Laser Doppler Measurements of the Vocal Fold Blood Micro-Circulation

The authors have developed a laser Doppler method, referred to as LDF+LS (laser Doppler flowmetry by laryngostereometry), for measuring the vocal fold micro-circulation. The vocal folds of 103 patients were examined during general anesthesia. A laser Doppler probe was placed on defined positions at the vocal fold edge: midmembranous position (MP), 2 mm and 4 mm behind, and 1 mm anterior to MP. Three parameters were derived, ie, the concentration (CMBC) and velocity (V) of moving blood cells, and the product of both resulting in perfusion: P = CMBCxV. The results of 53 subjects with normal vocal fold status showed that the V at MP was significantly lower than 2 mm behind MP (P < 0.05). Men had significantly higher velocity than women (P < 0.05). Subjects older than 65 years had higher perfusion and CMBC as compared with younger subjects (P < 0.01). Smokers with normal vocal folds had higher velocity than non-smokers (P < 0.05). Measurements of healthy vocal folds were compared with benign vocal fold pathology. Vocal fold polyps had significantly higher perfusion than normal vocal folds (P < 0.01). In conclusion, the laser Doppler measurement is a sensitive tool estimating superficial blood flow in both normal and pathological vocal folds. The blood flow in normals differs with respect to gender and age probably due to variations in micro-circulation of the mucosa and lamina propria. Vocal fold pathology and external factors such as smoking result in blood flow changes.     

Incidence of supraglottic activity in males and females: a preliminary report

Supraglottic activity was rated from flexible endoscopic video recordings of subjects with normal laryngeal structure and function as they sustained vowels and repeated syllables and sentences. Judges rated these recordings for false vocal fold (FVF) adduction and anterior-to-posterior (A-P) compression at the initiation of the speech task, throughout the whole speech task (static supraglottic activity), and as brief individual adductions within a speech task (dynamic supraglottic activity). Significant differences in A-P (p < 0.0003) and FVF (p < 0.0000001) compression were found between tasks. Dynamic FVF activity was associated with glottal stops. Static A-P and FVF activities were present in males significantly more (p < 0.0001) than females. FVF activity associated with speech initiation was found in females significantly more (p = 0.0256) than males. Supraglottic activity plays a role in normal speech production, and should not necessarily be considered suggestive of a voice use pattern with excessive muscle tension.     

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.     

Evolution of Vocal Fold Nodules from Childhood to Adolescence

SUMMARY: Bilateral (quasi) symmetrical lesions of the anterior third of the vocal folds, commonly called vocal fold nodules (VFNs) are the most frequent vocal fold lesions in childhood caused by vocal abuse and hyperfunction. This study evaluates their long-term genesis with or without surgery and voice therapy. A group of 91 postmutational adolescents (mean age, 16 years), in whom VFNs were diagnosed in childhood, were questioned to analyze the evolution of their complaints. Thirty four of them could be clinically reexamined by means of the European Laryngological Society-protocol, including a complete laryngological investigation and voice assessment. A total of 21% of the questioned group (n=91) had voice complaints persisting into postpubescence with a statistically significant difference (P 相似文献   

Oral Breathing Increases Pth and Vocal Effort by Superficial Drying of Vocal Fold Mucosa

Oral breathing superficially dehydrates the airway lumen by decreasing the depth of the sol layer in humans and animals. Conversely, nasal breathing can increase the humidity of inspired air. We compared the effects of short-term oral and nasal breathing on P_th and perceived vocal effort in 20 female subjects randomly assigned to two groups: oral breathing (N = 10, age 21–32 years); nasal breathing (N = 10, age 20–36 years). We hypothesized that short-term oral breathing, but not nasal breathing, would increase P_th, and that subjects would perceive this change as an increase in vocal effort. Following 15 minutes of oral breathing, P_th increased at comfortable and low pitch (p < 0.01) with 6 of 10 subjects reporting increased vocal effort. Nasal breathing reduced P_th at all three pitches (p < 0.01), and 7 of 10 subjects reported decreased vocal effort. Over all subjects, 49% of the variance in treatment-induced change in P_th was accounted for by change in vocal effort (R = 0.70). We posit that obligatory oral breathing places healthy subjects at risk for symptoms of increased vocal effort. The facilitatory role of superficial hydration on vocal fold oscillation should be considered in biomechanical models of phonation and in the clinical prevention of laryngeal dryness.     

