Voice range in superior laryngealnerve paresis and paralysis

Evaluation of Physiologic Frequency Range (PFR) and Musical FrequencyRange (MRP) of Phonation was performed on 56 adults (singers and nonsingers) presenting with superior laryngeal nerve (SLN) paresis or paralysis confirmed by laryngeal electromyography. The most common etiology was neuritis (69.7%), followed by iatrogenic and unlcnown causes,each accounting for 10.2 % of cases, and finally trauma (8.9%). Both female and male singers with SLN paresis or paralysis had significantly higher PFR and MPR than nonsingers. Female classical singers presented PFR and MPR of up to 10 semitones (ST) higher than nonclassical singers and nonsingers. The lowest PFR and musical ranges were found in patients with SLN paresis associated with recurrent laryngeal nerve paresis or paralysis. The authors suggest that voice range measurement is a useful parameter for analyzing the effects of SLN paresis or paralysis on voice and that it may also assist in measuring outcome following voice therapy.     

Objective Voice Measures in Nonsinging Patients With Unilateral Superior Laryngeal Nerve Paresis

The clinical value of objective voice measures in nonsinging patients with superior laryngeal nerve dysfunction is unknown. In this study, patients with symptomatic unilateral superior nerve paresis were evaluated for maximum phonation time, frequency range of phonation, and mean flow rate. Patients with coexisting pathology, bilateral superior nerve paresis, and those with recurrent laryngeal nerve paresis were excluded from this analysis. A total of 35 nonsinging patients, 14 men and 21 women, with unilateral superior laryngeal nerve paresis were examined between 1999 and 2002. The severity of superior laryngeal nerve paresis ranged from 25% to 85% of normal recruitment with a mean of 70% superior laryngeal nerve recruitment in men and 65% in women by electromyography. In both men and women with superior laryngeal nerve paresis, the maximum phonation time and frequency range of phonation were decreased and the mean air flow rate was increased when compared with normal population values. The jitter percent, shimmer percent, and noise-to-harmonic ratio were also increased in patients when compared with normative data. Selected objective voice measures are abnormal in voice patients with superior laryngeal nerve paresis, which suggests that the measures may be useful as outcomes measures after therapy. More research is encouraged.     

Superior laryngeal nerve paresis and paralysis

Superior laryngeal nerve paresis and paralysis are relatively common but often difficult to diagnose with certainty. They are most commonly caused by viral infections, though other etiologies must be considered. A thorough history and physical examination, including strobovideolaryngoscopy and laryngeal electromyography, are needed for definitive diagnosis. It is essential to establish the diagnosis accurately to differentiate an apparent superior laryngeal nerve paresis from other conditions, such as myasthenia gravis. Laryngeal electromyography is used to confirm clinical impressions, as a guide for therapy, and as one measure of recovery. In our experience, accurate and early diagnosis assure the best phonatory outcome by directing therapy that will prevent or eliminate compensatory vocal abuses, which may themselves lead to even more serious vocal injury.     

Analysis of Vocal-fold Vibrations from High-Speed Laryngeal Images Using a Hilbert Transform-Based Methodology

This paper presents a Hilbert transform-based approach to analyze vocal fold vibrations in human subjects exhibiting normal and abnormal voice productions. This new approach is applied to the analysis of glottal area waveform (GAW) and is capable of providing useful information on the vocal fold vibration. The GAW is extracted from high-speed laryngeal images by delineating the glottal edge for each image frame. An analytic signal is generated through the Hilbert transform of the GAW, which yields a recognizable pattern of the vocal fold vibration in the analytic phase plane. The vibratory pattern is comprehensive and can be correlated with specific voice conditions. Quantitative measures of the glottal perturbation are introduced using the analytic amplitude and instantaneous frequency obtained from the analysis. Examples of clinical voice recordings are used to evaluate and test the effectiveness of this approach in providing qualitative representation and quantitative characteristics of vocal fold vibratory behavior. The results demonstrate the potential of using this new analytical tool incorporated with the high-speed laryngeal imaging modality for clinical voice assessment.     

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.     

