Vocal Process Avulsion

Vocal process avulsion is a rare condition in which laryngeal trauma causes a separation of the vocal process from the body of the arytenoid cartilage. Typically symptoms are dysphonia and shortness of breath during phonation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography are helpful in establishing this important and sometimes elusive diagnosis. Several treatment modalities have been reported with varying success. We report four new cases, review four cases reported previously by the senior author, and suggest approaches to diagnosis and optimal treatment of vocal process avulsion.     

Arytenoid Cartilage Dislocation: A 20-year Experience

SUMMARY: Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Seventy-four cases have been reported in the literature to date. Intubation is the most common origin, followed by external laryngeal trauma. Decreased volume and breathiness are the most common presenting symptoms. We report on 63 patients with arytenoid cartilage dislocation treated by the senior author (RTS) since 1983. Significantly more posterior than anterior dislocations were represented. Although reestablishing joint mobility is difficult, endoscopic reduction should be considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography (CT) imaging are helpful in the evaluation of patients with vocal fold immobility to help distinguish arytenoid cartilage dislocation from vocal fold paralysis. Familiarity with signs and symptoms of arytenoid cartilage dislocation and current treatment techniques improves the chances for optimal therapeutic results.     

Permanent medialization of the paralyzed vocal fold utilizing botulinum toxin and Gelfoam

The clinical picture of a paralyzed vocal fold often has the same appearance as a subluxated arytenoid, with anterior and medial displacement of the arytenoid and a foreshortened and lax vocal fold. Previous work by the authors has shown that a subluxated arytenoid may be permanently repositioned by reduction and selective injection of the intrinsic laryngeal musculature with botulinum toxin. The injection changes the forces within the larynx, allowing the arytenoid to be brought back to proper position on the cricoid cartilage. This concept has been extended to the paralyzed vocal fold. It has been noted that even a clinically paralyzed vocal fold has voluntary motor units that may still act on the arytenoid through residual action from the interarytenoid and synkinesis. These forces are significant enough to manipulate the arytenoid and, thus, the vocal fold, into its correct, adducted position. In this paper, the arytenoid is mobilized to free any fibrosis. The thyroarytenoid and lateral cricoarytenoid muscles are then injected to prevent any forward synkinetic pull on the arytenoid. Next, a Gelfoam injection medializes the vocal fold to create glottic closure. This rebalancing sufficiently positions the arytenoid, so that valvular function is permanently restored. In the ten patients studied for over 1 year, there was a 90% success rate as measured by videostroboscopy, phonation time, and V-RQOL analysis. There were no untoward complications. All the materials used are nonpermanent. The procedure does not limit other techniques from being performed at a later time.     

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.     

Standardized laryngeal videostroboscopic rating: Differences between untrained and trained male and female subjects, and effects of varying sound intensity, fundamental frequency, and age

To determine the influence of the factors gender, vocal training, sound intensity, pitch, and aging on vocal function, videolaryngostroboscopic images of 214 subjects, subdivided according to gender and status of vocal training, were evaluated by three judges with standardized rating scales, comprising aspects of laryngeal appearance (larynx/pharynx ratio; epiglottal shape; asymmetry arytenoid region; compensatory adjustments; thickness, width, length, and elasticity of vocal folds) and glottal functioning (amplitudes of excursion; duration, percentage, and type of vocal fold closure; phase differences; location of glottal chink). The video registrations were made while the subjects performed a set of phonatory tasks, comprising the utterance of the vowel /i/ at three levels of both fundamental frequency and sound intensity. Analysis of the rating scales showed generally sufficient agreement among judges. With the exception of more frequently observed complete closure and lateral phase differences of vocal fold excursions in trained subjects, no further differences were established between untrained and trained subjects. With an α level of p = 0.005, men differed from women with respect to laryngeal appearance (larynx/pharynx ratio, compensatory adjustments, and the presence of omega and deviant-shaped epiglottises), and their vocal folds were rated thicker in the vertical dimension, smaller in the lateral dimension, longer, and more tense, with smaller amplitudes of excursion during vibration. Glottal closure in male subjects was rated more complete, but briefer in duration. Significant effects of the factors pitch, sound intensity, and age on vocal fold appearance and glottal functioning were ascertained. Awareness of the influence of these factors, as well as the factor gender, on the rated scales is essential for an adequate evaluation of laryngostroboscopic images.     

