Management of Vocal Fold Scar with Autologous Fat Implantation: Perceptual Results

Vocal fold scar disrupts the mucosal wave and interferes with glottic closure. Treatment involves a multidisciplinary approach that includes voice therapy, medical management, and sometimes surgery. We reviewed the records of the first eight patients who underwent autologous fat implantation for vocal fold scar. Information on the etiology of scar, physical findings, and prior interventions were collected. Videotapes of videostroboscopic findings and perceptual voice ratings [Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS)] were randomized and analyzed independently by four blinded observers. Etiology of scar included mass excision (7), vocal fold stripping (3), congenital sulcus (2), and hemorrhage (1). Prior surgical procedures performed included thyroplasty (1), autologous fat injection (9), excision of scar (2), and lysis of adhesions (2). Strobovideolaryngoscopy: Statistically significant improvement was found in glottic closure, mucosal wave, and stiffness (P = 0.05). Perceptual ratings (GRBAS): Statistically significant improvement was found in all five parameters, including overall Grade, Roughness, Breathiness, Asthenia, and Strain (P = 0.05). Patients appear to have improved vocal fold function and quality of voice after autologous fat implantation in the vocal fold. Autologous fat implantation is an important adjunctive procedure in the management of vocal fold scar, and a useful addition to the armamentarium of the experienced phonomicrosurgeon.     

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.     

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.     

The Relationship Between Dysphonia and Sinusitis: A Pilot Study

Though some clinicians believe chronic sinusitis is associated with dysphonia, studies confirming such a relationship are not available. This pilot study investigated vocal characteristics of chronic sinusitis patients compared to those of nonsinusitis patients. Nineteen male patients were evaluated in a single-blind, nonrandomized, prospective study at a Department of Veterans Affairs Medical Center. After candidates for the experimental and control groups were thoroughly screened [nasal and laryngology examinations, sinus computed tomography (CT) scan, history], 10 chronic sinusitis patients were assigned to the experimental group, nine patients without chronic sinusitis were assigned to the control group. Visi-Pitch analysis of their speech evaluated fundamental frequency, intensity, and perturbation. The evaluator described voice quality and vowel prolongation. Videostroboscopic examination evaluated glottic closure, supraglottic activity, vocal fold edge, amplitude, mucosal wave, and nonvibrating portion. Visi-Pitch analysis and vowel prolongation for each group was compared using an independent t-test. The average fundamental frequency mean was 113.43+/-32.75 Hz for the control group and 112.29+/-19.71 for the experimental group. This study established methods and parameters to determine if a relationship between chronic sinusitis and dysphonia actually exists. It did not establish a relationship between these entities, possibly due to the small sample size enrolled in the study, but determined that 126 subjects would be necessary to achieve significant results.     

Dysphonia associated with inhaled steroids

The use of inhaled steroids in the treatment of asthma is not without its complications. In some studies up to 50% of such patients complain of oropharyngeal and voice problems. We present the findings in 22 patients complaining of dysphonia who underwent videostrobolaryngoscopy (VSL) and computerized speech analysis. A number of abnormalities were identified. On VSL, these included mucosal changes (noted in 58%), apposition abnormalities (noted in 43%), and supraglottic hyperfunction (noted in 40%). On speech analysis, cycle-to-cycle irregularity was frequently noted (mean of 39%). Maximum phonation time was reduced in 73%. Our findings did not confirm the widely held views that steroid dysphonia is due primarily to a fungal infection or a steroid-induced adductor myasthenia of the larynx. A larger-scale prospective study is indicated.     

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.     

