Voice and Laryngeal Configuration of Men With Unilateral Vocal Fold Paralysis Before and After Medialization

Aim

To describe the laryngeal configuration and the voice of male patients diagnosed with unilateral vocal fold paralysis (UVFP) before and after medialization.

Methods

A retrospective study involving the collection of data from medical records of 142 patients diagnosed with UVFP from January 2003 to April 2009, submitted to auditory-perceptual assessment of voices and visual perception of laryngeal images before and after medialization.

Results

The study included data from 24 male patients, with an average of 60.7 years, who underwent three surgical medialization techniques (injection of hyaluronic acid, type I thyroplasty, and injection of Teflon). Before treatment, the position of the paralyzed vocal fold was seen to have a significant influence to the passing of the healthy vocal fold beyond the midline and on the overall degree of dysphonia. After treatment, the complete glottic closure; the free margin of the linear vocal fold; paralyzed vocal fold in the median position, reduction of hoarseness, roughness and breathiness (more frequently mild), and asthenia (more frequently normal and mild); tension and instability (more frequency normal); and a decrease in the overall degree of dysphonia were found to be significant.

Conclusion

The position of the paralyzed vocal fold influences the position of the healthy vocal fold in relation to the midline and the overall degree of dysphonia. All three treatments improved the glottic configuration and the voice of patients with UVFP.     

Noise-to-Harmonics Ratio as an Acoustic Measure of Voice Disorders in Boys

This prospective study assessed the efficacy of computerized noise-to-harmonics ratio (NHR) to quantify perceptual and endoscopic findings of dysphonia and/or structural lesion of the vocal fold. Fifty Brazilian boys without vocal complaints were submitted to computerized, perceptual, and endoscopic examination. Thirty boys were dysphonic--3 were classified into the grade category, 5 into breathiness, 9 into roughness, and 15 into grade/breathiness. Vocal fold lesions were observed in 25 boys (17 nodules and 8 cysts). The Mann-Whitney U test revealed that NHR was significantly higher in boys with a structural lesion (p = 0.007) and in boys with dysphonia (p < 0.0001). However, according to a logistic regression model, only the occurrence of dysphonia was explained by NHR; the risk for having dysphonia increased approximately twice (odds ratio = 1.92, 95% confidence interval = 1.3-2.9) with each increase of 0.01 in NHR. Our results suggest that noise is a useful quantitative index to confirm a perceptual diagnosis of dysphonia and to evaluate quantitative changes in a dysphonic voice over time. However, we believe that computerized analysis should be used as a complement, rather than a substitute, for perceptual evaluation. Further studies with a larger sample are required to investigate the relationship between noise and lesions of the vocal folds.     

The effects of excessive vocalization on acoustic and videostroboscopic measures of vocal fold condition

Although dysphonia is a recognized consequence of acute vocal abuse, associated changes in vocal fold appearance and function are not well understood. To document these presumed effects of vocal abuse, audio recordings of sustained vowel production were obtained from 42 drill sergeants daily during the first 6 days of a vocally demanding training exercise. Acoustic analysis showed abnormal levels of jitter and shimmer on Day 1 in 16 of the 42 subjects. Considering only the 26 subjects who showed normal voice acoustics on Day 1, the median levels of jitter and shimmer varied little over the course of training, and significant increases in jitter and shimmer were not seen during the study period. However, the distributions for both jitter and shimmer became more positively skewed and showed a greater number of positive outliers over the course of training. This trend was attributed to 11 subjects who showed two or more instances of abnormal voice acoustics over Days 2 through 6. Laryngeal videostroboscopic recordings of sustained vowel production also were obtained prior to and following training. Perceptual ratings of these recordings by 2 observers revealed significant increases in vocal fold edema, erythema, and edge irregularity, and decreases in vocal fold mucosal wave and amplitude of excursion following the 5-day training period. In general, there was considerable intersubject variability in the extent of acoustic and videostroboscopic effects over the course of training. Of the two types of data, videostroboscopy appears to provide a more sensitive indication of the effects of excessive vocalization.     