Cooperative Regulation of Vocal Fold Morphology and Stress by the Cricothyroid and Thyroarytenoid Muscles

Voice is produced by vibrations of vocal folds that consist of multiple layers. The portion of the vocal fold tissue that vibrates varies depending primarily on laryngeal muscle activity. The effective depth of tissue vibration should significantly influence the vibrational behavior of the tissue and resulting voice quality. However, thus far, the effect of the activation of individual muscles on the effective depth is not well understood. In this study, a three-dimensional finite element analysis is performed to investigate the effect of the activation of two major laryngeal muscles, the cricothyroid (CT) and thyroarytenoid (TA) muscles, on vocal fold morphology and stress distribution in the tissue. Because structures that bear less stress can easily be deformed and involved in vibration, information on the morphology and stress distribution may provide a useful estimate of the effective depth. The results of the analyses indicate that the two muscles perform distinct roles, which allow cooperative control of the morphology and stress. When the CT muscle is activated, the tip region of the vocal folds becomes thinner and curves upward, resulting in the elevation of the stress magnitude all over the tissue to a certain degree that depends on the stiffness of each layer. On the other hand, the TA muscle acts to suppress the morphological change and controls the stress magnitude in a position-dependent manner. Thus, the present analyses demonstrate quantitative relationships between the two muscles in their cooperative regulation of vocal fold morphology and stress.     

Vocal Warm-up Increases Phonation Threshold Pressure in Soprano Singers at High Pitch

Vocal warm-up is thought to optimize singing performance. We compared effects of short-term, submaximal, vocal warm-up exercise with those of vocal rest on the soprano voice (n = 10, ages 19-21 years). Dependent variables were the minimum subglottic air pressure required for vocal fold oscillation to occur (phonation threshold pressure, Pth), and the maximum and minimum phonation fundamental frequency. Warm-up increased Pth for high pitch phonation (p = 0.033), but not for comfortable (p = 0.297) or low (p = 0.087) pitch phonation. No significant difference in the maximum phonation frequency (p = 0.193) or minimum frequency (p = 0.222) was observed. An elevated Pth at controlled high pitch, but an unchanging maximum and minimum frequency production suggests that short-term vocal exercise may increase the viscosity of the vocal fold and thus serve to stabilize the high voice.     

Investigation of Anti-Hyaluronidase Treatment on Vocal Fold Wound Healing

SUMMARY: Phytochemical constituents of medicinal plants demonstrate inhibition of tissue and bacterial hyaluronidase. Echinacoside is a caffeoyl conjugate of Echinacea with known anti-hyaluronidase properties. The purpose of this study was to investigate the wound healing effects of Echinacea on vocal fold wound healing and functional voice outcomes. Pig animal model. Methods: Vocal fold injury was induced in 18 pigs by unilateral vocal fold stripping. The uninjured vocal fold served as control. Three groups of six pigs randomly received a topical application of 300, 600, or 1,200 mg of standardized Echinacea on the injured side. Animals were euthanized after 3, 10, and 15 days of wound healing. Phonation threshold pressure and vocal economy measurements were obtained from excised larynges. Treatment outcomes were examined by comparing the animals receiving treatment with a set of 19 untreated and 5 historical controls. Treatment effects on wound healing were evaluated by histologic staining for hyaluronan and collagen. Treated larynges revealed improved vocal economy and phonation threshold pressure compared with untreated larynges. Histologically, treated vocal folds revealed stable hyaluronan content and no significant accumulation of collagen compared with control. Findings provide a favorable outcome of anti-hyaluronidase treatment on acute vocal fold wound healing and functional measures of voice.     

