Voicing: requires frequent starts and stops at various sound pressure levels (SPL) and frequencies. Prior investigations using rigid laryngoscopy with oral endoscopy have shown variations in the ...duration of the vibration delay between normal and abnormal subjects. However, these studies were not physiological because the larynx was viewed using rigid endoscopes. We adapted a method to perform to perform simultaneous high-speed naso-endoscopic video while simultaneously acquiring the sound pressure, fundamental frequency, airflow rate, and subglottic pressure. This study aimed to investigate voice onset patterns in normophonic males and females during the onset of variable SPL and correlate them with acoustic and aerodynamic data.
Three healthy males and three healthy females were studied by simultaneous high-speed video laryngoscopy and recording with the production of the gesture pa:pa: at soft, medium, and loud voices. The fiber optic endoscope was threaded through a pneumotachograph mask for the simultaneous recording and analysis of acoustic and aerodynamic data.
The average increase in the sound pressure level (SPL) for the group was 15 dB, from 70 to 85 dB. The fundamental frequency increased by an average of 10 Hz. The flow was increased in two subjects, reduced in two subjects, and remained the same in two subjects as the SPL increased. There was a steady increase in the subglottic pressure from soft to loud phonation. Compared to soft to medium phonation, a significant increase in glottal resistance was observed with medium-to-loud phonation. Videokymogram analysis showed the onset of vibration for all voiced tokens without the need for full glottis closure. In loud phonation, there is a more rapid onset of a larger amplitude and prolonged closure of the glottal cycle; however, more cycles are required to achieve the intended SPL. There was a prolonged closed phase during loud phonation. Fast Fourier transform (FFT) analysis of the kymography waveform signal showed a more significant second- and third-harmonic energy above the fundamental frequency with loud phonation. There was an increase in the adjustments in the pharynx with the base of the tongue tilting, shortening of the vocal folds, and pharyngeal constriction.
Voice onset occurs in all modalities, without the need for full glottal closure. There was a more significant increase in glottal resistance with loud phonation than that with soft or middle phonation. Vibration analysis of the voice onset showed that more time was required during loud phonation before the oscillation stabilized to a steady state. With increasing SPL, there were significant variations in vocal tract adjustments. The most apparent change was the increase in tongue tension with posterior displacement of the epiglottis. There was an increase in pre-phonation time during loud phonation. Patterns of muscle tension dysphonia with laryngeal squeezing, shortening of the vocal folds, and epiglottis tilting with increasing loudness are features of loud phonation. These observations show that flexible high-speed video laryngoscopy can reveal observations that cannot be observed with rigid video laryngoscopy. An objective analysis of the digital kymography signal can be conducted in selected cases.
Abstract
Objective
Platelet‐rich plasma (PRP) is rich in growth factors and is easily obtained from blood samples. Long‐term data after PRP injection into the larynx should be improved. This study ...reports the short‐term (3 months) and long‐term (12 months) voice results after PRP injection.
Materials and Methods
Sixty‐three patients with scars (
n
= 34), sulcus vocalis (
n
= 17), recalcitrant nodules (
n
= 5), atrophy (
n
= 4), or a combination of these (
n
= 3) were included (158 injections; median follow‐up = 12.3 months). Stroboscopy, voice handicap index (VHI‐10), and cepstral spectral index of dysphonia (CSID) before and after treatment (3 months) and at 12 months were tabulated.
Results
VHI‐10 changed from 19.5 to 14 at 3 months and 21 to 15 in the long term. The CSID scores improved from 31 to 21 in the short term and 31 to 26 in the long term (
p
< 0.001, paired
t
‐test). Patients reported improved vocal effort and stamina with slight VHI or CSID score changes. Stroboscopy revealed improved closure and mucosal waves. Patients with severe dysphonia were less likely to improve compared to those with mild to moderate dysphonia. Some patients showed short‐term improvements and then deteriorated back to baseline CSID over time (
p
< .05, paired
t
‐test).
Conclusion
Both short‐ and long‐term improvements in voice following PRP injection have been reported. Patients with mild‐to‐moderate dysphonia had better outcomes. PRP injection is an alternative treatment for patients with mild‐to‐moderate dysphonia due to vocal fold scarring, sulcus, and atrophy.
Level of evidence
II Prospective case series treatment.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Summary Dr. Paul Moore pioneered the use of high-speed cinematography for observation of normal and abnormal vocal fold vibrations during phonation. His analysis of the glottal area waveform, opening ...and closing speed index, and open quotient from the high-speed films were labor intensive but relevant today. With advances in digital image capture and automated image extraction techniques, stroboscopy and high-speed images of vocal fold vibration may be analyzed with objective measures. Digital high-speed image capture in color is now clinically practical at high resolution. Digital kymography now allows analysis of the vibratory waveform from each vocal fold. Serial capture and comparison can document changes in vibratory function with treatment. Quantification of vocal fold vibration using such techniques is now practical. This is a review of vocal fold vibration capture and analysis techniques since Dr. Moore.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Diplophonia can occur in patients with polyps, atrophy, paralysis, or scars. Its vibratory patterns have not been well characterized. High-speed video (HSV) analysis can contribute to their ...understanding. Twenty subjects with a diplophonic voice quality were studied by HSV. Diplophonia was due to medical causes including vocal fold paresis (n = 7), vocal atrophy (n = 5), polyps (n = 5), and scars/sulci (n = 3). The HSV was analyzed using a multislice digital videokymography (DKG). The DKG tracing was analyzed qualitatively and then transformed into a vibrogram waveform signal for frequency analysis.