The Frequency of Perceived Stress, Anxiety, and Depression in Patients with Common Pathologies Affecting Voice

The study's objectives were to investigate (1) the frequency of perceived stress, anxiety, and depression for patients with common voice disorders, (2) the distribution of these variables by diagnosis, and (3) the distribution of the variables by gender. Retrospective data were derived from self-report questionnaires assessing recent stress (Perceived Stress Scale-10), anxiety, and depression (Hospital Anxiety and Depression Scale) in a cohort of new patients presenting to a voice clinic. Data are presented on 160 patients with muscle tension dysphonia (MTD), benign vocal fold lesions, paradoxical vocal fold movement disorder (PVFMD), or glottal insufficiency. Pooled data indicated that average stress, anxiety, and depression scores were similar to those found for the healthy population. However, 25.0%, 36.9%, and 31.2% of patients showed elevated stress, anxiety, and depression scores, respectively, compared to norms. Patients with PVFMD had the most frequent occurrence-and patients with glottal insufficiency had the least frequent occurrence of elevated stress, anxiety, and depression. Stress and depression were more common with MTD than with lesions, whereas reverse results were obtained for anxiety. More females than males had elevated stress, anxiety, and depression scores. The data are consistent with suggestions that stress, anxiety, and depression may be common among some patients with PVFMD, MTD, and vocal fold lesions and more common for women than men. However, individual variability in the data set was large. Further studies should evaluate the specific role of these conditions for selected categories of voice disorders in susceptible individuals.     

Voice-Related Quality of Life (V-RQOL) following type I thyroplasty for unilateral vocal fold paralysis

Unilateral vocal fold paralysis is a common clinical problem which frequently causes severe dysphonia. Various treatment options exist for this condition, with the type I thyroplasty being one of the more commonly performed surgical procedures for vocal rehabilitation. The Voice-Related Quality of Life (V-RQOL) Measure is a validated outcomes instrument for voice disorders. This study measured the V-RQOL of patients with unilateral vocal fold paralysis who had undergone a type I thyroplasty and compared these scores to those of patients with untreated and uncompensated unilateral vocal fold paralysis and to normals. Treated patients had significantly higher domain and overall V-RQOL scores than untreated patients, but also scored lower than normals. These differences were true across gender and age. Patients who were more distant from surgery had lower V-RQOL scores than those who had more recently been treated. It is concluded that type I thyroplasty leads to a significantly higher V-RQOL for patients with unilateral vocal fold paralysis. This study also demonstrates further the utility of patient-oriented measures of treatment outcome.     

Japanese version of voice handicap index for subjective evaluation of voice disorder

Recently, the Voice Handicap Index (VHI), developed in the United States, has been highlighted as a means to assess a patient's perceptions of the severity of his or her voice disorder. The VHI is based on a self-administered questionnaire that quantifies the degree of a patient's disability related to his/her voice disorder. The questionnaire was translated into Japanese and applied to Japanese patients with various kinds of disordered voice or dysphonia. The results were analyzed and the usefulness discussed. In this study, 546 patients (281 males and 265 females) were included. Mean VHI scores were 36.2/120 in males and 44.1/120 in females. In the male patients, VHI scores were the highest among teens. However, VHI scores did not vary with age in the female patients. Patients with vocal fold paralysis, functional dysphonia, psychological dysphonia, and spasmodic dysphonia showed relatively high VHI scores, whereas those with laryngeal granuloma and laryngopharyngeal reflux disease showed low scores. In most diseases, functional and physiological scores were higher than emotional scores. In any treated patients, those with vocal nodule, vocal polyp, polypoid vocal fold, and recurrent laryngeal nerve paralysis, VHI scores decreased after therapeutic intervention. These findings suggest that the Japanese VHI is a useful tool for monitoring a patient's psychological status, choosing appropriate treatment, and assessing the therapeutic outcome.     

The frequency of hard glottal attacks in patients with muscle tension dysphonia, unilateral benign masses and bilateral benign masses

Hard or abrupt glottal attack (HGA) is one of the vocal behaviors often associated with benign lesion of the vocal folds. This study was designed to determine whether the frequency of HGA was different in hyperfunctional voice patients with and without vocal fold masses. One hundred and forty-seven subjects were studied. All subjects received a complete otolaryngological evaluation including strobovideolaryngoscopy, objective voice measures, and evaluation by a speech-language pathologist. Thirty-two patients were diagnosed with muscle tension dysphonia (19 male, 13 female) without vocal fold masses. Fifty-seven patients were diagnosed with unilateral vocal fold masses (29 male, 28 female), most of which were cysts. Fifty-eight patients were diagnosed with bilateral vocal fold masses (13 male, 45 female). Of the 45 females with bilateral vocal fold masses. 26 had a vocal cyst and reactive nodule and 19 had bilateral vocal fold nodules. The control group was balanced and matched based on sex and on percentage of singers and nonsingers. It consisted of 49 subjects with no vocal fold pathology (20 male, 29 female). The group was composed of professional speakers, singers, and nonprofessional speakers. All voice disordered groups demonstrated higher frequencies of HGA than the control group. Differences were found between the male and female subjects in this study. No differences were found between the various disorders. Differences were also found between the subgroups of bilateral masses, where the bilateral nodules group presented a higher frequency of HGA than the cyst and contralateral reactive nodule.     