Optoreflectometry Determination of the Resonance Properties of a Vocal Fold

A new method of measuring the resonance properties of a vocal fold using electromagnetic excitation and laser optoreflectometry for response monitoring is described. Two resonance peaks were experimentally identified with one magnet stuck on the vocal fold at frequencies F0(1m)=54.7 Hz and F0'(1m)=35.8 Hz. The addition of a second magnet allowed calculation of the actual viscoelastic properties of the vocal fold: F0=71.8 Hz; quality factor Q=8.03; mass m=0.057 g; stiffness k=11.6 Nm; and damping zeta=0.0032 Nm(-1). A numerical simulation of a two-layered model verified the experimental data.     

Behavioral Characteristics of Children With Vocal Fold Nodules

Vocal fold nodules (VNs) in children are benign, bilateral lesions occurring on the mid-membranous vocal folds. Repetitive phonotraumatic behavior leading to chronic vocal fold injury and repair is frequently cited as the primary etiology; however, specific behavioral characteristics may predispose some children toward intense and potentially phonotraumatic voice use, thereby contributing secondarily to VN formation. The purpose of this case-control study was to determine whether children with VNs possess unique behavioral characteristics that may predispose them to VN development. Parents of 26 children with VNs (20 boys, 6 girls, mean age=7.2 years, SD=2.5 years), and 29 vocally normal, medical controls (22 boys, 7 girls, mean age=6.7 years, SD=2.4), completed the Childhood Behavior Checklist (CBCL/4-18, Achenbach, 1991), a standardized parent-rating scale with strong psychometric properties. No significant between-group differences were detected on any of the behavior problem syndrome scales. Group differences approached significance for the individual items "screams a lot" and "teases a lot" (VN group > Controls). The VN group scored significantly higher than the controls on the "Social Scale," a compilation of positive ratings of the child's social activity, frequency of contacts with friends, behavior with others, and behavior by themselves. Observed outcomes were consistent with previous characterizations of children with VN as "outgoing" or "extroverted" but were not consistent with other claims that this population may be at risk for "aggressive," "attentional," or "impulsive" behavior problems.     

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.     

Dilated Minute Chambers in Laryngeal Vocal Fold Polyps: Histopathological and Ultrastructural Features

In Reinke's space of human vocal fold, type III collagen forms a three dimensional network and this contains numerous minute chambers in between these fibers. These compartments are occupied by glycosaminoglycans and glycoproteins. In laryngeal fold lesions, such as Reinke's edema and vocal fold polyps, proteoglycan (PG)/hyaluronic acid (HA) components of extracellular matrix increased. We investigated the size and quantity of the minute chambers within Reinke's space, filled with PG/HA with the aid of transmission electron microscopy. Eight vocal fold polyps and 10 mucosal biopsies (as control group) were all evaluated by light microscopy and electron microscopy. We detected that PG/HA in extracellular matrix had been increased in vocal fold lesions when compared with control group, by Alcian Blue-pH 2.5 stain. The mean volume of the chambers in Reinke's space of normal larynx was measured as 0.040233 µm² whereas the mean volume of these chambers in vocal fold polyps was measured as 6.420221 µm². The difference between the volumes of these chambers in vocal fold polyps and in control group was statistically significant (P = 0.001). Within these chambers PG/HA were found and PG/HA filling these chambers were increased in vocal fold polyps. We think proteoglycan and glycosaminoglycans, especially HA, play an important role in determining biochemical properties of vocal fold lesions.     

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.     

