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.     

Laryngeal Mechanisms During Human 4-kHz Vocalization Studied With CT, Videostroboscopy, and Color Doppler Imaging

The objective of this study was to investigate the underlying laryngeal mechanisms during the specific human 4-kHz vocalization. The laryngeal configuration during this vocalization was measured using high-resolution computerized tomographic scan and videostrobolaryngoscopy. The color Doppler imaging (CDI) of medical ultrasound was used to detect the vibrations of glottal and supraglottal mucosa. During the 4-kHz vocalization, the ventricular folds were adducted in the shape of a bimodal chink and the vocal folds were shaped as a "V" with an opening at the posterior glottis. In the coronal view, the laryngeal ventricles had collapsed and a divergent shaped conduit was observed at the posterior portion of the larynx. The surface mucosa vibration detected by CDI was noted over the bilateral ventricular folds and aryepiglottic folds. The vibration displacement was estimated to be on the order of 0.1mm. This vibration amplitude was too small to be detected in videostrobolaryngoscopy. The laryngeal configuration and CDI data suggested a diffuser jet with periodic vorticity bursts in the larynx producing 4 kHz voice.     

Sarcoidosis Presenting as Bilateral Vocal Fold Paralysis

Sarcoidosis with cranial polyneuritis and mediastinal granulomatous compression as a cause of unilateral left vocal fold paralysis has been reported infrequently. No case of sarcoidosis causing bilateral vocal fold paralysis in the abducted position has been reported in the Otolaryngology/Voice literature. Vocal fold function can be impacted in sarcoidosis by direct laryngeal involvement or by neural pathways. In the patient described in this case, sarcoid cranial polyneuritis coupled with bilateral paratracheal and mediastinal adenopathy resulted in bilateral vocal fold paralysis. This patient had a dramatic response to treatment with steroids. Sarcoidosis should be included in the differential diagnosis of unilateral or bilateral vocal fold paralysis.     

Speech breathing during reading in women withvocal nodules

This study examined speech breathing patterns during reading bywomen with bilateral vocal fold nodules judged as mildly dysphonic and by women without vocal nodules. Although it might be predictable that the speech breathing patterns of individuals with laryngeal dysfunction will differ from those without laryngeal dysfunction, there is a lack of empirical data to support such assumptions.The results of the current study indicated that glottal airflow was greaterduring reading for the women with vocal nodules and that a larger volume of air was expended both per syllable and per breath group during reading. The rate of speech did not significantly differ between the two groups of women. There was no significant difference for the average duration of the breath groups and no significant difference for the number of syllables spoken per breath group. Additionally, both groups of women demonstrated a similar pattern of inspiratory pause location during the reading. The results suggest that speech breathing patterns associated with dysphonia be examined independently to distinguish specifically the nature of the interaction between the laryngeal dysfunction and the speech breathing pattern. Certainly, more information on how the severity of a voice disorder influences speech breathing is necessary.     

Stroboscopic and acoustic measures of inspiratory phonation

Inspiratory phonation (IP) is the production of voice as air is taken into the lungs. Although IP is promoted as a laryngeal assessment and voice treatment technique, it has been described quantitatively in very few speakers. This study quantified changes in laryngeal adduction, fundamental frequency, and intensity during IP relative to expiratory phonation (EP). We hypothesized that IP would increase laryngeal abduction and fundamental frequency. The experiment was a within-subjects, repeated measures design with each subject serving as her own control. Participants were 10 females (ages 19-50 years) who underwent simultaneous transoral videostrobolaryngoscopy and acoustic voice recording. We found that membranous vocal fold contact decreased significantly during IP relative to EP, while the trends for change of ventricular fold squeeze during IP varied across individuals. Vocal fundamental frequency increased significantly during IP relative to EP, but intensity did not vary consistently across conditions. Without teaching or coaching, changes that occurred during IP did not carry over to EP produced immediately following IP within the same respiratory cycle.     

Laryngeal sarcoidosis presenting as an isolated submucosal vocal fold mass

Sarcoidosis can affect the larynx as a manifestation of systemic disease or as isolated laryngeal involvement. Classically, laryngeal involvement affects the supraglottis, and less commonly the subglottis, and true vocal fold involvement is rare. The clinical course is often highlighted by frequent exacerbations and remissions that, when associated with vague complaints and constitutional symptoms, are probably the greatest contributor to delayed presentation and diagnosis. We describe an unusual case of sarcoidosis that presented after a long and protracted clinical course as an isolated submucosal vocal fold mass requiring deep biopsy for diagnosis. A review of the literature with emphasis on diagnosis, appropriate airway management, and treatment is presented.     

