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.     

Sex hormones and the female voice

In the following, the authors examine the relationship between hormonal climate and the female voice through discussion of hormonal biochemistry and physiology and informal reporting on a study of 197 women with either premenstrual or menopausal voice syndrome. These facts are placed in a larger historical and cultural context, which is inextricably bound to the understanding of the female voice. The female voice evolves from childhood to menopause, under the varied influences of estrogens, progesterone, and testosterone. These hormones are the dominant factor in determining voice changes throughout life. For example, a woman's voice always develops masculine characteristics after an injection of testosterone. Such a change is irreversible. Conversely, male castrati had feminine voices because they lacked the physiologic changes associated with testosterone. The vocal instrument is comprised of the vibratory body, the respiratory power source and the oropharyngeal resonating chambers. Voice is characterized by its intensity, frequency, and harmonics. The harmonics are hormonally dependent. This is illustrated by the changes that occur during male and female puberty: In the female, the impact of estrogens at puberty, in concert with progesterone, produces the characteristics of the female voice, with a fundamental frequency one third lower than that of a child. In the male, androgens released at puberty are responsible for the male vocal frequency, an octave lower than that of a child. Premenstrual vocal syndrome is characterized by vocal fatigue, decreased range, a loss of power and loss of certain harmonics. The syndrome usually starts some 4-5 days before menstruation in some 33% of women. Vocal professionals are particularly affected. Dynamic vocal exploration by televideoendoscopy shows congestion, microvarices, edema of the posterior third of the vocal folds and a loss of its vibratory amplitude. The authors studied 97 premenstrual women who were prescribed a treatment of multivitamins, venous tone stimulants (phlebotonics), and anti-edematous drugs. We obtained symptomatic improvement in 84 patients. The menopausal vocal syndrome is characterized by lowered vocal intensity, vocal fatigue, a decreased range with loss of the high tones and a loss of vocal quality. In a study of 100 menopausal women, 17 presented with a menopausal vocal syndrome. To rehabilitate their voices, and thus their professional lives, patients were prescribed hormone replacement therapy and multi-vitamins. All 97 women showed signs of vocal muscle atrophy, reduction in the thickness of the mucosa and reduced mobility in the cricoarytenoid joint. Multi-factorial therapy (hormone replacement therapy and multi-vitamins) has to be individually adjusted to each case depending on body type, vocal needs, and other factors.     

A comparison of injection techniques using botulinum toxin injection for treatment of the spasmodic dysphonias

The benefit duration and side effects following effective treatment of spasmodic dysphonia or voice tremor using botulinum toxin injection were studied following 477 open trial unilateral or bilateral injections provided to 178 patients. A comparison of unilateral and bilateral injections in male and female patients with adductor spasmodic dysphonia demonstrated an increased benefit duration following unilateral injections in women, longer periods of breathiness in men than in women following bilateral or unilateral injections, and a trend for reduced benefit durations following repeated treatments using bilateral injections. Outcomes were similar in the adductor spasmodic dysphonia and vocal tremor groups following thyroarytenoid injection while benefit durations were reduced and side effects lasted longer in patients with abductor spasmodic dysphonia following cricothyroid injections. Long-term benefit > 1 year occurred in 12.3% of patients following injection.     

Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: A 3-year retrospective

Unilateral vocal fold paralysis is now considered a common disorder seen in the practice of otolaryngology and voice pathology. Concern first is for the accurate diagnosis of the associated etiology in an efficient and thorough fashion. When etiology has been determined the focus of treatment becomes the management of the presenting symptoms, which typically include dysphonia and dysphagia. A retrospective study was conducted reviewing the records of 117 patients with unilateral adductor vocal fold paralysis who presented to a large otolaryngology practice and clinical voice lab from 1995 to 1998. Demographic data reveal most patients to range in age from 16 to 91 with a dominant clustering for ages 50 to 70. Gender distribution reveals males slightly exceed females in this sample. Data regarding etiology type are collected in great detail, revealing that disease and surgery involving the chest contribute the greatest to the overall number in this study and that anterior approach to cervical spine surgery contributes as much as thyroid surgery. General outcomes of the patients are reviewed. A small group (n = 25) of patients who had pretreatment and posttreatment data available revealed statistically significant differences between voice outcomes for patients who were treated with medialization and for those treated with therapy. Patients receiving therapy had less severe symptoms pretreatment, while greater gains pretreatment to posttreatment were shown for those who had surgical medialization.     

Acute and Subacute Awake Injection Laryngoplasty for Thoracic Surgery Patients

SUMMARY: The rehabilitation of glottic incompetence by injection laryngoplasty is important in the management of thoracic surgery patients with vocal cord paralysis. This group of patients presents special considerations that favor injection under local anesthesia. The objective of this study is to characterize our experience with this minimally invasive approach in both the acute and subacute settings. The study was conducted using a retrospective chart review. From a database of 108 patients who received awake percutaneous injection laryngoplasty over a 3-year period, 15 cases were identified that underwent augmentation shortly following thoracic surgery. These records were reviewed for patient demographics, clinical characteristics, complications, and short-term outcomes. Fifteen patients were identified (12 male, 3 female); the age range for the group was 18-91 years (median=55 years). All the patients reported vocal improvement following injection; all 15 also were improved by perceptual assessment. Five of six dysphagic patients improved following injection. One patient's injection was aborted due to vocal fold edema; no significant bleeding or airway embarrassment was observed. No procedures were terminated because of patient discomfort. Awake percutaneous injection laryngoplasty for vocal paralysis can be performed safely in the postoperative thoracic surgery patient. Swallowing and voice complaints were almost universally improved following treatment. For patients who cannot tolerate or choose not to have open thyroplasty or vocal fold injection under general anesthesia, this procedure may offer a safe and effective alternative.     

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.     

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.     

Vocal quality characteristics in children with cleft palate: a multiparameter approach

The main purpose of the present study was to examine the vocal quality and to investigate the effects of gender on vocal quality in 28 children with a unilateral or bilateral cleft palate. In this study, the vocal quality was determined using videolaryngostroboscopic and perceptual evaluations, aerodynamic, voice range, acoustic, and dysphonia severity index (DSI) measurements. The DSI is based on the weighted combination of four voice measurements and ranges from +5 to -5 for, respectively, normal and severely dysphonic voices. Additional objectives were to compare the vocal quality characteristics of children with cleft palate with the available normative data and to investigate the impact of the cleft type on vocal quality. Gender-related vocal quality differences were found. The male cleft palate children showed an overall vocal quality of +0.62 with the presence of a perceptual slight grade of hoarseness and roughness. The female vocal quality had a DSI value of +2.4 reflecting a perceptually normal voice. Irrespective of the type of cleft, all subjects demonstrated a significantly lower DSI-value in comparison with the available normative data. The results of the present study have provided valuable insights into the vocal quality characteristics of cleft palate children.     

Quantitative assessment of voice quality following laser surgery for reinke''s edema

Although laser surgery has been widely advocated for use in the treatment of vocal fold papilloma because it does not incur bleeding, it has been questioned for use in treating Reinke's edema due to the possibility of heat dispersion to normal surrounding tissue and of scarring. We present a series of 8 cases in which laser surgery was the method of treatment for bilateral Reinke's edema. In each case, voice therapy was selected as the initial treatment; laser surgery was performed following voice therapy. Prior to and following surgery, videostroboscopic examinations were performed on the subjects. Only 4 subjects were available for assessment at the 1-month postoperative period. From the audio track of the videotape, the speaking fundamental frequency, perturbation measures for the vowel /i/, and noise-to-harmonic ratio of a completely voiced sentence were obtained. From the videostroboscopic recordings, the symmetry of the vocal folds, the presence or absence of the mucosal wave and the glottic closure pattern, prior to and after surgery, were judged independently by 3 examiners. The fundamental frequencies approximated the normal male and female ranges for those subjects seen 1 month after surgery. In addition, the noise-to-harmonic ratio and the relative average perturbation improved. Stroboscopy revealed irregularities in the symmetry of vocal folds, mucosal wave, and glottic closure 1 month after surgery.     

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.     

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.     

Analysis of Voice and Quantitative Measurement of Glottal Gap After Thyroplasty Type I in the Treatment of Unilateral Vocal Paralysis

Thyroplasty type I is one of several surgical treatments in which improving the voice of unilateral vocal fold paralysis is the ultimate objective. The goal of the surgery is the medialization of the paralyzed vocal fold. The purpose of this study is to evaluate the effectiveness of thyroplasty type I through acoustical analysis, aerodynamic measures, and quantitative videostroboscopic measurements. We report on 20 patients with unilateral vocal cord paralysis who underwent thyroplasty type I. We performed preoperative and postoperative video image analysis (normalized glottal gap area) and computer-assisted voice analysis (fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, mean phonation time, mean flow rate, mean subglottic pressure) in all patients. The glottal gap was significantly reduced after thyroplasty type I. Postoperative voice quality was characterized by an improved pitch and amplitude pertubation (jitter and shimmer), phonation time (mean phonation time), and subglottic pressure (mean subglottic pressure). Thyroplasty type I is an effective method for regaining glottal closure and vocal function.     

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.     

Vocal fold augmentation with injectable calcium hydroxylapatite: short-term results.

Symptoms of unilateral vocal fold paralysis are improved significantly by augmenting the paralyzed vocal fold via vocal fold injection. In this trial, augmentation with a new calcium hydroxylapatite implant was evaluated. In addition, two different phonosurgical injection techniques were used, and these procedures were compared for accuracy and reliability. A total of 11 terminal patients with unilateral vocal fold paralysis underwent vocal fold injection with calcium hydroxylapatite. Efficacy of the implant was evaluated by comparing results from the Voice Handicap Index (VHI) and mean airflow measurements before and 6 months after injection. Surgeon evaluations determined the comparative benefits of either endoscopic direct vocal fold injection or percutaneous vocal fold injection. Six-month data were obtained for a cohort of five patients. VHI scores improved for all five patients available for full evaluation and four of the five achieved improvements in mean airflow rates. Of the remaining patients, one later had a medialization laryngoplasty, two died from their terminal diseases before the 6-month follow-up, and two of the remaining three reported satisfaction with the results via telephone follow-up. Vocal fold injection via endoscopic, direct laryngoscopy was found to be a more reliable procedure for vocal fold injection than percutaneous injection. Slight overinjection (10% to 15%) was found to provide optimum results. Vocal fold injection of calcium hydroxylapatite for unilateral vocal fold paralysis improved voice quality and reduced mean airflow rates in this patient group with short-term results. Long-term studies are needed to confirm the durability of these findings.     

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.     

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.     

Hoarseness Due to Bamboo Nodes in Patients with Autoimmune Diseases: A Review of Literature

SUMMARY: This is a retrospective report on clinical features, laryngoscopic examinations, and follow-up markers of laryngeal manifestation described as bamboo nodes in three female patients with transverse cystic lesions of the vocal folds, treated with logopedic therapy. This study examines logopedic and phoniatric aspects in patients with submucosal "bamboo joint-like nodes" of both vocal folds, and reveals an improvement of different voice quality features after conservative traditional voice therapy. There still exists no standard treatment regimen in patients with rheumatoid disease of the larynx; a lack of consensus is most evident in the role of voice therapy. We would like to emphasize the favorable impact of logopedic therapy in benign laryngeal disorders with underlying autoimmune diseases.     

Long-term preservation of voice improvement following surgical medialization and reinnervation for unilateral vocal fold paralysis

In June of 1996, we reported improved functional voice results when reinnervation was combined with surgical medialization for unilateral vocal fold paralysis. In addition, it was noted that further wasting of the reinnervated vocal fold was prevented in 96% of these patients beyond 2 years' follow-up. The study reported here compares the long-term preservation of voice improvement achieved by surgical medialization alone with that resulting from combined medialization and nerve-muscle pedicle reinnervation. Further significant wasting of the paralyzed vocal fold with voice deterioration from that achieved by surgical medialization alone was noted between 6 months and 2 years postoperatively in 28% of patients, while only 4% of those undergoing combined reinnervation demonstrated this finding at a minimum of 2 years' follow-up.     

Vocal Nodules and Laryngeal Morphology

Our purpose was to study the occurrence of vocal fold nodules under conditions of habitual vocal abuse associated with increased laryngeal muscle tension, to identify the existence of a relationship between vocal nodules and laryngeal morphology. We studied one group of 30 subjects with vocal nodules, 18 to 50 years old, who were compared with two control groups, one of females and one of males, consisting of 30 subjects each. The parameters evaluated were: type of vocal folds coaptation, glottic proportion (GP) and abduction angle (AA), obtained by videotelelaryngoscopy. In the nodules group, the larynges presented a mean value of GP similar to that of the female group, both of which were lower than the mean GP value of the male group. On the other hand, the mean AA was lower than the one in the female group, and closer to the one in the male group. We concluded that vocal nodules were present only in larynges with a predominantly young female morphology, with functional limitations of abduction.     

Determining the etiology of mild vocal fold hypomobility

The prevalence of mild vocal fold hypomobility is unknown. In a study by Heman-Ackah et al, vocal fold hypomobility in a population of singing teachers was found to be associated more frequently with vocal complaints than was the presence of vocal fold masses.¹ The etiology of mild vocal fold hypomobility has not been previously explored. In the present study, a retrospective chart review was performed of 134 patients who presented to a tertiary laryngology referral center over a 6-month period for evaluation of vocal complaints. Of the 134 patients, 61 (46%) were found to have mild vocal fold hypomobility previously undiagnosed by the referring otolaryngologist. Imaging studies and laboratory tests to evaluate for structural, metabolic, and infectious causes of the decreased mobility had been ordered. Forty-nine patients completed the work-up. Of these, 41 out of 49 (84%) were found to have imaging or laboratory findings that could explain the hypomobility. Thyroid abnormalities were found to be associated with vocal fold hypomobility in 21 out of 49 (43%) of those with a complete evaluation. Other causes of vocal fold hypomobility included idiopathic (8 of 49, 16%), viral neuritis (5 of 49, 10%), central nervous system abnormality (4 of 49, 8%), neural tumor (3 of 49, 6%), joint dysfunction (3 of 49, 6%), iatrogenic nerve injury (2 of 49, 4%), myopathy (2 of 49, 4%), and noniatrogenic traumatic nerve injury (1 of 49, 2%), This study shows that unilateral vocal fold hypomobility often is associated with a physiologic process, and a complete investigation to determine the etiology is warranted in all cases.