Relationship among glottal area, static supraglottic compression, and laryngeal function studies in unilateral vocal fold paresis and paralysis

In this study, we evaluated the relationship between laryngeal function measures and glottal gap ratio and normalized measures of supraglottic behaviors in patients with unilateral vocal fold paresis (UVFP). Thirty-one patients were found to have unilateral vocal fold paresis by videoendoscopy and laryngeal electromyography, and 13 controls participated in this study. Patients with UVFP demonstrated significantly larger glottal gap ratios (p = 0.016) than control subjects. The nonparalyzed or contralateral vocal fold was associated with significantly more static false vocal fold compression (p = 0.03) compared with the paralyzed vocal fold or with the controls. Patients with unilateral vocal fold paresis were divided into subgroups: those with normal or abnormal maximum phonation time, flow, or pressure measures. Smaller glottal gap ratios were identified in patients with normal maximum phonation times and flow measures. Greater false vocal fold activity was identified in unilateral vocal fold paresis patients with normal laryngeal function measures than in unilateral vocal fold paresis patients with abnormal measures. These findings suggest that some patients with documented unilateral paresis and glottal incompetence can compensate for vocal fold weakness such that their acoustic and aerodynamic measures are normal.     

Relationship between changes in voice pitch and loudness

Changes in mean fundamental frequency accompanying changes in loudness of phonation are analyzed in 9 professional singers, 9 nonsingers, and 10 male and 10 female patients suffering from vocal functional dysfunction. The subjects read discursive texts with noise in earphones, and some also at voluntarily varied vocal loudness. The healthy subjects phonated as softly and as loudly as possible at various fundamental frequencies throughout their pitch ranges, and the resulting mean phonetograms are compared. Mean pitch was found to increase by about half-semitones per decibel sound level. Grossly, the subject groups gave similar results, although the singers changed voice pitch more than the nonsingers. The voice pitch changes may be explained as passive results of changes of subglottal pressure required for the sound level variation.     

A virtual trajectory model predicts differences in vocal fold kinematics in individuals with vocal hyperfunction

A simple, one degree of freedom virtual trajectory model of vocal fold kinematics was developed to investigate whether kinematic features of vocal fold movement confirm increased muscle stiffness. Model simulations verified that increases in stiffness were associated with changes in kinematic parameters, suggesting that increases in gesture rate would affect kinematic features to a lesser degree in vocal hyperfunction patients given the increased levels of muscle tension they typically employ to phonate. This hypothesis was tested experimentally in individuals with muscle tension dysphonia (MTD; N = 10) and vocal nodules (N = 10) relative to controls with healthy normal voice (N = 10) who were examined with trans-nasal endoscopy during a simple vocal fold abductory-adductory task. Kinematic measures in MTD patients were less affected by increased gesture rate, consistent with the hypothesis that these individuals have elevated typical laryngeal muscle tension. Group comparisons of the difference between medium and fast gesture rates (Mann-Whitney, one-tailed) showed statistically significant differences between the control and MTD individuals on the two kinematic features examined (p<0.05). Results in nodules participants were mixed and are discussed independently. The findings support the potential use of vocal fold kinematics as an objective clinical assay of vocal hyperfunction.     

Mechanical and dynamic aspects of voice production as related to voice therapy and phonosurgery

Laryngeal framework surgery can change the position and tensionof the vocal folds safely without direct surgical intervention in the vocal fold proper. Some 23 years of experience with phonosurgery have proved its usefulness in treating dysphonia related to unilateral vocal fold paralysis, vocal fold atrophy, and pitch-related dysphonias. Meanwhile, much information about the mechanism of voice production has been obtained through intraoperative findings of voice and fiberscopic examination of the larynx . Based on such knowledge together with information obtained through model experiments, the human vocal organ was reconsidered mainly from the mechanical view point, and the roles of voice therapy and singing pedagogy were discussed in relation to phonosurgery. The vocal organ may not be an ideal musical organ and is rather vulnerable, but its potential is enormous.     