An Investigation of Cricoarytenoid Joint Mechanics Using Simulated Muscle Forces

Rotational and translational stiffnesses were calculated for arytenoid motion about the cricoarytenoid joint. These calculations were obtained from measurements on five excised human larynxes. For each larynx, known forces were applied to the arytenoid cartilage, and three markers were tracked as a function of applied forces. Assuming rigid body motion, arytenoid translations and rotations were computed for each applied force. Translational stiffnesses were obtained by plotting force versus displacement, and rotational stiffnesses were calculated by plotting torque versus angular rotation. A major finding was that the translational stiffness along the anterior-posterior direction was three times as great as the translational stiffnesses in the other two directions. This nonisotropic nature of the stiffnesses may be an important consideration for phonosurgeons who wish to avoid subluxation of the cricoarytenoid joint in patients. The computed rotational and translational stiffnesses currently are being implemented in 2D and 3D models. These stiffness parameters play a vital role in prephonatory glottal shaping, which in turn exerts a majorinfluence on all aspects of vocal fold vibration, including fundamental frequency, voice quality, voice register, and phonation threshold pressure.     

Determining the etiology of mild vocal fold hypomobility

The prevalence of mild vocal fold hypomobility is unknown. In a study by Heman-Ackah et al, vocal fold hypomobility in a population of singing teachers was found to be associated more frequently with vocal complaints than was the presence of vocal fold masses.¹ The etiology of mild vocal fold hypomobility has not been previously explored. In the present study, a retrospective chart review was performed of 134 patients who presented to a tertiary laryngology referral center over a 6-month period for evaluation of vocal complaints. Of the 134 patients, 61 (46%) were found to have mild vocal fold hypomobility previously undiagnosed by the referring otolaryngologist. Imaging studies and laboratory tests to evaluate for structural, metabolic, and infectious causes of the decreased mobility had been ordered. Forty-nine patients completed the work-up. Of these, 41 out of 49 (84%) were found to have imaging or laboratory findings that could explain the hypomobility. Thyroid abnormalities were found to be associated with vocal fold hypomobility in 21 out of 49 (43%) of those with a complete evaluation. Other causes of vocal fold hypomobility included idiopathic (8 of 49, 16%), viral neuritis (5 of 49, 10%), central nervous system abnormality (4 of 49, 8%), neural tumor (3 of 49, 6%), joint dysfunction (3 of 49, 6%), iatrogenic nerve injury (2 of 49, 4%), myopathy (2 of 49, 4%), and noniatrogenic traumatic nerve injury (1 of 49, 2%), This study shows that unilateral vocal fold hypomobility often is associated with a physiologic process, and a complete investigation to determine the etiology is warranted in all cases.     

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

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

Vocal Fold Mucosal Tears: Maintaining a High Clinical Index of Suspicion

Vocal fold mucosal tears have been discussed in the literature rarely, although they are not uncommon clinically. Disruptions in the epithelium usually follow trauma that may result from voice abuse and/or misuse, coughing, and other causes. A high index of suspicion is necessary to avoid missing vocal fold mucosal tears, and strobovideolaryngoscopy is indispensable in making the diagnosis. A brief period of complete voice rest is the standard of care and appears to be helpful in avoiding adverse sequelae and advancing the healing process, but there are no scientific studies to confirm its efficacy. Mucosal tears may heal completely or may be followed by the development of vocal fold masses, scar, and permanent dysphonia.     

Decomposition of Vocal Cycle Length Perturbations into Vocal Jitter and Vocal Microtremor, and Comparison of Their Size in Normophonic Speakers

A statistical method that enables raw vocal cycle length perturbations to be decomposed into perturbations ascribed to vocal jitter and vocal tremor is presented, together with a comparison of the size of jitter and tremor. The method is based on a time series model that splits the vocal cycle length perturbations into uncorrelated cycle-to-cycle perturbations ascribed to vocal jitter and supra-cycle perturbations ascribed to vocal tremor. The corpus was composed of 114 vocal cycle length time series for sustained vowels [a], [i], and [u] produced by 22 male and 16 female normophonic speakers. The results were the following. First, 100 out of 114 time series were decomposed successfully by means of the time series model. Second, vocal perturbations ascribed to tremor were significantly larger than perturbations ascribed to jitter. Third, the correlation between vocal jitter and vocal tremor was moderate, but statistically significant. Fourth, small but statistically significant differences were observed among the three vowel timbres in the relative jitter and the arithmetic difference of jitter and tremor. Fifth, the differences between male and female speakers were not statistically significant in the relative raw perturbations, the relative jitter, or the modulation level owing to tremor.     