Vocal fold and ventricular fold vibration in period-doubling phonation: physiological description and aerodynamic modeling

Occurrences of period-doubling are found in human phonation, in particular for pathological and some singing phonations such as Sardinian A Tenore Bassu vocal performance. The combined vibration of the vocal folds and the ventricular folds has been observed during the production of such low pitch bass-type sound. The present study aims to characterize the physiological correlates of this acoustical production and to provide a better understanding of the physical interaction between ventricular fold vibration and vocal fold self-sustained oscillation. The vibratory properties of the vocal folds and the ventricular folds during phonation produced by a professional singer are analyzed by means of acoustical and electroglottographic signals and by synchronized glottal images obtained by high-speed cinematography. The periodic variation in glottal cycle duration and the effect of ventricular fold closing on glottal closing time are demonstrated. Using the detected glottal and ventricular areas, the aerodynamic behavior of the laryngeal system is simulated using a simplified physical modeling previously validated in vitro using a larynx replica. An estimate of the ventricular aperture extracted from the in vivo data allows a theoretical prediction of the glottal aperture. The in vivo measurements of the glottal aperture are then compared to the simulated estimations.     

Treatment of spasmodic dysphonia (laryngeal dystonia) with local injections of Botulinum toxin

In 1984 the authors performed the first laryngeal injection of Botulinum toxin for laryngeal dystonia via percutaneous, electromyographically guided technique. Since that time we have treated 450 patients with adductor spasmodic dysphonia, abductor spasmodic dysphonia, and adductor breathing dystonia. In general, the adductor patients received bilateral injections of 1.25 U to 3.75 U, obtaining greater than 90% of normal voice. The abductor patients received unilateral or staged bilateral injections of the posterior cricoarytenoid muscles with 0.6 to 3.75 U, obtaining 70% of normal function. We have found laryngeal injections of Botulinum toxin to be safe and effective therapy for the symptoms of laryngeal dystonia (spasmodic dysphonia).     

Does botulinum toxin alter laryngeal secretionsand mucociliary transport?

Localized botulinum toxin injection disrupts cholinergic transmissionand has potential to cause focal dysautonomia. Mucociliary transport and laryngeal secretions are thought to be mediated in part by autonomic, cholinergic transmission. We questioned whether patients who receive Botox® injection for adductor spasmodic dysphonia (ADSD) report postinjection symptoms possibly related to altered mucociliary clearance or laryngeal secretions. Medical histories, audiotaped interviews, and symptom ratings were retrospectively examined for 29 patients with ADSD who were followed after one or more Botox injections. Patients had received bilateral, percutaneous Botox injections of 2.5 units using an EMG-guided approach. One or more weeks after injection, four patients reported either burning, tickling, or irritation of the larynx/throat, excessive thick secretions, or dryness. Symptoms recurred with subsequent injections in two patients and were not associated with swallowing difficulty. These symptoms are consistent with, but not diagnostic of, the known effects of botulinum toxin on cholinergic, autonomic transmission.     

Migration of the anterior segment following anterior commissure advancement: A case report

A 53-year-old man with severe vocal fold atrophy underwent bilateral type 1 thyroplasty and anterior commissure advancement. Postoperatively, he developed a strained voice with less projection and volume than prior to surgery. This was verified by objective assessment of vocal function. Videoendoscopy revealed bilateral false vocal fold fullness and blunting of the anterior commissure. Magnetic resonance imaging demonstrated cephalic migration of the posterior ends of the implants and retrusion of the anterior commissure segment. Surgical exploration revealed that the type 1 implants had rotated and buckled. The anterior commissure segment was rotated and displaced inferiorly, and its inferior surface was tethered to the cricoid by scar tissue. The implants were removed, the anterior segment was repositioned and rigidly fixed, and bilateral lipoinjection performed. Vocal function was significantly improved, and endoscopy revealed normal tension and length of the vocal folds and restoration of the anterior commissure. This case demonstrates the importance of stable fixation during laryngeal framework surgery     