Multiparametric Analysis of Vocal Fold Vibrations in Healthy and Disordered Voices in High-Speed Imaging

Objectives

The aim of this study was to look for visual subjective and objective parameters of vocal fold dynamics being capable of differentiating healthy from pathologic voices in daily clinical practice applying endoscopic high-speed digital imaging (HSI).

Study Design and Methods

Four hundred ninety-six datasets containing 80 healthy and 416 pathologic subjects (232 functional dysphonia (FD), 13 bilateral, and 171 unilateral vocal fold nerve paralysis) were analyzed retrospectively. Videos at 4000 Hz (256 × 256 pixel) were recorded during sustained phonation. Subjective parameters were visually evaluated and complemented by an analysis of objective parameters. Visual subjective parameters were mucosal wave, glottal closure type, glottal closure insufficiency (GI), asymmetries of the vocal folds, and phonovibrogram (PVG) symmetry. After image segmentation, objective parameters were computed: closed quotient, perturbation measures (PMs) of glottal area, and left-right asymmetry values.

Results

HSI evaluation enabled to distinguish healthy from pathologic voices. For visual subjective parameters, GI, symmetrical behavior, and PVG symmetry exhibited statistical significant differences. For 95% of the data, objective parameters could be computed. Among objective parameters, closed quotient, jitter, shimmer, harmonic-to-noise ratio, and signal-to-noise ratio for the glottal area function differentiated statistically significant normal from pathologic voices. Applying linear discriminant analysis by combining visual subjective and objective parameters, accurate classifications were made for 63.2% of the female and 87.5% of the male group for the three-class problem (healthy, FD, and unilateral vocal fold nerve paralysis).

Conclusion

Actual acoustically applied PMs can be transferred to clinical beneficial HSI analysis. Combining visual subjective and objective basic parameters succeeds in differentiating pathologic from healthy voices. The presented evaluation can easily be included into everyday clinical practice. However, further research is needed to broaden our understanding of the variability within and across healthy and pathologic vocal fold vibrations for diagnosing voice disorders and therapy control.     

The potential role of ultrasound in differentiating solid and cystic swellings of the true vocal fold

This study was designed to investigate the potential role of ultrasound in the diagnosis of cysts of the true vocal fold. Materials and Methods: Grayscale ultrasound of the larynx was carried out in 29 patients with a swelling of the true vocal fold and dysphonia. The findings were then compared with those at subsequent microlaryngoscopy, in the majority of cases. Results and Conclusions: Whereas preoperative laryngeal ultrasound correctly predicted the surgical findings of a cystic lesion in only 5 of 11 cases, it correctly identified that no cyst was present in 15 of 16 instances when this had been queried. This study suggests that ultrasound may have some role in investigation of unilateral vocal fold pathology, but that further fine-tuning of the technique may be necessary.     

Autologous fat implantation for vocal fold scar: A preliminary report

New insights into the anatomy and physiology of phonation, along with technological advances in voice assessment and quantification, have led to dramatic improvements in medical voice care. Techniques to prevent vocal fold scar have been among the most important, especially scarring and hoarseness associated with voice surgery. Nevertheless, dysphonia due to vocal fold scar is still encountered all too frequently. Although it is not generally possible to restore such injured voices to normal, patients with scar-induced dysphonia can usually be helped. Voice improvement is optimized through a team approach. Treatment may include sophisticated voice therapy and vocal fold surgery. Although experience with collagen injection has been encouraging in selected cases (particularly in those involving limited areas of vocal fold scar), there is no consistently successful surgical technique. Attempts to treat massive vocal fold scar, such as may be seen following vocal fold stripping, have been particularly unsuccessful. This paper reports preliminary experience with the implantation of autologous fat into the vibratory margin of the vocal fold of patients with severe, extensive scarring. Using this technique, it appears possible to recreate a mucosal wave and improve voice quality. Additional research is needed.     

Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports

Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder. Such dysphonias may often develop post-viral infection with laryngitis, and generally in close proximity to emotionally or psychologically taxing experiences, where "conflict over speaking out" is an issue. In more rare instances, severe and persistent psychogenic dysphonia may develop under innocuous or unrelated circumstances, but over time, it may be traced back to traumatic stress experiences that occurred many months or years prior to the onset of the voice disorder. In such cases, the qualitative nature of the traumatic experience may be reflected in the way the psychogenic voice disorder presents. The possible relationship between psychogenic dysphonia and earlier traumatic stress experience is discussed, and the reportedly low prevalence of conversion reaction (4% to 5%) as the basis for psychogenic dysphonia is challenged. Two cases are presented to illustrate the issues raised: the first, a young woman who was sexually assaulted and chose to "keep her secret," and the second, a 52-year-old woman who developed a psychogenic dysphonia following a second, modified thyroplasty for a unilateral vocal fold paresis.     

Epidemiological Study of Voice Disorders Among Teaching Professionals of La Rioja, Spain

The purpose of the present study was to calculate the prevalence and incidence of voice disorders among teaching staff and find out the associated occupational risk factors. A case-control study was performed with 905 teachers, 579 cases and 326 controls; 492 were randomly selected and 413 volunteered. All teachers were asked to fill out a standard questionnaire. Next, a complete laryngeal exam was performed including a general ear, nose, and throat evaluation and videolaryngostroboscopy. The prevalence of voice disorders among teaching staff was 57%. The most prevalent lesions were vocal overstrain (18%), nodular lesions (14%), and hyperfunctional dysphonia (8%). The incidence rate was 3.87 new cases per year per 1000 teachers. Women had organic lesions three times more than men (odds ratio [OR]: 3.52, confidence interval [CI]: 2.04-6.09). However, men had chronic laryngitis three times more than women (OR: 2.93, CI: 1.50-5.71) and functional dysphonia nearly twice more than women (OR: 1.81, CI: 1.21-2.69). We find a significant risk of suffering voice disorders in teachers who smoke daily (OR: 2.31, CI: 1.58-3.37) and who drink several cups of coffee or tea (OR: 1.87, CI: 1.36-2.56). It is advisable to carry out an annual evaluation of all teaching staff on account of the high prevalence of voice disorders among them.     

Mild Vocal Fold Paresis: Understanding Clinical Presentation and Electromyographic Findings

The implications of mild vocal fold hypomobility are incompletely understood. This study describes the clinical, electromyographic, and probable etiologic findings in patients who presented with complaints of dysphonia and whose physical examination revealed vocal fold paresis as a factor possibly contributing to their voice complaints. A retrospective chart review of all patients who presented to a tertiary laryngology referral center over a 13-month period, who had a clinical diagnosis of mild vocal fold hypomobility and who underwent laryngeal electromyography, were included in the study. A total of 22 patients completed the medical evaluation of their voice complaint. Of these patients, 19 (86.4%) were found to have evidence of neuropathy on laryngeal electromyography. The clinical picture indicated the following probable origins for the vocal fold paresis: goiter/thyroiditis (7/22 or 31.8%), idiopathic (4/22 or 18.2%), viral neuritis (4/22 or 18.2%), trauma (3/22 or 13.6%), and Lyme's disease (1/22 or 4.5%). This article describes the clinical entity of mild vocal fold hypomobility and associated flexible laryngoscopic, rigid strobovideolaryngoscopic, and laryngeal electromyographic findings.     

Symptomatology of adductor spasmodic dysphonia: A physiologic model

Vocal symptomatology of adductor spasmodic dysphonia (SD) is reviewed critically from historical, epidemiologic, and clinical perspectives. A model of symptomatology of this disorder based on a large patient population, and clinical and physiologic observations is advanced. The model incorporates crucial symptomatic and asymptomatic phonatory and nonphonatory physiologic parameters of laryngeal behavior in these patients. These parameters include vocal fold contact area, vocal fold collision force, glottic compression, and subglottic air pressure. Inappropriate efferent discharges from brain-stem basal ganglia are hypothesized as causing overadduction of the vocal folds in phonation, generating the basic and fundamental vocal symptom of adductor SD—strained, strangled, overpressured voice quality. Cortical loops are implicated as accountable for compensatory vocal behavior, not as the primary site of the disorder. Symptom occurrence, variability, magnitude, effects, and failure of treatment approaches, as well as recurrence of symptoms after ablative or invasive procedures, are explained by this model. The model also predicts that symptomatology of adductor spasmodic dysphonia is unique to this disorder and that symptoms are phonotopically organized. The minimal diagnostic battery based on the model is presented, and it is shown how this battery aids in the differential diagnosis of adductor SD and other phonatory disorders that closely mimic the vocal symptoms of adductor spasmodic dysphonia, including tremor.