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

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

Vocal Fold Polyp in a Professional Brass/Wind Instrumentalist and Singer

Wind instrumentalists, especially brass players, and singers share common factors, including vocal tract shape, function and pressure, vocal fold opening and closure, breath vector of force and air flow rates. To understand the mechanism and function of the vocal folds with a pathological lesion, it is necessary to visualize the differing interactions of the vocal tract during wind and brass instrument playing and in singing. A school band director, singer, wind and brass instrumentalist, was referred by musician colleagues with intermittent dysphonia, aphonia, and inability to sing high notes. Simultaneous videolaryngoscopy, with and without stroboscopy, and external video examination were documented. An hourglass glottis with a sessile, cystic polyp of the left vocal fold were recorded and studied during phonation and the playing of 3 instruments. The techniques of glottic opening, closure, configuration and function varied with the type of instrument and phonatory function. Singing was adversely affected by the vocal fold polyp but no harmful interaction occurred during wind/brass instrument playing. Down-stream loading in singers is at the laryngeal level and in wind/brass instrumentalists is at the embouchure. Preoperative voice therapy, phonomicrosurgery, and postoperative voice rest followed by voice therapy, succeeded in restoring her combined wind/brass instrumental and singing career.     

Bilateral Vocal Fold Posterior Glottic/Subglottic Stenotic Web Resected with Contact Tip Nd-YAG Laser

The standard treatment for respiratory failure remains endotracheal intubation, with periods of 22 or more days being commonplace. Posterior glottic stenotic web formation, from scarring in the posterior interarytenoid area, may occur after endotracheal intubation, thermal, corrosive, or direct surgical injury. A commonly used classification system for posterior glottic stenosis divides the occurrence into four types. Type I involves an interarytenoid scar band between the vocal folds that is anterior and separate from the posterior interarytenoid mucosa. Type II stenosis involves scarring of the mucosa or musculature of the posterior interarytenoid area. Types III and IV involve unilateral and bilateral cricoarytenoid joint fixation, respectively. Strobovideolaryngoscopy (SVL), rigid and flexible fiberoptic bronchoscopy, electromyography (EMG), radiologic imaging of the neck, larynx, and trachea as well as pulmonary function tests, including flow volume loops, provide important objective measurements of upper airway obstruction. A representative case of a professional voice user who suffered a Type II posterior glottic stenosis is presented. The treatment utilized a specific contact-tip neodymium-yttrium aluminum garnet (Nd-YAG) laser delivery system to achieve precise cutting, vaporization, and coagulation simultaneously, returning tactile touch technique to the airway/voice surgeon. Completely successful restoration of voice and airway have been maintained for 2 1/2 years postoperatively.     

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.     

Laryngeal Hyperfunction During Whispering: Reality or Myth?

For years, otolaryngologists and voice therapists have warned voice patients that whispering causes more trauma to the larynx than normal speech. However, no large series of patients has ever been examined fiberoptically during whispering to test this hypothesis. As part of our routine examination, patients are asked to count from 1 to 10 in a normal voice and in a whispered voice. We reviewed recorded fiberoptic examinations of 100 patients who had voice complaints. We compared supraglottic hyperfunction and vocal fold closure during the normal and whispered phonation of each patient. Sixty-nine percent of the patients demonstrated increased supraglottic hyperfunction with whispered voice. Eighteen percent had no change, and 13% had less severe hyperfunction. The most common glottal configuration during whisper was an inverted Y, which resulted from compression of the anterior and middle thirds of the true vocal folds. However, 12 patients had no true vocal fold contact during whispered voice, despite having adequate glottic closure with normal voice. Although whispering involves more severe hyperfunction in most patients, it does not seem to do so in all patients. In some patients, it may be less traumatic than normal voice.     