Laryngeal pathological findings following trauma to cricoarytenoid joint

Abnormal vocal cord mobility may result from trauma to the cricoarytenoid joint. A rabbit model of this kind of trauma was established in order to investigate pathological changes of the traumatized joint. Two types of pathological changes in the cricoarytenoid joint (acute inflammatory reaction in the early stage and fibrosis in the later stage) were noted. The above phenomena might be the mechanism of vocal cord dysfunction caused by trauma to the cricoarytenoid joint. The recovery of vocal cord function may depend on whether or not there is fibrosis of the cricoarytenoid joint. It is almost impossible to regain normal vocal cord function as soon as fibrosis of the joint occurs. Therefore, it is important to treat the patients effectively and immediately in the early stage of trauma for recovery.     

Minifenestration Type I Thyroplasty Using an Expanded Polytetrafluoroethylene Implant

Several methods have been used to treat laryngeal incompetence, but no ideal technique has been identified. This paper describes a clinical experience with minifenestration type I thyroplasty using a new device made of expanded polytetrafluoroethylene (ePTFE). The device, a thin ribbon of ePTFE, is inserted through a 4-mm fenestration to produce vocal fold medialization. At our center, 26 of these devices have been implanted in the past 3 years. Good or satisfactory results were achieved in 96% of cases. Advantages of this technique include easy insertion of the implant, nominal cost and biocompatibility of the ePTFE device, ready availability of all instruments required for the procedure, and elimination of the need to perform arytenoid adduction.     

Mild Vocal Fold Paresis: Understanding Clinical Presentation and Electromyographic Findings

The implications of mild vocal fold hypomobility are incompletely understood. This study describes the clinical, electromyographic, and probable etiologic findings in patients who presented with complaints of dysphonia and whose physical examination revealed vocal fold paresis as a factor possibly contributing to their voice complaints. A retrospective chart review of all patients who presented to a tertiary laryngology referral center over a 13-month period, who had a clinical diagnosis of mild vocal fold hypomobility and who underwent laryngeal electromyography, were included in the study. A total of 22 patients completed the medical evaluation of their voice complaint. Of these patients, 19 (86.4%) were found to have evidence of neuropathy on laryngeal electromyography. The clinical picture indicated the following probable origins for the vocal fold paresis: goiter/thyroiditis (7/22 or 31.8%), idiopathic (4/22 or 18.2%), viral neuritis (4/22 or 18.2%), trauma (3/22 or 13.6%), and Lyme's disease (1/22 or 4.5%). This article describes the clinical entity of mild vocal fold hypomobility and associated flexible laryngoscopic, rigid strobovideolaryngoscopic, and laryngeal electromyographic findings.     

Phonotrauma associated with crying

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

Vocal fold augmentation with injectable calcium hydroxylapatite: short-term results.

Symptoms of unilateral vocal fold paralysis are improved significantly by augmenting the paralyzed vocal fold via vocal fold injection. In this trial, augmentation with a new calcium hydroxylapatite implant was evaluated. In addition, two different phonosurgical injection techniques were used, and these procedures were compared for accuracy and reliability. A total of 11 terminal patients with unilateral vocal fold paralysis underwent vocal fold injection with calcium hydroxylapatite. Efficacy of the implant was evaluated by comparing results from the Voice Handicap Index (VHI) and mean airflow measurements before and 6 months after injection. Surgeon evaluations determined the comparative benefits of either endoscopic direct vocal fold injection or percutaneous vocal fold injection. Six-month data were obtained for a cohort of five patients. VHI scores improved for all five patients available for full evaluation and four of the five achieved improvements in mean airflow rates. Of the remaining patients, one later had a medialization laryngoplasty, two died from their terminal diseases before the 6-month follow-up, and two of the remaining three reported satisfaction with the results via telephone follow-up. Vocal fold injection via endoscopic, direct laryngoscopy was found to be a more reliable procedure for vocal fold injection than percutaneous injection. Slight overinjection (10% to 15%) was found to provide optimum results. Vocal fold injection of calcium hydroxylapatite for unilateral vocal fold paralysis improved voice quality and reduced mean airflow rates in this patient group with short-term results. Long-term studies are needed to confirm the durability of these findings.     