Vocal Problems Among Teachers: Evaluation of a Preventive Voice Program

Vocal education programs for teachers may prevent the emergence of vocal disorders; however, only a few studies have tried to evaluate the effectiveness of these preventive programs, particularly in the long term. Two hundred and sixty-four subjects, mostly kindergarten and primary school female teachers, participated in a course on voice care, including a theoretical seminar (120 minutes) and a short voice group therapy (180 minutes, small groups of 20 subjects). For 3 months, they had to either attend the vocal ergonomics norms and, as psychological reinforcement, they had to make out a daily report of vocal abuse, or to follow the given exercises for a more efficient vocal technique, reporting on whether the time scheduled was respected or not. The effectiveness of the course was assessed in a group of 21 female teachers through a randomized controlled study. Evaluation comprehended stroboscopy, perceptual and electro-acoustical voice analysis, Voice Handicap Index, and a course benefit questionnaire. A group of 20 teachers matched for age, working years, hoarseness grade, and vocal demand served as a control group. At 3 months evaluation, participants demonstrated amelioration in the global dysphonia rates (P=0.0003), jitter (P=0.0001), shimmer (P=0.0001), MPT (P=0.0001), and VHI (P=0.0001). Twelve months after the course, the positive effects remained, although they were slightly reduced. In conclusion, a course inclusive of two lectures, a short group voice therapy, home-controlled voice exercises, and hygiene, represents a feasible and cost-effective primary prevention of voice disorders in a homogeneous and well-motivated population of teachers.     

Predicted Singers' Vocal Fold Lengths and Voice Classification—A Study of X-Ray Morphological Measures

Students admitted to the solo singing education at the University of Music Dresden, Germany have been submitted to a detailed physical examination of a variety of factors with relevance to voice function since 1959. In the years 1959–1991, this scheme of examinations included X-ray profiles of the singers' vocal tracts. This material of 132 X-rays of voice professionals was used to investigate different laryngeal morphological measures and their relation to vocal fold length. Further, the study aimed to investigate if there are consistent anatomical differences between singers of different voice classifications. The study design used was a retrospective analysis. Vocal fold length could be measured in 29 of these singer subjects directly. These data showed a strong correlation with the anterior-posterior diameter of the subglottis and the trachea as well as with the distance from the anterior contour of the thyroid cartilage to the anterior contour of the spine. These relations were used in an attempt to predict the 132 singers' vocal fold lengths. The results revealed a clear covariation between predicted vocal fold length and voice classification. Anterior-posterior subglottic-tracheal diameter yielded mean vocal fold lengths of 14.9, 16.0, 16.6, 18.4, 19.5, and 20.9 mm for sopranos, mezzo-sopranos, altos, tenors, baritones, and basses, respectively. The data support the assumption that there are consistent anatomical laryngeal differences between singers of different voice classifications, which are of relevance to pitch range and timbre of the voice.     

Preliminary Results of a New Temporary Vocal Fold Injection Material

Temporary vocal fold injection is a valuable procedure for vocal fold paralysis or paresis of uncertain permanency and as a trial augmentation to decide the value of vocal fold augmentation. A new material made from glycerin, carboxymethylcellulose, and water has recently been developed for temporary vocal fold augmentation. Eleven patients underwent vocal fold injection for the treatment of glottal incompetence with this material. The duration of effectiveness of this injection material was 2 to 3 months depending on the injection amount. This new material satisfies several requirements for an ideal temporary vocal fold injection material in terms of injectability, convenience, duration of effectiveness, and safety. The authors conclude that this new material is a good option for temporary vocal fold augmentation.     

Biochemical Markers Associated With Acute Vocal Fold Wound Healing: A Rabbit Model

This study seeks to determine the ability of enzyme-linked immunosorbent assays (ELISAs) of vocal fold secretions to detect and describe the acute tissue response to injury in a rabbit vocal fold model. Vocal fold secretions were collected before the induction of a unilateral surgical injury to the vocal fold and at 6 timepoints after injury (1, 5, 7, 10, 14, and 21 days). Secretions were then subjected to ELISAs to assess concentrations of interleukin-1 beta (IL-1beta) and prostaglandin-E2 (PGE-2). The results indicate that ELISAs may be useful in documenting fluctuations in these markers associated with the wound healing process in the rabbit model. The temporal expression of both IL-1beta and PGE-2 was consistent with their proposed roles in the wound healing cascade in other systems, pointing to the potential that surface secretions may be at least partial indicators of wound healing events within the tissue.     