Cyclicity of laryngeal cavity resonance due to vocal fold vibration

Acoustic effects of the time-varying glottal area due to vocal fold vibration on the laryngeal cavity resonance were investigated based on vocal tract area functions and acoustic analysis. The laryngeal cavity consists of the vestibular and ventricular parts of the larynx, and gives rise to a regional acoustic resonance within the vocal tract, with this resonance imparting an extra formant to the vocal tract resonance pattern. Vocal tract transfer functions of the five Japanese vowels uttered by three male subjects were calculated under open- and closed-glottis conditions. The results revealed that the resonance appears at the frequency region from 3.0 to 3.7 kHz when the glottis is closed and disappears when it is open. Real spectra estimated from open- and closed-glottis periods of vowel sounds also showed the on-off pattern of the resonance within a pitch period. Furthermore, a time-domain acoustic analysis of vowels indicated that the resonance component could be observed as a pitch-synchronized rise-and-fall pattern of the bandpass amplitude. The cyclic nature of the resonance can be explained as the laryngeal cavity acting as a closed tube that generates the resonance during a closed-glottis period, but damps the resonance off during an open-glottis period.     

The treatment of essential voice tremor with botulinum toxin A: A longitudinal case report

The purpose of this study was to evaluate the effects of bilateral botulinum toxin injection into the thyroarytenoid (TA) muscles of a patient with essential voice tremor. Acoustic and aerodynamic data were collected weekly over a 16-week period. Flexible nasolaryngoscopy was performed prior to injection and 2, 6, 10, and 16 weeks postinjection. Perceptual analyses of the acoustic and nasolaryngoscopic data were performed. A reduction in frequency tremor and, to a lesser extent, amplitude tremor was observed during the 1-10 week period. Estimated laryngeal resistance decreased after injection and was accompanied in perceptual measures by a reduction in vocal effort, laryngeal tremor, and supraglottic hyperfunction. Essential voice tremor can be successfully attenuated with bilateral percutaneous injection of botulinum toxin A into the vocalis muscle.     

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.     

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.     

Endoscopic and stroboscopic description of adults with paradoxical vocal fold dysfunction

The purpose of this study was to determine if endoscopic and stroboscopic parameters of voice were normal between attacks of paradoxical vocal fold dysfunction (PVFD). Fifty adults (38 females, 12 males) and 54 adult controls (40 females, 14 males) were examined via endoscopy with and without stroboscopy. Endoscopy indicated paradoxical adduction of the folds during the respiratory cycle of all 50 participants with PVFD, although they were asymptomatic. Atypical laryngeal configurations were observed including abnormality of the anterior-posterior dimension and ventricular fold medialization in both groups of subjects. Stroboscopy demonstrated abnormalities including unstable zero phase, decreased amplitude of vibration, decreased mucosal waves, and phase asymmetry primarily for the PVFD subjects alone. Results indicate that persons with PVFD demonstrate subtle laryngeal abnormality endoscopically and stroboscopically when dyspnea is not reported. This supports the hypothesis that PVFD is not episodic but exists as a continuum of laryngeal instability that may, due to various precipitating factors, be exacerbated to breathing attacks.     

Differential diagnosis of spasmodic dysphonia: A kinematic perspective

Although originally considered an hysterical functional disorder, spasmodic dysphonia (SD) appears to be a heterogeneic symptom complex that is associated with several neurological diseases. Perceptual, acoustic, and electromyographic studies have not clearly differentiated the underlying pathologies that result in spasmodic phonatory dysfunction. Kinematic analysis of documented laryngeal examinations during phonation and respiration indicates that particular different movement disorders affect laryngeal function and are associated with spasmodic phonatory characteristics. The particular features of dystonia, tremors, myoclonus, and progressive supranuclear pathology should be recognized, since they may present with disease focal to the laryngeal muscles. Other movement disorders may also be associated with spasmodic phonatory abnormalities, but are less likely to be focal. Treatment of SD signs and symptoms is more likely to be successful and assessments of treatment more likely to be meaningful if the underlying pathophysiology of spasmodic phonatory behavior is identified.     

