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To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency.Retrospective study of professional singers and actors who presented for a vocal evaluation.A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR).A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n = 33), followed by cyst 27% (n = 25) and acute laryngitis, 14% (n = 13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n = 47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P = 0.008).Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

Summary Objectives The understanding of vocal fold hydration state, including dehydrated, euhydrated, rehydrated tissue, and how hydration affects vocal fold biomechanical properties is still evolving. Although clinical observations support the benefits of increasing vocal fold hydration after dehydrating events, more mechanistic information on the effects of vocal fold dehydration and the beneficial effects of rehydration are needed. Alterations to hyaluronic acid (HA), an important component of the vocal fold extracellular matrix, are likely to influence the biomechanical properties of vocal folds. In this study, we investigated the influence of hydration state and HA on vocal fold tissue stiffness via biomechanical testing. Study design Prospective, ex vivo study design. Methods Fresh porcine vocal folds (N = 18) were examined following sequential immersion in hypertonic (dehydration) and isotonic solutions (rehydration). In a separate experiment, vocal folds were incubated in hyaluronidase (Hyal) to remove HA. Control tissues were not exposed to any challenges. A custom micromechanical system with a microforce sensing probe was used to measure the force-displacement response. Optical strain was calculated, and ultrasound imaging was used to measure tissue cross-sectional area to obtain stress-strain curves. Results Significant increases (P ≤ 0.05) were found in tangent moduli between dehydrated and rehydrated vocal folds at strains of e = 0.15. The tangent moduli of Hyal-digested tissues significantly increased at both e = 0.15 and 0.3 (P ≤ 0.05). Conclusion Vocal fold dehydration increased tissue stiffness and rehydration reduced the stiffness. Loss of HA increased vocal fold stiffness, suggesting a potential mechanical role for HA in euhydrated vocal folds.

Summary Objective The diffusion characteristics of water molecules were measured in the vocal folds of canines exhibiting unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation. These characteristics were used in conjunction with a histological examination of the microstructural changes of vocal fold muscle fibers to explore the feasibility of diffusion tensor imaging (DTI) in distinguishing unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation as well as evaluating microstructural changes. Methods Ten beagles were randomly divided into three groups: four in the unilateral vocal fold paralysis group, four in the unilateral cricoarytenoid joint dislocation group, and two in the normal group. Unilateral recurrent laryngeal nerve resection was performed in the vocal fold paralysis group. Unilateral cricoarytenoid joint dislocation surgery was performed in the dislocation group. No intervention was performed in the normal group. Four months postintervention, the larynges were excised and put into a magnetic resonance imaging (MRI) system (9.4T BioSpec MRI, Bruker, German) for scanning, followed by an analysis of diffusion parameters among the different groups for statistical significance. After MRI scanning, the vocal folds were cut into sections, stained with hematoxylin and eosin, and scanned digitally. The mean cross-sectional area of muscle fibers, and the mean diameter of muscle fibers in the vocal folds were calculated by target detection and extraction technology. Mean values of each measurement were used to compare the differences among the three groups. Pearson correlation analysis was performed on the DTI parameters and the results from histological section extraction. Results The paralysis group had significantly higher Fractional Anisotropy (FA) compared to the dislocation group and normal group (P = 0.004). The paralysis group also had a significantly lower Tensor Trace value compared to the dislocation group and normal group (P = 0.000). The average cross-sectional area of vocal fold muscle fibers in the paralysis group was significantly smaller than the dislocation group and normal group (P = 0.000). Pearson correlation analysis yielded values of, r = -0.785, P = 0.01 between the average cross-sectional area of vocal muscle fibers and FA, and values of r = 0.881, P = 0.00 between Tensor Trace and the average cross-sectional area of vocal muscle. Conclusion FA and Tensor Trace can be used as effective parameters to reflect the changes of microstructure in vocal fold paralysis and cricoarytenoid joint dislocation. DTI is an objective and quantitative method to effectively evaluate unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation, also capable of noninvasively evaluating vocal fold muscle fiber microstructure.