Changes in Vocal Fold Morphology During Singing Over Two Octaves

ObjectiveVocal folds are widely assumed to only elongate to raise vocal pitch. However, the mechanisms seem to be more complex and involve both elongation and tensioning of the vocal folds in series. The aim of the present study was to show that changes in vocal fold morphology depend on vocal fold elongation and tensioning during singing.Study designThis was a prospective study.MethodsForty-nine professional female singers (25 sopranos, 24 altos) were recruited and three-dimensional laryngeal images analyzed in a coronal view derived from high-resolution computed tomography scans obtained at the mean speaking fundamental frequency (ƒ₀) and one (2ƒ₀) and two octaves (4ƒ₀) above ƒ₀.ResultsThe vocal fold angle, defined by a tangent above and below the vocal folds, was 58° at ƒ₀, 47° at 2ƒ₀, and 59° at 4ƒ₀.ConclusionThe decreased caudomedial angle of the vocal fold from ƒ₀ to 2ƒ₀ (change in muscle belly from “;fat” to “thin”) and increased angle from 2ƒ₀ to 4ƒ₀ (from “thin” to “fat”) strongly supports the hypothesis that the vocal folds elongate and then tension when singing from ƒ₀ to 4ƒ₀. This is the first study to show this relationship in vivo.     

Contact Telescopy Reveals Blood Vessel Alterations of Vocal Fold Mucosa in Reinke''s Edema

AIM: To evaluate contact telescopy findings for estimation of blood vessel changes in vocal fold mucosa in patients with Reinke's edema. Histological features significant for diagnosis of microvascular vocal fold alteration were correlated with clinical findings. METHODS: In 80 patients with Reinke's edema, laryngoscopy and video-telescopy image analysis of vocal folds were performed. Vocal fold mucosa biopsies were histologically analyzed and compared with contact telescopy findings. An interesting aspect of vocal fold microcirculation found both by contact telescopy imiging and by histological specimens was described. RESULTS: Contact telescopy in vivo revealed different forms of pathological blood vessel networks with unusual appearance of loops or branching. Some dilated varicose vascular channels had very thin walls, and within atypical capillaries, partial erythrocyte accumulation was found. Details of blood flow are also visible, showing multidirectional and discontinuous blood flow in neighboring vessels. CONCLUSION: The noninvasive contact telescope technique is very useful as an additional diagnostic tool for defining a condition of a subepithelial Reinke's space in a very short period of time. The great advantage of contact telescopy is systematic in vivo and in situ observation of microvascular details in the vocal folds. The contact technique allows dynamic follow-up of the microcirculation in Reinke's edema as well as simultaneous consultation of a pathologist in the operating theater.     

Towards the Expression of Sex Hormone Receptors in the Human Vocal Fold

BACKGROUND: The human larynx is assumed to be a steroid receptor target organ. There are only very limited data on the evidence of steroid receptors in the vocal folds, although voice alterations due to hormonal influence and treatment have been found. GOAL OF THE STUDY: To investigate the expression of estrogen alpha, progesterone, and androgen receptors in human vocal folds (vocalis muscle, glands, lamina propria, epithelium). METHODS: Immunohistochemically, vocal fold cadaver specimens of 15 autopsied patients (6 women, 9 men), which were taken approximately 4 to 8 hours postmortem were investigated. Furthermore, one (male) vocal fold biopsy obtained intraoperatively during a laryngectomy was tested. RESULTS: No specific immunohistochemical staining for the different types of steroid hormones investigated could be observed in either the postmortem taken biopsies nor the intraoperatively one. However, several unspecific staining patterns could be observed. CONCLUSION: The results of this study contradict recently published data and question the expression of sex hormone receptors in the vocal folds. Main causes of false interpretations of unspecific staining are discussed.