Longitudinal Effects of Botulinum Toxin Injections on Voice-Related Quality of Life (V-RQOL) for Patients with Adductory Spasmodic Dysphonia

Adductory spasmodic dysphonia is a focal dystonia of laryngeal muscles. Patients with this disorder typically have severe vocal difficulties, with significant functional, social, and emotional consequences. There is no widely accepted cure for this condition, however, botulinum toxin injections of the thyroarytenoid muscles are considered by most voice clinicians to be the state of the art treatment. Based on extensive experience treating patients for adductory spasmodic dysphonia, we feel that traditional means of voice assessment do not adequately measure either the disease severity or the treatment outcomes. That is, listening to or acoustically analyzing limited phonatory samples does not capture the functional, social, and emotional consequences of this disorder. These consequences will be reflected in a patient's voice-related quality of life (V-RQOL). Using a validated voice outcomes instrument, the V-RQOL Measure, the purpose of this study was to quantify longitudinal changes in the V-RQOL of patients with adductory spasmodic dysphonia who are undergoing botulinum toxin injections. Twenty-seven consecutive new patients presenting with dysphonia to our institution during an 18-month period were diagnosed with adductory spasmodic dysphonia, and treated patients were evaluated prospectively using the V-RQOL Measure. Results indicated that (1) V-RQOL was initially very low for these patients, (2) botulinum toxin injections improved it significantly for each injection cycle studied, and (3) the magnitude of the treatment effect appears to change across injections.     

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.     

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.     

Validation of an instrument to measure voice-related quality of life (V-RQOL)

When a patient presents for care of a voice disorder, the clinician attempts to diagnose the problem, quantify the degree of dysphonia, and prescribe appropriate treatment. Quantification of the degree of dysphonia is often difficult, as no universal index of vocal function exists. Decisions about the nature and intensity of treatment are often based on the magnitude of the voice-related problems experienced by the patient and the importance that the patient places on those problems, that is, the impact that the voice disorder is having on the patient's voice-related quality of life (V-RQOL). Measurement of post-treatment outcome is also not standardized. Regardless of how the clinician measures response to treatment, it will typically be measured by the patient in terms of how his or her voice-related problems are affected by the treatment.

Measurement of quality of life has not been a traditional part of the evaluation of the dysphonic patient. This study was undertaken to develop and validate an instrument for measuring V-RQOL using a population of 109 voice and 22 non-voice patients. The 10-item V-RQOL measure performs well in tests of reliability, validity, and responsiveness, and it carries a low burden. Measurement of V-RQOL is a valuable addition to the evaluation of dysphonic patients and their treatment outcomes.     

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.     

Combined surgical medialization and nerve-muscle pedicle reinnervation for unilateral vocal fold paralysis: Improved functional results and prevention of long-term deterioration of voice

Including those patients that were the subject of our previous report in 1990 (1) a total of 52 patients with unilateral vocal fold paralysis have been managed by combined surgical medialization and nerve-muscle pedicle reinnervation. The technique has been modified only slightly since 1985, when the first such surgery was performed. Short- and long-term voice results determined by a panel of sophisticated listeners are reported, as well as details of patient selection and complications. Better functional results were noted than were observed with surgical medialization alone, and long-term deterioration of the voice improvement initially achieved was prevented with this technique.     

Voice-related Quality of Life in Laryngectomees: Assessment Using the VHI and V-RQOL Symptom Scales