Strobovideolaryngoscopic Findings in Singing Teachers

Professional voice users often present to otolaryngologists and laryngologists with specific voice complaints. The contributions of pathologic lesions to the patients' vocal complaints are not always clear on examination, and often, premorbid examinations of the larynx are not available for review. This study examines the incidence of laryngeal pathology among singing teachers. At a national convention of singing teachers, volunteers were recruited for a "free strobovideolaryngoscopic examination." All volunteers completed a detailed questionnaire of their vocal and medical history and underwent strobovideolaryngoscopic examination. Strobovideolaryngoscopic examinations were completed in 20 volunteers, 7 of whom had voice complaints and 13 of whom perceived their voices to be normal. Vocal fold masses were common among the asymptomatic singing teachers. Evidence of reflux laryngitis was a common finding among both symptomatic and asymptomatic singing teachers. Asymmetries in vocal fold hypomobility were more common among those with voice complaints than was the presence of vocal fold masses in the population studied.     

Dysphonia and bulimia: Vomiting laryngeal injury

Voice problems associated with vomiting laryngeal injury in bulimic patients have not been previously described in the literature. Injuries found include subepithelial vocal fold hemorrhages that probably go on to produce mucosal wave tethering. More severe scarring may also result, but superficial telangiectasia of the glottic mucosa seems to be a more common feature. Three patients from a voice clinic population are described, and a further 10 patients from an eating disorders clinic who had not presented with voice complaints were studied with questionnaires, history, video laryngostroboscopy, and voice recordings.     

Intensive voice treatment in parkinson disease: Laryngostroboscopic findings

As part of ongoing research to investigate and document the efficacy of intensive voice therapy to improve functional communication in patients with idiopathic Parkinson disease, 45 patients were enrolled in a controlled, randomized, prospective study. Pre- to posttreatment comparisons are presented here on 22 of those patients who underwent laryngeal imaging examination. Of the 22 patients, 13 patients received intensive therapy aimed at increasing vocal and respiratory effort (VR), whereas nine received intensive therapy aimed at increasing respiratory effort (R) only. All patients had a pretreatment evaluation that included two (but sometimes only one) voice recordings and an otolaryngologic examination with laryngostroboscopy. At the completion of 4 weeks of therapy (16 sessions), two voice recordings were made, and laryngostroboscopy was again performed. The pre- and posttherapy videolaryngostroboscopy tapes were then randomized and rated by four judges. Raters' findings were then compared with vocal intensity measured before and after therapy. The VR therapy group showed improvements on laryngostroboscopic variables: less glottal incompetence and no significant change in supraglottal hyperfunction after therapy. No differences were observed in the R-only group. The mean intensity increase in the VR therapy group was 12.5 dB, compared with a decrease of 1.9 dB in the R-only group. These findings suggest that in patients with Parkinson disease, intensive therapy focusing on phonatory effort improves adduction of the vocal folds as assessed by laryngostroboscopy. Differences in laryngeal function in these patients observed with fiberoptic laryngoscopy and rigid telescopic laryngoscopy are discussed.     

The effect of topical anesthesia on vocal fold motion

The objective of this study was to determine if topical anesthesia to the larynx and pharynx affects vocal fold motion during dynamic voice evaluation with transnasal flexible endoscopy. Transnasal dynamic laryngeal examinations of 10 patients with no voice complaints were evaluated by five blinded fellowship-trained laryngologists. Each patient was examined before and after application of topical anesthetic. Reviewers rated briskness of right and left vocal fold movement and longitudinal tension on a visual analogue scale. Statistical comparisons were made between individual subject scores before and after anesthetic application. Inter-rater reliability was also assessed. No statistical difference was observed between subject scores before and after anesthetic application. Average intraclass correlation coefficients were 0.643 and 0.591 for pre- and postanesthesia scores, respectively. Application of topical anesthesia to the larynx and pharynx does not affect vocal fold motion.     

Strobovideolaryngoscopy in the management of acute laryngeal trauma

Surgical intervention in the management of acute laryngeal trauma can sometimes pose a difficult decision. The objective of this study is to evaluate the effectiveness of strobovideolaryngoscopy (SVL) in determining the course of management for patients sustaining acute laryngeal trauma. A 20-year retrospective study of patients presenting with acute laryngeal trauma was performed in order to determine if the addition of SVL during the study period changed the management of certain acute laryngeal injuries. Patients sustaining blunt laryngeal trauma evaluated at our institution from 1981 to the present were reviewed. There were 40 patients identified that were grouped by severity according to the Schaefer classification. Analysis included mechanism of injury, clinical presentation, assessment, treatment, and outcome. Group 1 injuries were the most common, with motor vehicle accident (MVA) the most frequent mechanism of injury. Initial assessment included fiberoptic laryngoscopy and computed tomography (CT) imaging in all patients not requiring immediate exploration. SVL was used in 20 patients, with 7 undergoing stroboscopy within 24 hours of presentation. All 7 patients were managed conservatively without surgical intervention or the need to establish an alternative airway. SVL improves the clinical assessment of patients with acute laryngeal injury. This study supports its use and found it to be an important factor in determining the need for surgical intervention. SVL may also shorten the hospital stay in these patients.     