Vibratory abnormalities seen on HSVs explained the diplophonia. Subharmonics to the fundamental frequency can be visualized by DKG. None could be resolved by stroboscopy. One can stratify diplophonia as symmetric or asymmetric based on the involvement of one or both vocal folds. Scars and atrophy showed symmetric subharmonic production with ectopic beats every 4–10 beats. Some subjects showed anterior and posterior independent vocal fold oscillators. Asymmetric causes of diplophonia are common in patients with paralysis. Two different oscillation frequencies of each vocal fold generate in and then out of phase interaction between the two sides. Vibrogram analysis documents the frequent presence of interharmonic energy peaks above the dominant fundamental frequency. Eighteen of the 20 subjects have obvious subharmonic peaks.
Patients with diplophonia have vibratory abnormalities arising from the vocal folds. HSV and vibrogram analysis followed by frequency analysis of the vibrogram can resolve vibratory abnormality into symmetric versus asymmetric causes and can document the type of vibratory abnormality.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Introduction
Narrow‐band imaging (NBI) can improve detection of lesions in the aerodigestive tract. However, its role in benign lesions of the larynx is unclear. This study aims to determine whether ...NBI improves the detection of scars, sulci, and nodules compared to panchromatic lighting using objective image analysis.
Methods
In total, 120 vocal folds (VFs) were analyzed with and without NBI (21 normal, 15 scars, 16 sulci, and 45 nodules). Each VF image had anterior, middle, and posterior thirds analyzed for brightness using an area morphometry software (Optimas 5.1a). The middle‐third with the lesion was analyzed against surrounding VF segments for average and standard deviation (SD) in absolute grayscale.
Results
The use of panchromatic light resulted in greater illumination and grayscale values than NBI. All lesions tended to be in the mid‐membranous fold. Under panchromatic light, change in brightness when comparing anterior versus middle (A–M) was +6.1% for normal, versus 6.5%, 8.1%, and 7.1% for sulci, nodules, and scars, respectively. Under NBI, they were 9.0% (normal), 12.3% (sulci), 13.7% (nodules), and 13.1% (scars). A greater SD of luminescence was observed at pathology sites (p < 0.05) when using NBI. The change in absolute grayscale at all lesion sites was greater when using NBI than when using panchromatic light (p < 0.05).
Conclusion
NBI significantly enhanced the area of pathology in patients with nodules, sulci, and scars. Greater SD values in grayscale at pathologic sites were observed compared at normal sites. Thus, NBI may improve the detection of phonotraumatic lesions compared to panchromatic light.
Level of Evidence
N/A Laryngoscope, 134:4066–4070, 2024
This article show that narrow band imaging provides greater contrast for lesion areas compared than panchromatic light in sulcus, scar, and nodules. It provides objective evidence that NBI can aid in detecting benign vocal fold lesions during routine office laryngoscopy.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
We propose a modification of the transverse cordotomy procedure which improves the predictable airway outcome and allows for better voice.
Laryngoscope, 134:2790–2792, 2024
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objectives
Multiple topical anesthesia techniques exist for office‐based laryngeal surgery. Our objective was to assess patient and surgeon satisfaction for three different techniques.
Study Design
...Cohort study.
Methods
All consecutive patients presenting to an outpatient laryngology office for awake surgical procedures were enrolled. Patients were anesthetized with local anesthesia (2 cubic centimeters of 4% lidocaine) in one of three ways: 1) nebulizer, 2) flexible cannula through a channeled laryngoscope, or 3) transtracheal instillation. Demographics, procedure times, and surgeon satisfaction were recorded. A validated 11‐item patient satisfaction questionnaire (Iowa Satisfaction with Anesthesia Survey) was administered after the procedure to calculate an overall satisfaction score (−3worst to 3best). Descriptive and correlative statistics were performed.
Results
One hundred consecutive patients were included (37 females, 73 males), with relatively equal numbers between groups (32 nebulizer, 35 cannula, 33 transtracheal). Seven procedures were aborted (4 nebulizer, 2 cannula, 1 transtracheal) due to movement, anxiety, or technical issues. Three patients did not adequately complete the survey. Of the 90 remaining patients, patient satisfaction was highest with the transtracheal technique (2.04) versus cannula (1.46) or nebulizer (1.45), and this was statistically significant (P = 0.0167). This difference was driven by decreased pain and nausea scores in the transtracheal group. Surgeon satisfaction was lower with nebulizer and higher with transtracheal injection (P = 0.0081). There was a correlation between surgeon satisfaction and patient satisfaction (P < 0.0001).
