Consistency of the preoperative and intraoperative diagnosis of benign vocal fold lesions

The purpose of this retrospective study was to compare the preoperative and intraoperative diagnosis of benign vocal fold lesions for consistency. The diagnosis was made in 221 consecutive patients with benign vocal fold lesions for which a microlaryngoscopy was carried out in a general ENT-clinic. The preoperative diagnosis was obtained by both white halogen and stroboscopic light. The intraoperative diagnosis was obtained by direct microscopic visualization and palpation of the vocal folds. In 36% of the patients, the preoperative diagnosis was changed intraoperatively. In 31% of the patients, a lesion was missed at the preoperative examination and a lesion was diagnosed only during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively, and in 82% of the patients intraoperatively. Specially intracordal lesions constituted a diagnostic pitfall. Because the preoperative and intraoperative diagnosis often differed, both the patients and the ENT-surgeon must keep an open mind about what may need to be done at surgery.     

Videokymography: High-speed line scanning of vocal fold vibration

A digital technique for high-speed visualization of vibration, called videokymography, was developed and applied to the vocal folds. The system uses a modified video camera able to work in two modes: high-speed (nearly 8,000 images/s) and standard (50 images/s in CCIR norm). In the high-speed mode, the camera selects one active horizontal line (transverse to the glottis) from the whole laryngeal image. The successive line images are presented in real time on a commercial TV monitor, filling each video frame from top to bottom. The system makes it possible to observe left-right asymmetries, open quotient, propagation of mucosal waves, movement of the upper and, in the closing phase, the lower margins of the vocal folds, etc. The technique is suitable for further processing and quantification of recorded vibration.     

Strobophotoglottographic transillumination as a method for the analysis of vocal fold vibration patterns

The purpose of this exploratory study was to determine if laryngeal transillumination in combination with stroboscopy (strobophotoglottography; SPGG) is useful for (1) the visualization of vocal fold vibration (VFV) opening patterns, (2) the localization of initial vocal fold opening in horizontal glottal thirds (anterior, midmembranous, and posterior), (3) determination of the temporal correspondence of the so-called electroglottography (EGG)-knee and initial vocal fold separation, and, finally, (4) automatized quantitative measurements of glottal area function within endoscopic images. With stroboscopic transillumination, initial inferior vocal fold separation was detectable during the "closed" phase, where the vocal folds were still closed in the upper portion and therefore initial inferior vocal fold separation could not be visualized with usual laryngoscopy techniques. In the horizontal plane within similar fundamental frequencies in modal voice registers in two male subjects, localization of initial glottal opening depended on the voice types used (soft, normal, or pressed phonation). We found zipperlike posterior-to-anterior openings, initial midmembranous openings, initial anterior openings, as well as simultaneous initial opening of all three portions in the two healthy male adults examined. This technique proved to add temporal and spatial information to vocal fold opening patterns and extends our examination techniques to the very beginning of vocal fold opening at the inferior portion. Simultaneous electroglottogram tracking and comparison with bidirectionally illuminated stroboscopic images revealed a time-locked correspondence of the EGG-knee with the aforementioned initial inferior vocal fold separation. Bidirectional illumination combined with digital color extraction techniques allowed for image separation of subglottally and supraglottally illuminated structures. This facilitated vocal fold contour detection and automatized image processing, for example, for determination of glottal area function, and is considered to be a further step to objective automatized quantitative measurements within endoscopic images.     

Investigation of vocal fold impact stress in human subjects

The primary purpose of the study was to explore a methodology for measuring vocal fold impact stress (SI) in awake humans, and to provide information about the general magnitude of SIs that may occur at the midpoint of the membranous vocal folds during phonation. A secondary purpose was to examine the potential use of the electroglottographic closed quotient (EGG CQ) to indirectly reflect SI. Seven male and 13 female adults were enrolled as subjects, of whom 18 had normal larynges and normal voices, 1 had nodules, and 1 had vocal fold paresis and bowing. Subjects attempted to produce 3 different voice types (pressed, normal, breathy), at 3 different pitches (low, medium, high) and 3 different loudness levels (quiet, medium, loud). For a first set of trials, only EGG data were collected. For a second set, a sensor was also introduced to the midmembranous glottis for the collection of SI data. The primary findings were that (1) endolaryngeal sensor placement was achieved during phonation trials for 17 of 20 subjects; however, grossly consistent anteroposterior positioning was accomplished, and analyzable data were obtained, for only 7 subjects; (2) SIs ranged from less than 1 kPa to about 3 kPa for those 7 subjects; and (3) no relation was detected between simultaneous CQs and SIs for individual data, although a relation was reported in a prior canine study. One possible reason for the failure to show such a relation in the present study was subtle variations in vertical as well as anteroposterior positioning of the sensor during the trials. Future studies should focus on developing a methodology for ensuring invariant 3-dimensional sensor positioning between the membranous folds, so that the stability of both SI and simultaneous CQ data can be improved.     