Strobovideolaryngoscopy in professional voice users: Results and clinical value

Evaluation of the vibratory margin of the vocal fold is essential for accurate diagnosis and treatment of voice patients. Traditionally, physicians have performed this evaluation using their subjective impressions of the sound of the voice in conjunction with laryngoscopy under continuous light. Strobovideolaryngoscopy is a valuable addition to the diagnostic armementarium. It allows the physician to perform a proper physical examination of the vibratory margin. A review of 486 strobovideolaryngoscopy procedures in 343 voice patients during a 2-year period reveals that stroboscopic information influenced diagnosis or treatment in approximately one-third of the entities diagnosed.     

From Voice Clinic to Operating Room: Are We Out of Tune?

Introduction: To determine the consistency and accuracy of preoperative diagnosis in the voice clinic with intraoperative diagnosis and to suggest a standardized laryngeal examination protocol in the UK that is supported by evidence-based findings.Method: From January 2011-September 2014, 164 patients were referred to the Multidisciplinary Team voice clinic and diagnosed with laryngeal pathology that required phonosurgery. The visualization (videostrobolaryngoscopy) in clinic was performed using either rigid laryngoscope or a video-naso-laryngoscope. Intraoperatively, laryngeal visualization and surgical procedure was conducted using Storz Aida HD system, 10-mm rigid laryngoscope 0° or 5-mm rigid laryngoscope 0°/30° and a Zeiss S7 microscope.Results: Of the 164 patients seen in the multidisciplinary voice clinic, 86 clinic diagnoses were confirmed intraoperatively (52.4%), 15 patients had the diagnosis confirmed intraoperatively with additional lesion found (9.1%). The clinic diagnosis changed intraoperatively in 63 cases (38.4%). 61 (37.2%) patients seen in the voice clinic were diagnosed with cyst, in 39.3% the diagnosis was confirmed intraoperatively with 5 cases (8.2%) having an additional diagnosis. Twenty (12.2%) patients were diagnosed with polyps, with 80% confirmation intraoperatively; 3 patients (10%) had an additional diagnosis.Conclusion: Videolaryngostroboscopy imaging of the larynx provides an outpatient tool for accurately diagnosing more than 50% of laryngeal pathologies when interpreted by multidisciplinary voice clinicians. However direct laryngeal examination under general anesthesia remains the gold standard when obtaining accurate diagnoses of laryngeal pathology. Patients diagnosed with nonorganic voice disorders should be considered for direct laryngoscopy under general anesthetic should they fail to respond to conservative management.     

Laryngeal Hyperfunction During Whispering: Reality or Myth?

For years, otolaryngologists and voice therapists have warned voice patients that whispering causes more trauma to the larynx than normal speech. However, no large series of patients has ever been examined fiberoptically during whispering to test this hypothesis. As part of our routine examination, patients are asked to count from 1 to 10 in a normal voice and in a whispered voice. We reviewed recorded fiberoptic examinations of 100 patients who had voice complaints. We compared supraglottic hyperfunction and vocal fold closure during the normal and whispered phonation of each patient. Sixty-nine percent of the patients demonstrated increased supraglottic hyperfunction with whispered voice. Eighteen percent had no change, and 13% had less severe hyperfunction. The most common glottal configuration during whisper was an inverted Y, which resulted from compression of the anterior and middle thirds of the true vocal folds. However, 12 patients had no true vocal fold contact during whispered voice, despite having adequate glottic closure with normal voice. Although whispering involves more severe hyperfunction in most patients, it does not seem to do so in all patients. In some patients, it may be less traumatic than normal voice.     

