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.     

Spatial arrangement of the structural elements ofvocal fold layers: An adjustment to the vibration process

It is well established that the multilayered structure of the vocal fold is highly adjusted to the requirements of the vibration process during phonation. There is also some partial data indicating that the spatial arrangement of each vocal fold layer corresponds to the functional requirements, and thus facilitate the phonation process. Nevertheless, all reports on the spatial arrangement of the vocal fold structures deal only with an individual element of the vocal fold histologic structure. The present study encompasses the spatial histologic analysis of all major elements of the vocal fold layers. It was demonstrated that the vocal fold epithelial cells, the connective and muscle fibers, and even the blood vessels run parallel to the vocal fold free edge, which indicates a high adjustment to the phonation requirements and the vibration process.     

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.     

Vestibular vocal fold behavior during phonation in unilateral vocal fold paralysis

Voice quality in patients with vocal fold paralysis can be affected by several factors, such as the position of the paralyzed vocal fold, its degree of atrophy, the configuration of its free edge, and the level differences between both vocal folds. Depending on the related vocal deficiency the patient will attempt to compensate using different maneuvers, such as increment of vocal tract and neck muscle contraction to improve glottal closure. This is probably one of the reasons why ventricular folds are frequently requested. The objective of this study is to analyze the behavior of the homolateral and contralateral vestibular folds to delineate patterns of vestibular motion during sustained phonation, in cases of unilateral vocal fold paralysis.     

Unilateral recurrent laryngeal nerve paralysis: A re-examination

Re-examination of flexible fiberoptic videotaped laryngeal images of 39 patients with unilateral recurrent laryngeal nerve paralysis (URLNP) by four observer-judges revealed consistent findings of a unilaterally appearing shorter vocal fold with asymmetry of the arytenoid complex on the involved side. No previous similar experience in otolaryngological training or practice has been encountered. Multiple discrepancies between and among observer-judges regarding vocal fold positions during phonation were encountered. Possible explanations are discussed. The need for further investigation to determine the mechanics causing these differences is stressed. It is suggested that for the present, such terms as median, paramedian, and intermediate be used in teaching and in practice as generalities only.     

Autologous fat implantation for vocal fold scar: A preliminary report

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

Phonotrauma associated with crying

Vocal fold hemorrhage often results in a sudden change in voice quality. Traumatic use of the voice (phonation or singing) is generally thought to be the cause of the vocal fold hemorrhage. The current report reviews three cases in which the traumatic event was crying. In one case, the patient's voice was only used for crying. All three patients were female and all were professional singers. The treatment of these individuals consisted of voice rest and subsequent phonomicrosurgery for lesions associated with the vocal fold hemorrhage. These case studies suggest that crying as a traumatic vocal behavior may result in vocal fold hemorrhage.     

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.     

The role of strap muscles in phonation—In vivo caninelaryngeal model

In spite of the presumed importance of the strap muscles on laryngealvalving and speech production, there is little research concerning the physiological role and the functional differences among the strap muscles. Generally, the strap muscles have been shown to cause a decrease in the fundamental frequency (F₀) of phonation during contraction. In this study, an in vivo canine laryngeal model was used to show the effects of strap muscles on the laryngeal function by measuring the F₀, subglottic pressure, vocal intensity, vocal fold length, cricothyroid distance, and vertical laryngeal movement. Results demonstrated that the contraction of sternohyoid and sternothyroid muscles corresponded to a rise in subglottic pressure, shortened cricothyroid distance, lengthened vocal fold, and raised F₀ and vocal intensity. The thyrohyoid muscle corresponded to lowered subglottic pressure, widened cricothyroid distance, shortened vocal fold, and lowered F₀ and vocal intensity. We postulate that the mechanism of altering F₀ and other variables after stimulation of the strap muscles is due to the effects of laryngotracheal pulling, upward or downward, and laryngotracheal forward bending, by the external forces during strap muscle contraction.     

Laryngeal function and vocal fatigue after prolonged reading in individuals with unilateral vocal fold paralysis

The purpose of the present study was to examine the effect of prolonged loud reading, intended to induce fatigue, on vocal function in adults with unilateral vocal fold paralysis (UVFP). Subjects were 20 adults, 37–60 years old, with UVFP secondary to recurrent laryngeal nerve paralysis. Subjective ratings and instrumental measures of vocal function were obtained before and after reading. Statistical analysis revealed subjects rated their vocal quality and physical effort for voicing more severely following prolonged loud reading, whereas expert raters did not detect a significant perceptual difference in vocal quality. Reading fundamental frequency (Fo) was significantly increased following prolonged loud reading, as were mean airflow rates at all pitch conditions. Maximum phonation times for comfort and low pitches significantly decreased during posttests. Multiple regression analyses revealed significant associations between ratings of posttest physical effort and select posttest measures. Interpretation of results indicates the prolonged loud reading task was successful in vocally fatiguing most of the UVFP subjects. Key physiologic correlates of vocal fatigue, in individuals with UVFP, include further reduction of glottic efficiency, resulting in decreased regulation of glottic airflow and a temporary destabilization of speaking fundamental frequency.     

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.     