What happens during vocal warm-up?

Most singers prefer to warm up their voices before performing. Although the subjective effect is often considerable, the underlying physiological effects are largely unknown. Because warm-up tends to increase blood flow in muscles, it seems likely that vocal warm-up might induce decreased viscosity in the vocal folds. According to the theory of vocal-fold vibration, such a decrease should lead to a lower phonation threshold pressure. In this investigation the effect of vocal warm-up on the phonation threshold pressure was examined in a group of male and female singers. The effect varied considerably between subjects, presumably because the vocal-fold viscosity was not a dominating factor for the phonation-threshold pressure.     

Allergies and vocal fold edema: A preliminary report

This paper describes different tools to rule out the etiology of vocal fold edema. A complete voice assessment is used in our Voice Center. This includes patient history, acoustic analysis, laryngeal video-stroboscopy, otolaryngology consultation, allergy testing from our Allergy Clinic, and gastroenterology consultation as appropriate. Inhalant allergy can be a hidden, yet very common cause of chronic laryngitis. Respiratory allergies can also cause decreased pulmonary function; excessive secretions in either the lower airway, trachea, bronchi or in the upper airway of the pharynx; edema of the vocal folds themselves; and unusual resonance characteristics of the pharynx or nasal cavity due to congestion of the membrane in those areas. Voice patients with a history of seasonal hay fever, a history of allergic reactions around cats or dogs, or a strong family history of allergies should be allergy tested. Screening tests for allergies are available, which include a screening radioallergosorbent test or a screening panel of scratch or intradermal skin tests. Once specific allergens are identified, recommendations for therapy or other intervention can be made. Straining the voice, in combination with the above conditions, can increase the voice problem. The histories, allergy test results, and voice laboratory evaluations of several patients are described. Identifying these voice patients and treating their allergies are important in keeping these patients healthy and maintaining a clear, good voice quality. The multidisciplinary approach in voice disorders is indispensable in diagnosis and treatment of these disorders.     

Interstitial protein alterations in rabbit vocal fold with scar

Fibrous and interstitial proteins compose the extracellular matrix of the vocal fold lamina propria and account for its biomechanic properties. Vocal fold scarring is characterized by altered biomechanical properties, which create dysphonia. Although alterations of the fibrous proteins have been confirmed in the rabbit vocal fold scar, interstitial proteins, which are known to be important in wound repair, have not been investigated to date. Using a rabbit model, interstitial proteins decorin, fibromodulin, and fibronectin were examined immunohistologically, two months postinduction of vocal fold scar by means of forcep biopsy. Significantly decreased decorin and fibromodulin with significantly increased fibronectin characterized scarred vocal fold tissue. The implications of altered interstitial proteins levels and their affect on the fibrous proteins will be discussed in relation to increased vocal fold stiffness and viscosity, which characterizes vocal fold scar.     

Nonlinear behavior of vocal fold vibration: The role of coupling between the vocal folds

Coupling between the vocal folds is one of the nonlinear mechanisms allowing regulation and synchronization of mucosal vibration. The purpose of this study was to establish that modulations such as diplophonia and abnormalities observed in vocal signals that may be observed in some cases of laryngeal pathology can be considered as nonlinear behavior due to the persistence of some physical interaction (coupling). An experimental model using excised porcine larynx was designed to create tension asymmetry between the vocal folds and to obtain vocal signals with modulations. Signals were analyzed by spectral analysis and the phase portrait method. Results were compared with computer-generated synthetic signals corresponding to nonlinear combinations of sinusoid signals. Under these conditions, evidence of nonlinear behavior was detected in 85% of experimental signals. These findings were interpreted as a demonstration of vocal fold interaction. Based on these findings, the authors conclude that (1) coupling must be taken into account in physical models of laryngeal physiology, and that (2) methods of nonlinear dynamics may be used for objective voice analysis.     

Ultrastructural study of muscle in vocal fold: postmortem damage observations

Various authors have published results related to the ultrastructure of vocal folds in specific areas proceeding from human cadavers. Nevertheless, starting from the premise that a fundamental principle of sampling and the samples should be a true representative of the whole, the authors decided to examine vocal folds from human cadavers and compare them to normal vocal folds from the guinea pig (Cavia porcellus). The findings of these authors demonstrated clearly that the conclusion of Rhodin (1954) is correct, that a biological sample must be preserved immediately after blood circulation ceases, and that the intermediary time between biopsy and fixation cannot be more than 3 minutes. Cells fixed a few hours after death appeared disaggregated, and many of their endocellular components were profoundly altered. The results obtained by the authors suggests that ultrastructural studies with cadaverous material may lead to serious risks or doubts about the accuracy of the results and consequently result in dubious interpretations.     

The effect of viscosity changes in the vocal folds on the range of oscillation

Changes in vocal fold oscillation threshold pressure were induced in excised canine larynges by experimentally causing fluid movement into and out of the vocal folds. The transport was facilitated by exposing the vocal folds to various osmotic solutions, and it was assumed that changes in hydration caused changes in the internal tissue viscosity. A range of oscillation threshold pressures was measured for each condition of hydration by varying length and glottal width. The oscillation threshold pressure shifted as predicted. Decreased hydration (increased viscosity) raised the threshold of oscillation, and increased hydration (decreased viscosity) lowered the threshold of oscillation. This apparently represents the first in vitro model for the study of the effect of viscosity changes of the internal environment of the vocal folds on phonation.     

Phonatory control in male singing: A study of the effects of subglottal pressure, fundamental frequency, and mode of phonation on the voice source

This article describes experiments carried out in order to gain a deeper understanding of the mechanisms underlying variation of vocal loudness in singers. Ten singers, two of whom are famous professional opera tenor soloists, phonated at different pitches and different loudnesses. Their voice source characteristics were analyzed by inverse filtering the oral airflow signal. It was found that the main physiological variable underlying loudness variation is subglottal pressure (Ps). The voice source property determining most of the loudness variation is the amplitude of the negative peak of the differentiated flow signal, as predicted by previous research. Increases in this amplitude are achieved by (a) increasing the pulse amplitude of the flow waveform; (b) moving the moment of vocal fold contact earlier in time, closer to the center of the pulse; and (c) skewing the pulses. The last mentioned alternative seems dependent on both Ps and the ratio between the fundamental frequency and the first formant. On the average, the singers doubled Ps when they increased fundamental frequency by one octave, and a doubling of the excess Ps over threshold caused the sound pressure level (SPL) to increase by 8–9 dB for neutral phonation, less if mode of phonation was changed to pressed. A shift of mode of phonation from flow over neutral to pressed was associated with a reduction of the peak glottal permittance i.e., the ratio between peak transglottal airflow to Ps. Flow phonation had the most favorable relationship between Ps and SPL.     

The perceptual nature of vocal register change

This study focuses on the perceptual nature of chest and falsetto registers as a function of various production tokens and methods of perceptual evaluation. Fifteen target tones, ranging from G#3 to A#4, were sung by a male and a female subject in the context of ascending and descending sequences on the vowels /a/ and /i/. Register transitions were elicited by setting strict constraints on production. Segments of 1-s duration were extracted from the target notes, digitized, and acoustically analyzed. These excerpts were presented to ten trained listeners in four different perceptual tasks. Identification and discrimination tasks yielded nearly identical results, suggesting that the primary registers are perceived as distinct entities. The marked change from chest to falsetto as well as the locus of the transition between these registers did not vary systematically as a function of production token or perceptual task. Mean register shift-point frequencies of the male and female subjects were perceived at 320 Hz and 353 Hz, respectively. Multidimensional scaling and hierarchical clustering analyses were utilized to capture the dimensionality and the internal structure of perceptual data sets derived from the pair-wise similarity ratings. Optimal spatial representation of these data required no more than two orthogonal dimensions, with the quality attribute represented by the dominant dimension. The representation of pitch differences was reflected only in the internal ordering of the stimuli within registers, but did not affect the perceptual discontinuity between registers.     

Phonomicrosurgical management of vocal fold polyps: The subepithelial microflap resection technique

Vocal fold polyps are typically caused by acute and chronic trauma to the microvasculature of the superficial lamina propria (SLP). Shearing stresses that are induced by hyperfunctional glottal sound production lead to bleeding into the SLP and malformed neo-vascularized masses. Because the primary process does not involve the epithelium, the authors designed a technique to resect hemorrhagic polyps by epithelial cordotomy with partial or complete preservation of the vocal fold epithelium. This approach is different from the traditional microsurgical resection of hemorrhagic polyps by amputation with or without the carbon dioxide laser. Forty patients who underwent microlaryngoscopic resection of hemorrhagic polyps from 1996 through 1998 were reviewed retrospectively. Thirty-six of the 40 procedures were by epithelial cordotomy and subepithelial removal of the polyp contents. Sixteen of 36 were assisted by a subepithelial infusion of saline and epinephrine, and all were 3 mm to 6 mm. Four of 40 polyps were amputated; all of these were less than 3 mm and were pedicled on a narrow base. Cold instruments were used exclusively in all 40 patients. Postoperative laryngeal stroboscopy within 2 weeks revealed improved mucosal wave propagation and improved glottal closure in all 33 patients in whom postoperative strobovideolaryngoscopy was available. The epithelial cordotomy technique was introduced to minimize disturbance of normal SLP and epithelium. Despite the hemorrhagic nature of these lesions, cold instruments could be used exclusively with facility due to careful microdissection between the polyp and the residual normal SLP and the enhanced hemostasis provided by the subepithelial infusion of saline and epinephrine. The rapid return to improved glottal function is the result of this ultra tissue-sparing technique.     

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.     

Infraglottic aspect of canine vocal fold vibration: Effect of increase of mean airflow rate and lengthening of vocal fold

The mucosal upheaval (MU), where the mucosal wave starts and propagates upward, appears only when the vocal fold vibrates. The location of the MU histologically and the effect of changes in mean air flow rate (MFR) and vocal fold length on occurrence of the MU were studied in twelve excised canine larynges. The lower surface of the vocal fold was marked to serve as a landmark for subsequent study. Cricothyroid approximation was performed to lengthen the vocal fold. After taking high-speed pictures or recording stroboscopic images from the tracheal side, a small cut wound was made at the mark. This wound served to compare the position of the MU with the histologically identified location of the mark. The larynx was then sectioned in the frontal plane. Before lengthening the vocal fold, the MU occurred on the area where the lamina propria became thinner and where the muscular layer neared the epithelial layer. After lengthening the vocal fold, the MU actually shifted medially compared with its original position. The subglottic area surrounded by the bilateral MUs became longer and thinner. Whether or not complete glottal closure during a vibratory cycle was achieved did not alter these findings. In contrast, with a fixed vocal fold length the MU appeared more laterally as MFR increased, but, based on the relation with the mark, its location on the vocal fold did not change from its original position before increase of MFR.     

Correspondence of electroglottographic closed quotient to vocal fold impact stress in excised canine larynges

The purpose of this study was to explore the possible use of the electroglottographic closed quotient (EGG CQ) as a noninvasive estimate of vocal fold impact stress (SI). Two excised canine larynges were used. Each larynx was mounted and vocal fold oscillation was induced using a humidified air source. Twentyseven experimental trials were conducted for each larynx. Trials involved variations in vocal process gap, vocal fold elongation, and subglottic pressure. Simultaneous measures were made of vocal fold SI at the midpoint of the membranous vocal folds, and EGG CQ (dimensionless ratio). The results indicated that when threshold and saturation effects were excluded, the SI and the CQ were strongly related (linear correlation r = .83 and .96 for the two individual larynges, and .81 for the combined data). Within the region of linear relation, an increase of .15 in the CQ corresponded to about 1 kPa increase in SI for the combined data. Discussion focuses on possible clinical implications and the likely reasons for threshold and saturation phenomena.     

Cyclicity of laryngeal cavity resonance due to vocal fold vibration

Acoustic effects of the time-varying glottal area due to vocal fold vibration on the laryngeal cavity resonance were investigated based on vocal tract area functions and acoustic analysis. The laryngeal cavity consists of the vestibular and ventricular parts of the larynx, and gives rise to a regional acoustic resonance within the vocal tract, with this resonance imparting an extra formant to the vocal tract resonance pattern. Vocal tract transfer functions of the five Japanese vowels uttered by three male subjects were calculated under open- and closed-glottis conditions. The results revealed that the resonance appears at the frequency region from 3.0 to 3.7 kHz when the glottis is closed and disappears when it is open. Real spectra estimated from open- and closed-glottis periods of vowel sounds also showed the on-off pattern of the resonance within a pitch period. Furthermore, a time-domain acoustic analysis of vowels indicated that the resonance component could be observed as a pitch-synchronized rise-and-fall pattern of the bandpass amplitude. The cyclic nature of the resonance can be explained as the laryngeal cavity acting as a closed tube that generates the resonance during a closed-glottis period, but damps the resonance off during an open-glottis period.     

The effects of preventive vocal hygiene education on the vocal hygiene habits and perceptual vocal characteristics of training singers

The purpose of the present study was to determine the effects of vocal hygiene education on the vocal hygiene behaviors and perceptual vocal characteristics of untrained singers. Eleven adult untrained singers served as subjects. They attended four 1-hour class sessions on vocal hygiene, including anatomy and physiology of the phonatory mechanism, vocally abusive behaviors, voice disorders commonly seen in singers, and measures to prevent voice disorders. Pre- and postinstruction surveys were used to record subjects' vocal abuses and their perceptions of their speaking and singing voice. They also rated their perceived value of vocal hygiene education. Results revealed minimal changes in vocal hygiene behaviors and perceptual voice characteristics. The subjects did report a high degree of benefit and learning, however.     

Rhabdomyoma of the true vocal fold

Rhabdomyomas of the larynx are exceedingly rare. The incidence, sites of occurrence in the larynx, and treatment of these benign striated muscle tumors are reviewed. A case of rhabdomyoma involving the vocalis muscle is presented with magnetic resonance imaging and video-stroboscopic documentation.