Examination of air usage during phonation: Correlations among test parameters

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

Laryngostroboscopic Evaluation After Supracricoid Partial Laryngectomy

BACKGROUND: Supracricoid partial laryngectomy (SCPL) results in laryngeal preservation in more than 95% of patients with T2 glottic carcinoma. Postsurgical glottic function is characterized by an absence of vocal cords, and phonation quality is a key post-SCPL quality-of-life factor. OBJECTIVE: This investigation was designed to enhance post-SCPL vocal function, study anatomic function of the post-SCPL larynx, and correlate anatomic findings with perceptual and instrumented measurements of voice. METHOD: Twenty-five patients were included. All had undergone SCPL with cricoepiglottopexy for T2 glottic carcinoma. All patients were evaluated by laryngostroboscopic examination, voice sample recording, and instrumented voice analysis with the aim of gaining further insight into postoperative larynx function. Laryngostroboscopic parameters such as laryngeal occlusion, epiglottic length, arytenoid movement, and vibratory area were assessed. The perceptual evaluation was based on the GRBAS scale. Acoustic and aerodynamic parameters were recorded, including fundamental frequency (F0), intensity, jitter, shimmer, signal-to-noise ratio (SNR), oral airflow (OAF), maximum phonation time (MPT), and estimated subglottic pressure (ESGP). Nonparametric tests were used to compare laryngostroboscopic parameters with instrumented measurements and perceptual evaluations of voice quality. RESULTS: Correlations were established among occlusion, epiglottic length, and general grade of dysphonia. Oral air flow (P = 0.006) was found to be correlated with occlusion. Voice roughness was correlated with the presence of a clearly identifiable vibratory area (P = 0.003), whereas these vibratory areas were correlated with shimmer (P = 0.041), OAF (P = 0.001), and SNR (P = 0.001). The number of preserved arytenoids was not identified as a voice quality factor (P = 0.423). CONCLUSION: This study highlighted correlations between the laryngostroboscopic examination results and the perceptive and instrumented measurements of voice. Glottis occlusion and epiglottis length were found to be key factors for postoperative voice quality. These results should help to advance technical development on surgical techniques to enhance voice results.     

Dysphonia and bulimia: Vomiting laryngeal injury

Voice problems associated with vomiting laryngeal injury in bulimic patients have not been previously described in the literature. Injuries found include subepithelial vocal fold hemorrhages that probably go on to produce mucosal wave tethering. More severe scarring may also result, but superficial telangiectasia of the glottic mucosa seems to be a more common feature. Three patients from a voice clinic population are described, and a further 10 patients from an eating disorders clinic who had not presented with voice complaints were studied with questionnaires, history, video laryngostroboscopy, and voice recordings.     

The Parkinson larynx: Tremor and videostroboscopic findings

Patients with Parkinson's disease have a high incidence of speech, voice, and laryngeal abnormalities. To characterize laryngeal abnormalities, visual-perceptual ratings of endoscopic and stroboscopic examinations of 22 patients diagnosed with idiopathic Parkinson's disease and 7 patients with Parkinson's-plus syndromes were carried out by four trained viewers. Incidence of tremor, tremor location, phase closure, phase symmetry, amplitude, and mucosal waveform were scored. Tremor was observed in one or more of these conditions—rest, normal pitch and loudness, or loud phonation—for most of the 29 patients. Fifty-five percent of the idiopathic Parkinson's disease patients had tremor, with the primary location being vertical laryngeal tremor. Sixty-four percent of the Parkinson's-plus patients had tremor, with the arytenoid cartilages being the primary location. Laryngeal tremor was observed early in the disease in these Parkinson's disease patients. The most striking stroboscopic findings for the idiopathic Parkinson's disease patients were abnormal phase closure and phase asymmetry. Amplitude and mucosal wave-form were essentially within normal limits in the majority of the idiopathic Parkinson patients.     