The primary purpose of this study was to investigate the effect of the voice impairment across the physical, emotional, and functional domains in patients using valved speech following total laryngectomy with the help of two symptom specific scales. The study design used was a cross-sectional cohort. The setting was the Head and Neck Oncology Unit of a tertiary referral centre. Subjects were 54 patients who had undergone total laryngectomy. Two voice-specific questionnaires, the Voice-Related Quality of Life (V-RQOL-short form) Measure, and the Voice Handicap Index (VHI-long form) were used. The main outcome measure was patient perception of the voice following total laryngectomy in response to specific questions correlated with sociodemographic/treatment factors. Responses were received from 40 males and 14 females (response rate of 85.7%) with a median age of 63.4 years (range: 37-84). The V-RQOL overall analysis showed that 3 patients (5.6%) scored "excellent," 29 patients (53.7%) "fair to good," 14 patients (25.9%) "poor to fair," and 8 patients (14.8%) "poor." Analysis of the VHI revealed that 20 patients (37.0%) had a minimal handicap, 20 patients (37.0%) a moderate handicap, and 14 patients (25.9%) had a serious voice handicap. The individual domain or subscale scores for the VHI revealed a mean (SD) functional score of 15.8 (7.7), a physical score of 13.6 (7.2), and finally an emotional score of 11.6 (8.9). Functional aspects of the voice were significantly affected by age, radiotherapy, and chemotherapy (Spearman rho, P=0.01; Mann-Whitney, P=0.04 and P=0.01). The physical aspects of the voice were significantly affected by age and chemotherapy (Spearman rho, P=0.004; Mann-Whitney, P=0.04). Only age significantly affected the emotional aspects of the voice (Spearman rho, P=0.002). We found a strong correlation (Spearman rho, P<0.001) between the V-RQOL and VHI questionnaires. Our study revealed that the V-RQOL and VHI scores in our series of patients following voice restoration in laryngectomees were consistent with that reported in the literature. Only age, radiation, and chemotherapy were seen to influence the voice handicap scores. In addition, both symptom scales had good correlation between them and either one could be used with reliability in laryngectomees with a few modifications.     

Early results of transcutaneous injection laryngoplasty with micronized acellular dermis versus type-I thyroplasty for glottic incompetence dysphonia due to unilateral vocal fold paralysis

Medialization thyroplasty (type I) has become the gold standard to improve glottic closure due to unilateral vocal fold paralysis. A newer injection method utilizing homologous collagen from cadaveric human tissue has been described as an attractive alternative as no donor site is required, there is a very low risk of hypersensitivity, and the intact, acellular collagen fibers may suffer a reduced long-term reabsorption rate. Preliminary results on eight patients comparing presurgical and postsurgical parameters (perceptual, stroboscopic, acoustic, and aerodynamic) revealed comparable results when compared with a control group of individuals, age- and sex-matched, that had undergone standard medialization thyroplasty (type I). Further study is needed to assess the long-term results with this minimally invasive method of vocal fold medialization.     

Correlation of the Voice Handicap Index (VHI) and the Voice-Related Quality of Life Measure (V-RQOL)

The purpose of this study was to investigate the correlation between the Voice Handicap Index (VHI) and the Voice-Related Quality of Life Measure (V-RQOL), and to test conversion of scores between the two instruments. Understanding the relationship between instruments will facilitate comparison of voice outcome studies using different measures. A retrospective medical chart review of 140 consecutive patients with a chief complaint related to their voice presenting for speech pathology voice evaluation following laryngology evaluation and diagnosis was adopted. Each patient who filled out the VHI and V-RQOL within a 2-week period with no intervening treatment was included in the study. Correlation analysis for total scores was performed for the patients meeting inclusion criteria (n=132). Correlations were also performed as a function of diagnosis. Calculated VHI score based on measured V-RQOL score was compared to measured VHI score. Pearson correlation between scores on the VHI and V-RQOL was -0.82. There was no significant difference between the mean measured and mean calculated VHI scores. For individual scores, however, regression analysis did reveal a significant difference between calculated and measured VHI. The VHI and V-RQOL are highly correlated; however, this study suggests that the two instruments are not interchangeable for individuals.     