Conclusion
Transtracheal instillation was favored by both patients and the surgeon. Choice of local anesthetic techniques may impact patient preferences and surgical success. This may serve as a basis for optimizing anesthetic care in office‐based laryngeal surgery.
Level of Evidence
4 Laryngoscope, 130:166–170, 2020
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
8.
Office Steroid Injections of the Larynx Mortensen, Melissa; Woo, Peak
The Laryngoscope,
October 2006, Volume:
116, Issue:
10
Journal Article, Conference Proceeding
Peer reviewed
Objective: Steroid injection into the larynx has been sporadically reported as helpful in benign lesions of the larynx. Its role in laryngology remains unclear. This study reviews the indications and ...results of 47 steroid injections in 34 patients in an office setting.
Methods: The authors conducted a retrospective review of 47 injections in 34 patients. Methylprednisolone acetate suspension, USP (40 mg/mL), was injected by indirect laryngoscopy under local anesthesia. Results were evaluated by stroboscopy and by perceptual evaluation of the GRABS scale before and after injection. Pre‐ versus postinjection ratings were compared by paired t test.
Results: Indications for injection were: 1) postoperative scar with local stiffness (12 patients), 2) vocal nodules and polyp (18 patients), and 3) sarcoidosis/granuloma (4 patients). Steroid injections were done in professional singers instead of repeated oral administration of steroids and/or to avoid surgery in patients with polyps and cysts. Improvement was noted in 28 of 34 (82%). Eleven of the 18 patients with polyps and nodules had significant improvement and avoided surgery. Vocal fold scars improved after injection with an improved voice grade (P < .01), an improved amplitude (P < .05), and improved mucosal wave (P < .05). There were no complications. Only two patients could not tolerate office injection.
Conclusion: Office steroid injections are a valuable adjunct in management of vocal fold scars, polyps, nodules, and granulomas.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Long-term voice outcome (LTVO) after radiation (XRT) or trans-oral laser microsurgery (TLM) is unclear. This study is a multi-modality analysis of LTVO following XRT or TLM in patients with early ...glottic cancer. We hypothesize that as compared with TLM, LTVO is worse in the XRT group because of progressive fibrosis in the glottic tissue
One hundred and two patients with early glottic carcinoma (carcinoma in situ, T1, T2) were included. Multi-modality voice analyses were performed with self-perception using Voice Handicap Index-10, objective analysis using Analysis of Dysphonia in Speech and Voice Software (Cepstral Spectral Index of Dysphonia score for Consensus Auditory-Perceptual Evaluation of Voice sentences), and perceptual rating by two blinded speech language pathologists (GRBAS scale).
Fifty-five patients received TLM (mean follow-up = 52 months) and 47 patients had XRT (mean follow-up = 65 months). There is no difference between the two groups in sex, age, stage, and follow-up time. Intraclass correlation coefficient between raters was high at 0.94. Controlling for age and stage, XRT increases total GRBAS score by 1.38 points (P = 0.006) and increases Cepstral Spectral Index of Dysphonia score by 13.7 points (P < 0.001) when compared with the TLM group. No significant differences were found in the Voice Handicap Index score between the XRT and the TLM groups.
This is the first multi-modality voice analysis to suggest TLM results in better LTVO than XRT in GRBAS score and objective voice analysis but not in self-perception. These differences may reflect the progressive effects of XRT on glottic tissue. A randomized controlled study is required to confirm our findings.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
10.
Clinical grading of Reinke's edema Tan, Melin; Bryson, Paul C.; Pitts, Casey ...
The Laryngoscope,
October 2017, 2017-10-00, 20171001, Volume:
127, Issue:
10
Journal Article
Peer reviewed
Objective
Reinke's edema (RE) is a pathologically benign structural change of the vocal folds with a wide spectrum of clinical severity. We aim to propose and validate a clinical grading system based ...on size of the lesion to facilitate effective universal communication of disease severity.
Study Design
Retrospective review.
Methods
Patients diagnosed with RE exclusive of other glottic pathology between December 2010 and December 2014 were included. Sixty laryngoscopy photographs were extracted from recorded archived laryngeal videostroboscopy exams, blinded and graded by four laryngologists with experience diagnosing RE.
Results
A high degree of agreement among all four raters was demonstrated by high interclass correlation coefficients with a 95% confidence interval. Similarly, high intra‐rater reliability was seen across all raters. Forty‐nine (33%) lesions were grade 1. Thirty‐five lesions (29.17%) were grade 2; 18 (15%) lesions were grade 3; and nine (7.5%) lesions were grade 4. Contralateral vocal fold was not graded in cases of grade 4.
Conclusion
This clinical grading for RE is a reliable tool for conveying severity of disease. High inter‐ and intra‐rater reliability strongly suggest that RE similarly can be graded by different raters, and that a single rater is expected to grade RE similarly at different times.
Level of Evidence
4. Laryngoscope, 127:2310–2313, 2017
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK