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.     

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 SG-Ps 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.     

Communicative Suitability of Voice Following Radiotherapy for T1 Glottic Carcinoma: Testing the Reliability of a Rating Instrument

The objective of the study was to determine whether a communicative suitability rating instrument could be used in a meaningful way to assess functionality of voice following radiotherapy for T1 glottic cancer. Seventeen naive listeners judged the suitability of voice of a patient group with T1 glottic carcinoma (n = 20) just before treatment, a group of patients (n = 40) after radiotherapy, and a matched control group (n = 20) of normal speakers. Listeners rated suitability on a 10-point scale for 10 speaking situations, which supposedly make different demands. In order to validate scores on communicative suitability, ratings were related to perceptual voice quality evaluations and videolaryngostroboscopic evaluations. Results indicate that the concept of measuring listener judgments of communicative suitability of voice is basically sound. Raters are reliable and can discriminate between groups of normal and pathological voices. Patients with T1 glottic carcinoma (assessed before the start of treatment) have on average the least suitable voices. Following radiotherapy suitability is, on average, improved, but does not approach the suitability of normal voices. Ratings on communicative suitability were clearly related to perceptual voice quality aspects and videolaryngostroboscopic evaluations. A subset of three communicative suitability rating scales is recommended as part of the protocol for evaluating voice outcome after radiotherapy for early glottic cancer, besides perceptual evaluation of voice quality by trained and naive raters, videolaryngostroboscopy, acoustical analyses, and self-ratings of vocal performance.     

Determination of largest lyapunov exponents of vocal signal: Application to unilateral laryngeal paralysis

It has been shown that voice signal abnormalities, particularly in unilateral laryngeal paralysis (ULP), are not always randomly distributed and that "statistical" indexes of regularity, such as jitter and shimmer, may be unreliable in these cases. The techniques of nonlinear dynamics, particularly phase portraits, have been used to demonstrate that some of the abnormalities observed were the consequence of nonlinearity of glottic function. From a theoretical point of view, determination of Lyapunov exponents allows quantification of the complexity of the phase portraits. The authors studied vocal signals recorded in 12 normal subjects and 26 patients with ULP and calculated the largest Lyapunov exponent (LLE). In normal subjects, LLE mean value was 0.380 (SD = 0.182). In patients with ULP, LLE mean value was 0.570 (SD = 0.337). The difference is significant at P = 0.031. Determination of LLE was compared to more "classical" indexes such as jitter and oral airflow during phonation. A principal component analysis showed that information contained in LLE was not redundant but complementary to the other parameters.     

Perceptual and Acoustic Assessment of Voice Pathology and the Efficacy of Endolaryngeal Phonomicrosurgery

Values for acoustic voice measurements were obtained from 88 normal individuals and 98 pathological cases of mass lesions of vocal fold and 50 cases of unilateral vocal fold paralysis. Overall, all items reflecting perturbations of pitch and amplitude as well as glottal noise were significantly higher in the groups of patients compared with the normal group. The measurement of normalized noise energy (NNE) was found to be an optimum parameter for discrimination of normal/abnormal voices. The voices of patients with vocal fold nodules and vocal fold polyps were analyzed before endolaryngeal phonomicrosurgery (EPM) and 2 weeks after. Statistically significant (p < 0.01) improvement was achieved both in perceptual and acoustic analysis. EPM resulted in a significant decrease of mean jitter, shimmer, and NNE. Clinically, these measures provided documentable and measurable evidence of vocal function and were helpful for comparing patients with normal speakers. They also were useful for a thorough documentation of patient's voice pathology and for evaluation of the presurgical and postsurgical voice status.     

Acoustic Analysis of Voice Quality with or without False Vocal Fold Displacement After Cordectomy

Conventional cordectomy by means of a laryngofissure is one of the therapeutic options for treatment of early glottic cancer. To improve the poor voice quality related to this kind of operation, many authors have developed different techniques to repair the mucosal defect. We analyzed voice quality acoustically and compared it after cordectomy alone and after cordectomy with the reconstruction of the vocal cord in a group of 14 patients affected by T1 glottic carcinoma. All the patients underwent postoperative speech therapy. Three patients who underwent cordectomy with reconstruction showed the presence of diplophonia, while two patients without reconstruction showed the presence of bitonality. The differences of the acoustic parameters (jitter, shimmer, harmonic-to-noise ratio) between the two groups of patients were not statistically significant. Reconstruction of the vocal cord does not seem to improve voice quality after cordectomy even in combination with postoperative speech therapy.     