Comparing the Long-Term Outcome of Immediate Postoperative Facial Nerve Dysfunction and Vocal Fold Immobility After Parotid and Thyroid Surgery

SUMMARY: Hypothesis: The long-term recovery rate of immediate postoperative facial nerve dysfunction with an electrophysiologically and anatomically intact facial nerve is higher than the long-term recovery rate of immediate postoperative vocal fold immobility with an electrophysiologically and anatomically intact recurrent laryngeal nerve. Methods: A retrospective review of parotid and thyroid surgery with electrophysiologic monitoring of the facial and recurrent laryngeal nerves, respectively. Results: Forty-five consecutive patients had electrophysiologic and anatomic integrity of the facial nerve at the conclusion of the parotidectomy. Eight of 45 (18%) patients developed a postoperative facial nerve dysfunction. All eight patients with facial nerve dysfunction had complete return of facial nerve function within 3 months. A total of 102 consecutive patients underwent dissection of the recurrent laryngeal nerve during thyroid surgery. Seven of 102 (7%) had immediate unilateral vocal fold dysfunction. All 102 had electrophysiologic and anatomic integrity of the recurrent laryngeal nerve at the conclusion of the procedure. Two of 102 (2%) have clinically complete permanent vocal fold dysfunction. Five of seven (71%) with immediate complete vocal fold immobility had complete return of mobility. Conclusions: A higher immediate postoperative rate of transient facial nerve dysfunction is reported compared with vocal fold immobility in parotid and thyroid surgery, respectively (P < 0.05). Immediate postoperative facial nerve dysfunction with an electrophysiologically response at 1 mA and an anatomically intact facial nerve during parotid surgery resulted in a complete return of function in all cases in this series. Immediate postoperative vocal fold immobility with an electrophysiological response at 1 mA and an anatomically intact recurrent laryngeal nerve had a 30% rate of being permanent in this series.     

Laryngostroboscopic Evaluation After Supracricoid Partial Laryngectomy

BACKGROUND: Supracricoid partial laryngectomy (SCPL) results in laryngeal preservation in more than 95% of patients with T2 glottic carcinoma. Postsurgical glottic function is characterized by an absence of vocal cords, and phonation quality is a key post-SCPL quality-of-life factor. OBJECTIVE: This investigation was designed to enhance post-SCPL vocal function, study anatomic function of the post-SCPL larynx, and correlate anatomic findings with perceptual and instrumented measurements of voice. METHOD: Twenty-five patients were included. All had undergone SCPL with cricoepiglottopexy for T2 glottic carcinoma. All patients were evaluated by laryngostroboscopic examination, voice sample recording, and instrumented voice analysis with the aim of gaining further insight into postoperative larynx function. Laryngostroboscopic parameters such as laryngeal occlusion, epiglottic length, arytenoid movement, and vibratory area were assessed. The perceptual evaluation was based on the GRBAS scale. Acoustic and aerodynamic parameters were recorded, including fundamental frequency (F0), intensity, jitter, shimmer, signal-to-noise ratio (SNR), oral airflow (OAF), maximum phonation time (MPT), and estimated subglottic pressure (ESGP). Nonparametric tests were used to compare laryngostroboscopic parameters with instrumented measurements and perceptual evaluations of voice quality. RESULTS: Correlations were established among occlusion, epiglottic length, and general grade of dysphonia. Oral air flow (P = 0.006) was found to be correlated with occlusion. Voice roughness was correlated with the presence of a clearly identifiable vibratory area (P = 0.003), whereas these vibratory areas were correlated with shimmer (P = 0.041), OAF (P = 0.001), and SNR (P = 0.001). The number of preserved arytenoids was not identified as a voice quality factor (P = 0.423). CONCLUSION: This study highlighted correlations between the laryngostroboscopic examination results and the perceptive and instrumented measurements of voice. Glottis occlusion and epiglottis length were found to be key factors for postoperative voice quality. These results should help to advance technical development on surgical techniques to enhance voice results.     