The Evolving Etiology of Bilateral Vocal Fold Immobility

In the past, bilateral vocal fold immobility (BVFI) occurred most commonly after thyroidectomy. However, no large series documenting the etiology of adult BVFI has been published within the past fifteen years. This study reviews the etiologic patterns of BVFI at our institutions. We compare BVFI from before and after 1980. We also review combined studies of unilateral vocal fold immobility (UVFI) to compare and unilateral versus bilateral etiologic trends. In comparison with previously published series, fewer cases of BVFI present today as a complication of thyroid surgery and more as the result of malignancies and nonsurgical trauma. Unfortunately, BVFI caused by malignancy is not usually an initial sign of local disease, but an ominous sign of recurrence or metastases. In comparing UVFI and BVFI we found that thyroidectomy causes a higher percentage of BVFI than of UVFI. Over one-third of UVFI cases were caused by neoplasm which further underscores the potential seriousness of immobile vocal folds and the need for careful investigation.     

A simplified model of mouth radiation impedance closed by mask cavity

Acoustic radiation impedance of the mouth is an important parameter when the vocal tract is modelled by the equivalent electrical circuit. If the vocal tract is closed by a cavity, as when the speaker wears some kind of mask, total impedance acoustically loading the vocal tract becomes serial connection of the mouth radiation impedance and the mask impedance. In that case the mouth radiation impedance has to be changed compared to free field conditions. This paper introduces a simplified approach to the modelling of that change by an appropriate reduction coefficient. The analysis based on an experiment preformed by measurement in the vocal tract physical model accompanied with analytical estimation has shown that the value of such reduction coefficient is 0.5. The results reveal that for a vocal tract closed with mask cavity the change in mouth radiation impedance introduced in an equivalent electrical circuit can be approximated by the value for free field radiation decreased by about 50%.     

Thyroplasty as primary and adjunctive treatment of glottic insufficiency

This study addresses the role of medialization thyroplasty in a variety of vocal fold pathological conditions manifested by glottic insufficiency. In this series, most patients had preceding or concurrent phonosurgical procedures. Success of surgery was determined by subjective, audioperceptual judgments, acoustic analysis, and vocal function measures. Vocal fold pathology played a greater role in determining success than did the presence or absence of adjunctive surgical procedures. Thyroplasty Type I was effective in treating glottic insufficiency in patients previously treated with various augmentation procedures as well as in those undergoing simultaneous reinnervation and arytenoid adduction. Technical factors predisposing to complications included violation of inner thyroid cartilage perichondrium, small shim size, sacrifice of cartilagenous window, and mucosal penetration. Thyroplasty should be considered as a primary or adjunctive treatment of patients with glottic insufficiency, especially when preservation of membranous vocal fold structure is of primary importance.     

The membranous contact quotient: A new phonatory measure of glottal competence

The membranous contact quotient (MCQ) is introduced as a measure of dynamic glottal competence. It is defined as the ratio of the membranous contact glottis (the anterior-posterior length of contact between the two membranous vocal folds) and the membranous vocal fold length. An elliptical approximation to the vocal fold contour during phonation was used to predict MCQ values as a function of vocal process gap (adduction), maximum glottal width, and membranous glottal length. MCQ is highly dependent on the vocal process gap and the maximum glottal width, but not on vocal fold length. Five excised larynges were used to obtain MCQ data for a wide range of vocal process gaps and maximum glottal widths. Predicted and measured MCQ values had a correlation of 0.93, with an average absolute difference of 9.6% (SD = 10.5%). The model is better at higher values of MCQ. The theory for MCQ is also expressed as a function of vocal process gap and subglottal pressure to suggest production control potential. The MCQ measure is obtainable with the use of stroboscopy and appears to be a potentially useful clinical measure.