usually caused by recurrent or superior laryngeal nerve injury. This voice dysfunction may also be associated with laryngotracheal fixation with impairment of vertical movement or by temporary malfunction of the strap muscles after surgery. In this study, we evaluated the voice function phonetically before and after thyroidectomy in 54 patients, although function of the recurrent and superior laryngeal nerves was normal. During surgery, the superior and recurrent laryngeal nerves were identified and protected, and after surgery electromyographic testing of the cricothyroid muscle was performed. Typical voice symptoms after surgery were easy fatigue during phonation and difficulty with high pitch and singing voice. Acoustic analysis revealed that the phonation time and fundamental frequency were not changed after surgery, but the speaking fundamental frequency, range of speaking fundamental frequency, and vocal range were significantly diminished after surgery. These data allowed us to suggest that the cause of voice dysfunction is not seen in neural lesions, but in a disturbance of the extralaryngeal skeleton. These voice changes emphasize the importance of the extralaryngeal mechanism for pitch control. (Otolaryngol Head Neck Surg 1997;117:399-404.)

Airway reactivity induced reversible voice dysfunction in singers.

As the power source for vocalization, the lower respiratory tract plays a key role in voice production. This is particularly true with sustained singing, where continued high ventilatory demands are present. Changes in pulmonary function that are insignificant with normal speech have been shown to lead to performance impairment. The purpose of this study was to examine and characterize this problem in a large group of singers. Systematic evaluation of a defined population, along with inhalational and singing challenge, was the design. The demographic characteristics, history, pulmonary function, and response to treatment were evaluated in 20 professional or serious amateur singers with voice problems, who did not have causal laryngeal pathology, whose history and evaluation suggested increased airway reactivity, and who responded to anti-asthma therapy. An additional patient was challenged by the exercise of singing in the office, with pulmonary function measurements before and after. This group of serious singers demonstrated vocalization complaints referable to bronchodilator responsive airway obstruction. They responded to treatment for asthma, with improvement in their performance-related difficulties. An additional subject demonstrated a small decline in expiratory flow rates with only 20 minutes of singing in the office. This was readily reversed by an inhaled bronchodilator. Singers who present with complaints of impaired vocalization, such as vocal fatigue, decreased control, and excessive muscular tension, should be evaluated for increased airway reactivity as a possible cause of their complaints.

Genetics of the voice

Substantial advances have led to the evolution of voice as the newest subspecialty of otolaryngology. Nevertheless, little is known about the genetics of voice. Genetic research is needed to further elucidate the relationship between vocal tract structure (including ultrastructure) and function, mechanisms of voice dysfunction, and transmission of normal and abnormal voice characteristics.

Voice Dysfunction in the Broadcasting Professional

Voice Dysfunction in the Broadcasting Professional

Geriatrie Voice and Laryngeal Dysfunction

Vocal disorders are a common dysfunction associated with aging that can have a significant effect on the quality of life. An appreciation for the many causes of vocal dysfunction in the elderly is a first step to providing better care for the geriatric patient with complaints about voice dysfunction.

Vocal dysfunction following cricothyroidotomy: A prospective study

Voice dysfunction is a known consequence of cricothyroidotomy, but few detailed analyses have been published. This study reports an investigation of voice function in 19 patients who underwent cricothyroidotomy during a 12-month period (54 were patients operated on, 29 survived the primary disease or injury, and 19 agreed to participate in the investigation). The patients were interviewed regarding signs of dysfunction of the cricothyroid muscles, or a diminished external tensor effect on the vocal folds. Laryngoscopy with a magnifying-angled endoscope, stroboscopy, phonetography, determination of mean speaking fundamental frequency, perceptual analysis of the voice, and electromyogram of the cricothyroid muscle were all performed. Four patients had signs of diminished external tensor effect on the vocal folds (mild or moderate voice dysfunction), 5 patients had other voice disorders, and 10 were classified as having normal voice. Elective cricothyroidotomy should be avoided in patients with professional or other activities that place heavy demands on the voice.

The cricothyroid muscle after cricothyroidotomy. A porcine experimental study.

Cricothyroidotomy in elective use or emergency situations has been discussed by several authors during recent years. The main complication reported has been subglottic stenosis. We have used this method for several years and among our patients there has been no case of stenosis. The major complication in our material has been voice dysfunction. Some of the patients had a change in voice quality consistent with dysfunction in the cricothyroid muscles (diminished voice range and a lowered pitch). The aim of this study was to investigate whether cricothyroidotomy and insertion of a tracheostomy tube caused physiological or morphological changes in the cricothyroid muscle, by direct injury or secondary to a peripheral nerve lesion. In the six animals that were cricothyroidotomized during 7-9 days and examined after 9-15 weeks, we found neither changes in the EMG nor in the muscle morphology indicating injury to the muscle or its peripheral nerve supply.