Mucosal Wave: A Normophonic Study Across Visualization Techniques

Visualization of vocal fold vibration is essential for accurate diagnoses and optimal treatment of persons with voice disorders. Recently, scientific and anecdotal reports have evidenced an increased amount of variation in the diagnostically relevant features of extent and symmetry of mucosal wave magnitude in normophonic speakers. The objectives of this study were to preliminarily ascertain the variation in mucosal wave magnitude and symmetry for normophonic speakers as assessed via standard and novel techniques, and compare findings across modal and pressed phonations. A correlational design with a multiple baseline across visualization methods approach was used. Mucosal wave presence, magnitude, and symmetry from 52 normophonic speakers were judged via stroboscopy, high-speed videoendoscopy (HSV) playback, mucosal wave playback, and mucosal wave kymography playback. Results demonstrate a prevalence of atypical magnitude and symmetry of mucosal wave during modal and pressed phonations by normophonic persons, differences across techniques, and a relationship between judgments and habitual fundamental frequency. Given the prevalence of mucosal wave magnitude and symmetry variations in the normophonic population, overdiagnosis may be possible without caution. The various visualization techniques provided unique information suggesting that it may be beneficial to use both full view and kymographic visualization techniques in combination. A major restriction of the current commercial HSV systems is the frame rate, typically limited to 2000 frames per second, which appears insufficient for most female habitual phonations.     

Pushing exercise program to correct glottal incompetence

A voice therapy program using pushing exercises to correct glottal incompetence is described. The program utilizes various types of instrumentation to determine whether or not a given patient is likely to benefit from the treatment. The program also provides feedback of target voices. Three cases with incomplete glottal closure and subsequent vocal dysphonia characterized by an asthenic breathy quality are used to illustrate the program. Details of the program, termination criteria, and problems and precautions learned from treating 29 patients over a 3-year period are presented.     

Abnormal soft palate posturing in patients with laryngeal movement disorders

Laryngeal movement disorders (LMDs), including spasmodic dysphonia and essential voice tremor, have been described as focal disorders affecting the muscles of the larynx. Little reference has been made to possible hyperfunction of supralaryngeal structures and/or palatal involvement. Videonasolaryngoscopic examinations of 83 patients with LMDs revealed a significantly high incidence of abnormal soft palate posturing (84%). Further associations and implications are presented.     

Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports

Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder. Such dysphonias may often develop post-viral infection with laryngitis, and generally in close proximity to emotionally or psychologically taxing experiences, where "conflict over speaking out" is an issue. In more rare instances, severe and persistent psychogenic dysphonia may develop under innocuous or unrelated circumstances, but over time, it may be traced back to traumatic stress experiences that occurred many months or years prior to the onset of the voice disorder. In such cases, the qualitative nature of the traumatic experience may be reflected in the way the psychogenic voice disorder presents. The possible relationship between psychogenic dysphonia and earlier traumatic stress experience is discussed, and the reportedly low prevalence of conversion reaction (4% to 5%) as the basis for psychogenic dysphonia is challenged. Two cases are presented to illustrate the issues raised: the first, a young woman who was sexually assaulted and chose to "keep her secret," and the second, a 52-year-old woman who developed a psychogenic dysphonia following a second, modified thyroplasty for a unilateral vocal fold paresis.     

Objective and Subjective Evaluation of Voice Quality in Multiple Sclerosis

The aim of this comparative, controlled, cross-sectional study is to evaluate the voice quality in patients with multiple sclerosis (MS) by subjective and objective methods. Female patients with MS (n=27) and age- and sex-matched healthy controls (n=27) were included in this study. Vocal functions were evaluated by a multidimensional set composed of videolaryngostroboscopic examination, acoustic analysis, and subjective measurements (GRBAS and "Voice Handicap Index"). Jitter percent, shimmer percent, and soft phonation index (SPI) values were higher in MS patients compared to controls (Jitt, P=0.001; Shim, P=0.033; SPI P<0.0001). Maximum phonation time was significantly shorter for MS patients compared to controls (P<0.0001). Stroboscopic examination revealed that 16 out of 27 MS patients have a "posterior chink" as glottic closure pattern with higher SPI values (40%). Noise to harmonic ratio (NHR) and mean fundamental frequency (F0) values were similar for MS and control groups (NHR, P=0.737; F0, P=0.976). In this study, most of the MS patients had dysphonia due to weakness of voice. MS tends to worsen acoustic parameters including fundamental frequency, SPI, and jitter values. These results are consistent with the more asthenic voice quality observed in MS group.