“Compensatory falsetto”: Effects on vocal quality

The term “compensatory falsetto”, for the purpose of this investigation, refers to the development of an abnormally high-pitched voice in the presence of laryngeal pathology where more socially acceptable lower pitched voice production is possible. The purpose of this investigation was to compare laryngeal compensations and their effects on objective measures of vocal function during production of compensatory falsetto voice. Eighteen patients with abnormally high-pitched voice in the presence of underlying laryngeal pathology were evaluated in the Department of Otolaryngology at the University of Miami School of Medicine from January 1988 through December 1992 and were diagnosed with “compensatory falsetto”. Vocal fold paralysis (n = 11) was the most common laryngeal pathology. Vibratory characteristics were evaluated through videostrobolaryngoscopic examination. Acoustic and aerodynamic parameters assessed included fundamental frequency, jitter rate, harmonic-to-noise ratio, glottal air flow, and maximum phonation time. Production of a higher-pitched voice appeared to improve glottic closure and decrease the amount of air loss during phonation. A corresponding increase in maximum phonation time and improvement in acoustic characteristics of jitter and harmonic-to-noise ratio was also observed.     

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.     

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.     

Examination of air usage during phonation: Correlations among test parameters

Correlations among parameters indicating air usage during phonation were investigated in 60 normal subjects and 1,545 voice patients. The parameters examined were maximum phonation time (MPT), mean air flow rate for maximum sustained phonation (MFRm), mean air flow rate for comfortable phonation (MFRc), and phonation quotient (PQ). In normal subjects, correlations among MPT, MFRm, and PQ were high, but those between MFRc and the others were moderate. In cases of paralysis and hypofunctional dysphonia, all correlations between the four parameters were high. In the cases of polyp, nodule, epithelial hyperplasia, glottic carcinoma, and hyperfunctional dysphonia, the correlation between MPT and MFRc was moderate or not significant. The low correlation between these parameters was associated with the variations in flow rate differences between maximum and comfortable phonations. The results suggest that measurement of all four parameters is not necessary in routine tests and that MPT and MFRc should be measured in most voice patients.     

Cepstral and Perceptual Investigations in Female Teachers With Functionally Healthy Voice

PurposeThe present study aimed at measuring the smoothed and non-smoothed cepstral peak prominence (CPPS and CPP) in teachers who considered themselves to have normal voice but some of them had laryngeal pathology. The changes of CPP, CPPS, sound pressure level (SPL) and perceptual ratings with different voice tasks were investigated and the influence of vocal pathology on these measures was studied.MethodEighty-four Finnish female primary school teachers volunteered as participants. Laryngoscopically, 52.4% of these had laryngeal changes (39.3% mild, 13.1% disordered). Sound recordings were made for phonations of comfortable sustained vowel, comfortable speech, and speech produced at increased loudness level as used during teaching. CPP, CPPS and SPL values were extracted using Praat software for all three voice samples. Sound samples were also perceptually evaluated by five voice experts for overall voice quality (10 point scale from poor to excellent) and vocal firmness (10 point scale from breathy to pressed, with normal in the middle).ResultsThe CPP, CPPS and SPL values were significantly higher for vowels than for comfortable speech and for loud speech compared to comfortable speech (P < 0.001). Significant correlations were found between SPL and cepstral measures. The loud speech was perceived to be firmer and have a better voice quality than comfortable speech. No significant relationships of the laryngeal pathology status with cepstral values, perceptual ratings, or voice SPLs were found (P > 0.05).ConclusionNeither the acoustic measures (CPP, CPPS, and SPL) nor the perceptual evaluations could clearly distinguish teachers with laryngeal changes from laryngeally healthy teachers. Considering no vocal complaints of the subjects, the data could be considered representative of teachers with functionally healthy voice.     

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.     

Traumatic vocal fold avulsion injury in a newborn

A full-term newborn developed respiratory compromise in the immediate postparturition period requiring urgent intubation. Evaluation of post-extubation stridor later the same day revealed an avulsion injury extending from the left vocal fold into the lateral glottic musculature. Primary repair was accomplished with anatomic realignment of the torn vocal fold and muscle. Endotracheal intubation was utilized for stenting and the patient was extubated following 3 days of paralysis with sedation. Follow-up examination revealed a reparative granuloma, which was lasered. Eight-week follow-up examination revealed normal vocal fold architecture. At 18 months the patient continues to have a normal voice and normal laryngeal development.     

The effect of head position on glottic closure in patients with unilateral vocal fold paralysis

The present study was designed to assess the effect of head position on glottic closure as reflected in airflow rates (open quotient and maximum flow declination rate), in patients with unilateral vocal fold paralysis. Ten patients, 2 males and 8 females ranging in age from 40 to 75, with a mean age of 57.3, served as subjects. Airflow measures were taken during sustained phonation of two vowels (/i/ and /a/) in 3 head positions (center, right, left). Vowels /i/ and /a/ were produced at subject's comfortable pitch and loudness, with random ordering of both vowel order and head orientation. Subjects were trained to focus eye gaze on right and left markers (70-degree angle) and a central marker at eye level directly in front of the subject. Theoretically, if turning the head during phonation alters the laryngeal anatomic relationship by bringing the vocal folds in closer proximity to one another, then airflow rate should lessen. Our results indicate that head position does not improve glottic closure in these patients, which is in contrast to previously published research.(1) Our results question the utility and underlying theoretical construct for the use of head turning as a therapeutic technique for improvement of voice in patients with unilateral vocal fold paralysis.     

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.     