Mutual information analysis reveals bigeminy patterns in Andersen-Tawil syndrome and in subjects with a history of sudden cardiac death

Herein we introduce the Mutual Information Function (MIF) as a mathematical method to analyze ventricular bigeminy in certain pathological conditions of the heart known to be associated with frequent ventricular arrhythmias. In particular, we show that the MIF is sensitive enough to detect the bigeminy pattern in symbolic series from patients with Andersen-Tawil syndrome as well as in a group of patients from the Sudden Cardiac Death Holter Databases. The results confirm that MIF is an adequate method to detect the autocorrelation between the appearance of sinus and ventricular premature beats resulting in a bigeminy pattern. It is also shown that MIF reflects the bigeminy patterns as a function of the percentage of ventricular premature beats present in the symbolic series and also as a function of the percentage of bigeminy. The MIF was also useful to establish a consistent difference in the bigeminy pattern related to the diurnal and nocturnal periods presumably associated to the circadian rhythm of the heart. Understanding of the ventricular bigeminy patterns throughout 24-hours could provide some insights into the pathogenesis of ventricular tachyarrhythmias in these pathological conditions.     

Anterior-Posterior and medial compression of the supraglottis: signs of nonorganic dysphoniaor normal postures?

Summary: Two vocal tract postures commonly identified as hallmarks of nonorganic dysphonia are anterior–posterior and medial compression of the supraglottis. However, insufficient data exist to support their diagnostic utility. The purpose of this study was to compare these two postures in patients with nonorganic dysphonia and normal controls using interval data derived from quantitative measures of videostroboscopic images obtained with an oral endoscope. Retrospectively, 40 patients with nonorganic dysphonia and 40 normal controls were selected. Relative anterior–posterior compression (LO_AP) was calculated as the laryngeal outlet (LO) (the view of the true vocal folds during phonation) normalized to the anterior–posterior dimension in pixels. Relative ventricular fold medial compression (LO_W) was calculated as the laryngeal outlet normalized to the medial dimension in pixels. Results were as follows: (1) LO_AP was significantly greater for the dysphonic group, (2) the range of LO_AP values between the two groups overlapped considerably, (3) no significant difference was found between groups for LO_w, (4) the correlation between LO_AP and LO_W within each subject yielded r values of 0.71 and 0.67 for the nonorganic dysphonia and normal control groups, respectively. It is concluded that medial compression of the ventricular folds can be a normal laryngeal posture, and that although anterior–posterior compression is present in greater degree in dysphonics, it is sufficiently common in normals to question its utility as a diagnostic sign of phonatory dysfunction.     

Vocal fold hemorrhage associated with coumadin therapy in an opera singer

Vocal fold hemorrhage can represent a disastrous and potentially career ending injury to a singer or professional voice user. The risk factors of vocal fold hemorrhage, including laryngeal trauma, phonotrauma, aspirin and nonsteroidal antiinflammatories, and hormonal imbalances are well known. We present a case of an opera singer who developed recurrent vocal fold hemorrhage associated with coumadin anticoagulation therapy. This case highlights the importance of the risk of vocal fold hemorrhage to professional singers and professional voice users and offers an alternative to long-term coumadin therapy in this select population.     

Analysis of spasmodic dysphonia by aerodynamic and laryngostroboscopic measurements

Sequential assessment of laryngeal function using laryngostroboscopy and phonatory air flow assessment was carried out in 18 patients with spasmodic dysphonia (SD). Comparison was made between findings in patients before treatment (n = 18), after unilateral recurrent nerve block by lidocaine (n = 6), after bilateral injections of botulinum toxin (Botox) (n = 13), and prior to Botox reinjection (n = 3). Unilateral nerve block resulted in higher mean phonatory airflows than after bilateral Botox injections. Both unilateral nerve block and Botox injections increased fluctuant or alternating flow source (AC); however, unilateral nerve block resulted in more unmodulated airflow leakage. Phonation time on a single breath was longer than with Botox injection. Bilateral Botox injections resulted in better glottal closure, fewer instances of vocal fold level differences, and, better vocal fold vibrations with phase symmetry, as determined by laryngostroboscopy. Partial bilateral denervation using Botox resulted in laryngeal function, which appeared to be intermediate between that of tightly squeezed pretreatment status and a breathy voice with incomplete adduction after unilateral nerve block. Of all treatments assessed, bilateral partial denervation by Botox appeared to be the most physiologic in restoring normal vocal fold vibratory function and airflow.