Electrophysiologic monitoring of the recurrent laryngeal nerves may not predict bilateral vocal fold immobility after thyroid surgery

Two cases of bilateral vocal fold immobility (VFI) after identification and preservation of the recurrent laryngeal nerves (RLNs) required tracheotomy until vocal fold recovery. The first patient underwent thyroid surgery without preoperative or postoperative evaluation of the vocal folds, administration of postoperative intravenous steroids, or electrophysiologic monitoring of the RLNs, whereas the second patient underwent a thyroid procedure in which all of the aforementioned were executed. Preoperative and postoperative clinical evaluation of the RLNs is strongly suggested in patients undergoing thyroid surgery, especially revision surgery. Patients potentially undergoing total thyroidectomy should be counseled about the remote chance of airway obstruction and should be properly selected for this operation. Subclinical stretching of the RLNs or ischemia from the endotracheal tube cuff can result in unilateral VFI, and rarely bilateral VFI, requiring reintubation, tracheotomy, or vocal fold lateralization. Electrophysiologic monitoring may not always predict bilateral VFI.     

Extrinsic Laryngeal Muscular Tension in Patients with Voice Disorders

The objective of this study was to establish a standard clinical evaluation tool for assessment by palpation of extrinsic laryngeal muscular tension (ELMT) and investigate the relationship between ELMT and different voice disorder diagnosis categories, particularly muscle misuse dysphonia (MMD), and the presence or absence of gastroesophageal reflux (GER). A palpation technique and tension grading system for four separate muscle groups (suprahyoid, thyrohyoid, cricothyroid, and pharyngolaryngeal) were established. 465 patients, 65% female and 35% male, were assessed sequentially and ELMT results were analyzed in relation to diagnosis and reflux status. A strong relationship was found between thyrohyoid muscle tension and both GER and MMD (p < or = 0.01). Thyrohyoid muscle tension is the only group that demonstrated a significant relationship with MMD. No significant difference in the ELMT scores was found between GER and non-GER patients, although a possible causal relationship was found between MMD type 3 and reflux. It is postulated that palpation of extrinsic laryngeal muscles can yield important information about internal laryngeal postures and diagnosis of muscle misuse voice disorders, particularly MMD type 3 (anteroposterior supraglottic compression). Integration of this technique into routine laryngeal examination can be a significant aid to diagnostic accuracy.     

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.     

Bilateral Mixed Laryngoceles: Simultaneous Strobovideolaryngoscopy and External Video Examination

A music medicine practice affords a unique opportunity to diagnose and treat laryngeal music performers. Strobovideolaryngoscopic (SVL) and external video examination of the voice professional or brass instrument player may focus on the vocal folds, yet abnormalities of the supraglottis, neck, and thorax should be appreciated and documented. Laryngoceles are uncommon laryngeal disorders but may occur in up to 5% of benign laryngeal lesions. While many laryngoceles are asymptomatic, they may cause a cough, hoarseness, stridor, sore throat, pain, snoring, or globus sensation. In particular, musicians who play brass instruments are at high risk for laryngocele development. We highlight two patients with symptomatic laryngoceles to present anatomical, historical, classification, epidemiological, diagnostic, and management considerations.     

Effects of Inhalatory Abdominal Wall Movement on Vertical Laryngeal Position During Phonation

The configuration of the body resulting from inhalatory behavior is sometimes considered a factor of relevance to voice production in singing and speaking pedagogy and in clinical voice therapy. The present investigation compares two different inhalatory behaviors: (1) with a "paradoxical" inward movement of the abdominal wall, and (2) with an expansion of the abdominal wall, both with regard to the effect on vertical laryngeal position during the subsequent phonation. Seventeen male and 17 female healthy, vocally untrained subjects participated. No instructions were given regarding movements of the rib cage. Inhaled air volume as measured by respiratory inductive plethysmography, was controlled to reach 70% inspiratory capacity. Vertical laryngeal position was recorded by two-channel electroglottography during the subsequent vowel production. A significant effect was found; the abdomen-out condition was associated with a higher laryngeal position than the abdomen-in condition. This result apparently contradicted a hypothesis that an expansion of the abdominal wall would allow the diaphragm to descend deeper in the torso, thereby increasing the tracheal pull, which would result in a lower laryngeal position. In a post-hoc experiment including 6 of the subjects, body posture was studied by digital video recordings, revealing that the two inhalatory modes were clearly associated with postural changes affecting laryngeal position. The "paradoxical" inward movement of the abdominal wall was associated with a recession of the chin toward the neck, such that the larynx appeared in a lower position in the neck, for reasons of a postural change. The results suggest that the laryngeal position can be affected by the inhalatory behavior if no attention is paid to posture, implying that instructions from clinicians and pedagogues regarding breathing behavior must be carefully formulated and adjusted in order to ensure that the intended goals are reached.