Laryngeal adduction in resonant voice

The primary question in this study was whether subjects with nodules and subjects with healthy larynges would produce “resonant voice” with a similar laryngeal configuration. A second question regarded whether the electroglottographic closed quotient (EGG CQ) could be used to noninvasively distinguish resonant from other voice types. Twelve adult singers and actors served as subjects, including 6 persons with healthy larynges and 6 persons with nodules. Performers were used as an attempt to maximize token validity and stability. Subjects produced repeated tokens of resonant, pressed, normal, and breathy voice during sustained vowels. Laryngeal adduction was directly estimated using blinded, ordinal, visual-perceptual ratings based on videoscopic views of the larynx. EGG CQs were further calculated based on separate trials. The perceptual ratings indicated that subjects in both groups produced resonant voice with a barely adducted or barely abducted laryngeal configuration that was distinct from configurations for pressed and breathy (but not normal) voice. Previous literature suggests that this configuration may be relevant in many cases of voice therapy (I). Average CQs distinguished resonant from pressed voice, but inconsistently distinguished resonant from breathy voice. Further CQs were reliably different across healthy subjects and subjects with nodules. Thus, the utility of this measure to noninvasively estimate resonant voice may be limited, particularly without ongoing subject-specific calibration procedures.     

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.     

Acoustic analysis of voice in multiple sclerosis patients

The objective is to investigate the presence of dysphonic symptoms in multiple sclerosis (MS) patients and to compare quantitative acoustic parameters in multiple sclerosis patients and normal individuals. The method of study was an 8-month controlled cross-sectional that was carried out with 106 individuals (30 MS, 76 controls). Both groups included males and females from 20 to 55 years. Exclusion criteria were prior vocal disorder, laryngeal microsurgery, recent endotracheal intubation, tumors, laryngeal, lung or mediastinal metastases, respiratory disease, and other associated neurological diagnoses. For dysphonic symptoms (qualitative variables), associations were assessed using Mantel-Haenszel's chi2 test, with Yates correction or the Fisher exact test when necessary. Statistical significance was set at p< or =0.05. Dysphonia was observed in 70% of MS individuals versus 33% of controls (p=0.01). Association was found between MS and dysphonia (OR: 2.2, CI 95%: 1.13-4.25). Fundamental frequency was higher among MS patients (p=0.01). Fundamental frequency deviation was significantly higher in MS women (but not men) than controls (p=0.00). Jitter was higher in MS men than in all other groups (p=0.00). Results suggest that evaluation and treatment of MS patients should be revised, evaluating voice alterations in relation to other signs. MS seems to intensify gender effect on fundamental frequency deviation, noise, and jitter, with MS women presenting fewer voice variations than men.     

Acoustic Analyses of Sustained and Running Voices From Patients With Laryngeal Pathologies

In this paper, we investigated the acoustic characteristics of sustained and running vowels from normal subjects and patients with laryngeal pathologies. Perturbation methods (including jitter and shimmer), signal-to-noise ratio (SNR), and nonlinear dynamic methods (such as correlation dimension and second-order entropy) were used to analyze sustained and running vowels. We found that the sustained vowels and running voices from normal subjects and patients with laryngeal pathologies had low-dimensional dynamic characteristics. For sustained vowels, the analyses of jitter, shimmer, correlation dimension, and second-order entropy revealed significant differences between normal and pathological voices. For running voices, jitter and shimmer did not statistically discriminate between normal and pathological voices, but a significant difference was found for SNR, correlation dimension, and second-order entropy. The results suggest that nonlinear dynamic analysis and traditional SNR analysis may be valuable for the analysis of sustained and running vowels; perturbation analysis may be applicable for the analysis of sustained vowels but should be applied with caution for running voice analysis.     

Voice of Postradiotherapy Nasopharyngeal Carcinoma Patients: Evidence of Vocal Tract Effect

This study was aimed at identifying acoustic and physiological measures useful for monitoring voice changes in postnasopharyngeal patients with nonlaryngeal malignancies, and providing evidences of vocal tract effect on voice through comparisons between individuals with and without intact vocal tract. Simultaneous acoustic-electroglottographic signals recorded during phonation of vowels /i/ and /a/ sustained at habitual, high, and low pitch levels were compared among 10 postradiotherapy patients with nasopharyngeal carcinoma (NPC), 10 voice patients (VPs) with intact vocal tract, and 10 healthy individuals with normal voice (NORM). Results from a series of discriminant analyses revealed that the NPC group generally exhibited lower signal-to-noise (SNR) and open quotient (OQ) and higher Formant 1 frequency (F(1)) and speed quotient (SQ) than the NORM group. Unlike both VP and NORM groups, the NPC group failed to show a pitch effect on all voice measures, including OQ, SQ, percent jitter, percent shimmer, and SNR, suggesting an effect of radiotherapy and/or vocal tract on laryngeal behaviors. For the vowel /i/, on the other hand, only the NPC and NORM groups showed a pattern of pitch-dependent F(1) raising, a reflection of increased pharyngeal narrowing. These findings suggested that the pitch effect on laryngeal behaviors differed not only between individuals with intact vocal tract and those without but also between those with structural and dynamic changes of vocal tract.