Gender differences in vocal fold contact computed from electroglottographic signals: the influence of measurement criteria

EGGW is a phonatory parameter that can be derived from electroglottographic (EGG) signals and used to infer the relative degree of vocal fold contact. Vocal fold models predict that men will exhibit medial bulging of their vocal folds during phonation but women will not. These models lead us to expect gender differences in the magnitude of EGGW. Nevertheless, significant gender differences in EGGW for adults with normal voices have not been documented in previous studies when EGGW was computed from criterion lines placed at 25%-40% of the amplitude of the uninverted EGG wave form. We hypothesized that EGGW would better reflect gender differences in vocal fold adductory patterns if EGGW was computed from portions of the wave form that were associated with more vocal fold contact. EGGW was measured for seven men and seven women with normal voices. When EGGW was computed from segments of the wave form that were associated with relatively greater vocal fold contact (i.e., using criterion levels of > or = 55%), findings were consistent with the gender-specific adductory patterns that have been proposed from vocal fold models. Guidelines for appropriate placement of criterion lines when computing EGGW are discussed.     

Model-based classification of nonstationary vocal fold vibrations

Classification of vocal fold vibrations is an essential task of the objective assessment of voice disorders. For historical reasons, the conventional clinical examination of vocal fold vibrations is done during stationary, sustained phonation. However, the conclusions drawn from a stationary phonation are restricted to the observed steady-state vocal fold vibrations and cannot be generalized to voice mechanisms during running speech. This study addresses the approach of classifying real-time recordings of vocal fold oscillations during a nonstationary phonation paradigm in the form of a pitch raise. The classification is based on asymmetry measures derived from a time-dependent biomechanical two-mass model of the vocal folds which is adapted to observed vocal fold motion curves with an optimization procedure. After verification of the algorithm performance the method was applied to clinical problems. Recordings of ten subjects with normal voice and ten dysphonic subjects have been evaluated during stationary as well as nonstationary phonation. In the case of nonstationary phonation the model-based classification into "normal" and "dysphonic" succeeds in all cases, while it fails in the case of sustained phonation. The nonstationary vocal fold vibrations contain additional information about vocal fold irregularities, which are needed for an objective interpretation and classification of voice disorders.     

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.     

Inverse filtering

Inverse filtering is a noninvasive method of producing a glottogram thought to reflect the vibratory motions of the vocal fold. The flow glottogram provides information related to the type of phonation, the sound pressure level, the regularity of vocal fold vibrations, and to the presence or absence of vocal fold closure. Limited data, speech samples, filter tuning, and lack of unanimity on waveform display and interpretation have contributed to slow application of the techniques to the clinical population. The author argues the technique has utility in both diagnosis and treatment     

Deviant Vocal Fold Vibration as Observed During Videokymography: The Effect on Voice Quality

Videokymographic images of deviant or irregular vocal fold vibration, including diplophonia, the transition from falsetto to modal voice, irregular vibration onset and offset, and phonation following partial laryngectomy were compared with the synchronously recorded acoustic speech signals. A clear relation was shown between videokymographic image sequences and acoustic speech signals, and the effect of irregular or incomplete vocal fold vibration patterns was recognized in the amount of perceived breathiness and roughness and by the harmonics-to-noise ratio in the speech signal. Mechanisms causing roughness are the presence of mucus, phase differences between the left and right vocal fold, and short-term frequency and amplitude modulation. It can be concluded that the use of simultaneously recorded videokymographic image sequences and speech signals contributes to the understanding of the effect of irregular vocal fold vibration on voice quality.     

Paradoxical vocal fold movement: A case report

We present a case of one patient with respiratory stridor that was resolved by speech therapy. Paradoxical vocal fold movements were observed by flexible fiberoptic videolaryngoscopy in this patient during episodes of wheezing and dyspnea. Otherwise, normal vocal fold movement was observed in normal conditions of breathing (out of the crisis) and during phonation. Many different terms have been used to describe this entity in the literature, and it is crucial that clinicians recognize the subtle signs of functional stridor. Paradoxical vocal fold motion has to be considered as an important cause of respiratory disease. Its recognition and treatment are discussed in this report.     

Influence of supraglottal structures on the glottal jet exiting a two-layer synthetic, self-oscillating vocal fold model

A synthetic two-layer, self-oscillating, life-size vocal fold model was used to study the influence of the vocal tract and false folds on the glottal jet. The model vibrated at frequencies, pressures, flow rates, and amplitudes consistent with human phonation, although some differences in behavior between the model and the human vocal folds are noted. High-speed images of model motion and flow visualization were acquired. Phase-locked ensemble-averaged glottal jet velocity measurements using particle image velocimetry (PIV) were acquired with and without an idealized vocal tract, with and without false folds. PIV data were obtained with varying degrees of lateral asymmetric model positioning. Glottal jet velocity magnitudes were consistent with those measured using excised larynges. A starting vortex was observed in all test cases. The false folds interfered with the starting vortex, and in some cases vortex shedding from the false folds was observed. In asymmetric cases without false folds, the glottal jet tended to skew toward the nearest wall; with the false folds, the opposite trend was observed. rms velocity calculations showed the jet shear layer and laminar core. The rms velocities were higher in the vocal tract cases compared to the open jet and false fold cases.     

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.     

Optimal glottal configuration for ease of phonation

Recent experimental studies have shown the existence of optimalvalues of the glottal width and convergence angle, at which the phonation threshold pressure is minimum. These results indicate the existence of an optimal glottal configuration for ease of phonation, not predicted by the previous theory. In this paper, the origin of the optimal configuration is investigated using a low dimensional mathematical model of the vocal fold. Two phenomena of glottal aerodynamics are examined: pressure losses due to air viscosity, and air flow separation from a divergent glottis. The optimal glottal configuration seems to be a consequence of the combined effect of both factors. The results agree with the experimental data, showing that the phonation threshold pressure is minimum when the vocal folds are slightly separated in a near rectangular glottis.