Comparison between thyroplasty type I andArytenoid rotation: a study of vocal fold vibration using excised human larynges

The purpose of this paper was to compare the vibration of the vocal fold submitted to Isshiki thyroplasty type I (TPI) to that of the contralateral one adducted by the arytenoid rotation (AR) technique. The vocal folds of ten human fresh excised larynges were medialized by TPI on one side and by rotation of the arytenoid on the contralateral side. Laryngeal vibration was artificially produced and was recorded by videostroboscopy. The images were subjectively and objectively analyzed. Subjective analysis included periodicity of vibratory cycles, features of the mucosal wave present on the TPI side, amplitude of vibration, and profile of free border of each vocal fold during the opening phase. Objective analyses were carried out on frame-by-frame digitalized images to determine amplitudes of vibrations and phase differences between the folds in three glottic regions (anterior, middle, and posterior). Subjective analysis revealed regular periodicity in 100% of the larynges, a decrease in the mucosal wave on the TPI side in 70%, reduction in amplitude in 30%, and a sigmoid profile of the free border on the TPI side in 80%. Objective analysis showed mean amplitude in the posterior glottic region on the TPI side significantly larger than that on the arytenoids rotation side and phase asymmetry in 90% of the larynges.     

Inspiratory pressure threshold training for upper airway limitation: a case of bilateral abductor vocal fold paralysis

A single subject design was used to determine if pressure threshold training strengthens the inspiratory muscles in a subject with a limited glottal airway as well as diminish dyspnea and improve parameters of speech. The subject was a 19-year-old woman whose glottal airway was limited due to bilateral abductor vocal fold paralysis following a thyroidectomy. A 5-week inspiratory muscle strength-training program was implemented using a pressure-threshold trainer to strengthen the inspiratory muscles with the intent of enabling the generation of higher inspiratory pressures. The pressure threshold on the trainer was set at 75% of the subject's maximum inspiratory pressure (MIP). The subject was required to generate sufficient inspiratory pressure to bring air through the trainer during an inspiratory maneuver. MIP was the dependent variable used as an indication of inspiratory muscle strength. MIP increased by 47% following the training program. Maximal minute ventilation and oxygen uptake increased posttraining. Dyspnea during exercise and speech decreased as reported by the subject. Total reading duration and pause duration demonstrated a declining trend during connected speech. The results indicated that inspiratory muscle training using a pressure threshold device improves functional tasks such as exercise and speech in a subject with upper airway limitation.     

The biomechanics of the medialization laryngoplasty(thyroplasty type 1) in an ex vivo canine model

The biomechanics of medialization laryngoplasty are not well understood. An excised canine larynx model was used to test the effects of various sized silicon implants. The vocal fold length, position, and tension were measured. Medialization laryngoplasty did not affect vocal fold length. At the mid-membranous vocal fold, larger shims resulted in greater medialization and tension. Medialization laryngoplasty neither medialized nor stiffened the vocal process to resist lateralizing forces. We conclude that medialization laryngoplasty provides bulk and support for defects of the membranous region of the vocal fold, but does not appear to close a posterior glottal gap. The selection of a surgical procedure to treat glottal incompetence should take into account the unique biomechanical properties of the anterior (membranous vocal folds) and posterior (cartilaginous portion) glottis.     

Reliability of Clinician-Based (GRBAS and CAPE-V) and Patient-Based (V-RQOL and IPVI) Documentation of Voice Disorders

This study examined the reliability of two methods for documenting voice quality by clinicians and compared the methods for documenting patients' perceptions of voice quality. It involved a prospective reliability study and a retrospective chart review. Reliability of two clinician-based voice assessment protocols-Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) and Consensus Auditory Perceptual Evaluation-Voice (CAPE-V)-was evaluated. These two protocols were then compared after use in voice assessments of 42 males and 61 females performed by a certified speech-language pathologist specializing in the assessment of voice disorders. In addition, two patient-based scales (Voice Related Quality of Life, or V-RQOL, and Iowa Patient's Voice Index, or IPVI) obtained from the same patients were compared with each other and with the clinician-based scales. Reliability of clinicians' ratings of overall severity of dysphonia using GRBAS and CAPE-V scales was very good (r>0.80). Agreement between V-RQOL Total scores and IPVI ratings of the patient's perceptions of impact of dysphonia was less strong (Spearman's r=-0.76). There was relatively weak agreement between patient-based and clinician-based scales. Clinician's perceptions of dysphonia appeared to be reliable and unaffected by rating tool, as indicated by the high level of agreement between the two rating systems when they were used together. The CAPE-V system appeared to be more sensitive to small differences within and among patients than the GRBAS system. The V-RQOL and IPVI approaches to documenting patient's perceptions of dysphonia agreed less well possibly due to differences in patient dependence on voice and on interpretation of the rating tool items. The differences between clinician-based and patient-based data support the conclusion that clinicians and patients experience and consider dysphonia very differently.     

核磁共振波谱研究氟化膦配体及其金属配合物的氟谱化学位移

研究了氟化膦类系列配位体(GPF₂:G=F,Et₂N,Me₂N,C₅H₁₀N,nPrO,PhO,neoPnO,2,5-diMePh,isoPr,etc.)及其与金属镍₍₀₎铜_(I)钼₍₀₎金_(I)形成的配合物的核磁共振氟谱化学位移的定量分子建模,发现了其中的一些有用规律.     

核磁共振波谱研究氟化膦配体及其金属配合物的氟谱化学位移

研究了氟化膦类系列配位体（ＧＰＦ２：Ｇ＝Ｆ，Ｅｔ２Ｎ，Ｍｅ２Ｎ，Ｃ５Ｈ１０Ｎ，ｎＰｒＯ，ＰｈＯ，ｎｅｏＰｎＯ，２，５ｄｉＭｅＰｈ，ｉｓｏＰｒ，ｅｔｃ．）及其与金属镍（０）铜（Ｉ）钼（０）金（Ｉ）形成的配合物的核磁共振氟谱化学位移的定量分子建模，发现了其中的一些有用规律．     

Theoretical studies of spin-Hamiltonian parameters for Ni ions in CsMgX3 (X=Cl, Br, I) crystals from the two-mechanism model

In this paper, the high-order perturbation formulas of spin-Hamiltonian (SH) parameters (g factors g, g and zero-field splitting D), including both the crystal-field (CF) and for the first time charge-transfer (CT) mechanisms, are established for 3d⁸ ions in trigonal octahedral clusters. By using these formulas, the SH parameters of Ni²⁺ ions in CsMgX₃ (X=Cl, Br, I) crystals are calculated. The results are consistent with the experimental values. The calculations suggest that the sign of Q^CT (Q=Δg, Δg or D, where the g-shift Δg_i=g_i−g_e, g_e≈2.0023 is the value of free-electron) due to CT mechanism is the same as that of the corresponding Q^CF due to CF mechanism, and the relative importance of CT mechanism (characterized by Q^CT/Q^CF) increases with the increasing atomic number of ligand X. So, for the 3dⁿ ML_m clusters with ligand having large atomic number, the reasonable theoretical explanations of all SH parameters should take both CF and CT mechanisms into account. The defect structure of (NiX₆)⁴⁻ impurity centers in CsMgX₃:Ni²⁺ crystals is also considered in our model.     

近红外光谱快速分析技术及其在动物饲料和产品品质检测中的应用

近红外光谱是近年来发展最快、最引人注目的光谱学技术。主要介绍了近红外光谱技术的基本原理和发展, 包括近红外光谱预处理技术如微分处理、信号平滑等技术的发展和近红外光谱分析模型如多元线性回归、主成分分析、偏最小二乘法和人工神经网络等的发展。综述了国内外近几年来此技术在动物饲料和产品品质检测中的应用。文献调查显示, 近红外光谱分析技术以其快速、无损、不污染环境等诸多优点在国内外饲料和动物产品检测方面得到广泛应用。在饲料分析方面,近红外不仅能用于其常量成分干物质、粗蛋白、粗纤维、粗脂肪等的测定,而且能用于微量成分、有毒有害成分的测定。在动物产品分析方面,该技术已用于禽蛋、牛肉、羊肉、猪肉等的各种物理和化学指标的测定。文中详细给出了已经报道的利用近红外光谱技术测定饲料和动物产品测定指标和光谱处理以及模型建立的情况, 并讨论了近红外光谱快速检测技术的在饲料分析和动物产品分析领域的应用新趋势和局限性。