Objective To present and validate a new simulation model for endoscopic phonomicrosurgery training as an improved teaching method. Methods A low-cost artificial model was assembled using 3D printing, silicone, and gelatin. The study was designed to test the model's ability to carry out training and teaching of endoscopic phonomicrosurgery. The synthetic model was built to simulate normal and pathological vocal folds such as polyps, intracordal cysts and keratoses, made of silicone and gelatin and embedded in a larynx framework made by 3D printing. Simulations of endoscopic surgical procedures were performed and documented through photographs and videos and the images were submitted to the evaluation of a group of 17 otorhinolaryngologists who used a Likert scale questionnaire. The responses were submitted to an agreement analysis using the sum of the scores obtained for the responses as an appropriate level of validation. Cronbach's alpha index was calculated to measure the degree of the questionnaire internal consistency. Result The evaluations indicated maximum approval for the model adequacy for use in practical classes and for the teaching of the procedures, as well as in the overall satisfaction with the model in the use of surgical training. Conclusion The present proposal for training laryngeal endoscopic surgery in a 3D synthetic model is a viable option according to the validation methodology used in the present study.

Lichen planus (LP) is an immune-mediated chronic inflammatory disease affecting the skin and mucosal membranes, either alone or in combination. LP rarely occurs in the larynx, where it presents as leukoplakia. Additionally, due to its responsiveness to corticosteroid drugs, differential diagnosis from other causes of laryngeal leukoplakia is needed (e.g., dysplasia and squamous cell carcinoma [SCC]). A 71 years old male smoker presented with progressive hoarseness and cough without fever. Vocal folds' motility was preserved. At fiberoptic laryngoscopy, he presented with bilateral cordal erythema and leukoplakia of the right true vocal fold. A sub-epithelial CO2 laser cordectomy was performed. Histological findings were consistent with mucosal LP. After surgical excision, the patient experienced symptomatic relief without medical treatment. A relapsing lesion became clinically evident six months later. A pinch biopsy was performed, and the histological examination confirmed the presence of laryngeal-LP. Hence, the patient underwent a 10-week corticosteroid-based treatment. After that, and during the subsequent 12 months of follow-up, the patient showed no signs of recurrence. LP is an exceedingly rare cause of leukoplakia in the larynx. Histological evaluation plays a key role in the diagnosis, in order to establish a proper therapeutic approach. Since LP is responsive to corticosteroid drugs and untreated disease tends to relapse, the medical treatment is advisable in such instances.

Summary Mechanical impact stress on the vocal fold surface, particularly when excessive, has been postulated to cause the so-called phonotraumatic tissue lesions, such as nodules and polyps. The collision stress between the vocal folds depends on the vocal fold velocity at the time of impact. Hence this vocal fold collision speed is a relevant parameter when considering biomechanical economy of phonation, especially in voice professionals needing a louder voice than normal. Combining a precise photometric measurement of glottal area and simultaneous measurements of translaryngeal impedance (electroglottogram) for identifying the time of the maximum rate of increase of vocal fold contact allows computing the vocal fold collision speed in a wide range of loudnesses. The vocal fold collision speed is - for modal voicing - always smaller than the maximum vocal fold velocity during the closing phase, but it strongly increases with intensity. Moreover, this increase shows a biphasic pattern, with a significant enhancement from a certain value of dB on. Understanding physiological variables that influence vocal fold collision forces provides relevant insight into the pathophysiology and the prevention of voice disorders associated with phonotraumatic vocal hyperfunction.

Summary Introduction College students use their voices at excessively loud intensities and long durations during college fests. The accumulative effect of vocally abusive behaviors in the presence of high ambient noise, poor vocal hygiene, and other environmental factors contribute significantly towards reducing vocal effectiveness in college students. Objective The present study aimed to study the effect of a vocally demanding situation (college Fest) on perceptual and objective voice features of college students. Methodology In this study, a total number of 27 undergraduate female students participated in the age range of 18–27 years. Pre-test—post-test research design was applied. Data analysis consisted of video stroboscopic examination, acoustic analysis using the Multi-dimensional voice program (MDVP), and perceptual evaluation with the GRBAS scale. The data obtained were processed using descriptive statistics and non-parametric tests to determine the difference in each measured parameter pre- and postfest. Results and Discussion Incomplete glottis closure, asymmetric vibration of vocal folds, and aperiodicity of vocal folds increased significantly postcollege Fest. GRBAS parameters also showed a change from pre Fest scores on grade (hoarseness) increased by 38%, breathiness in 34%, roughness in 26%, Asthenia in 15%, and strain increased in 38% participants. A P-value estimation revealed significantly higher scores in Jitter percent, Shimmer percent, and relative average perturbation than pre-fest scores. Conclusion The results of the present study indicate a high risk of vocal disorders among college students post Fest. This study suggests a potential unmet need for college students to receive education before cultural events on optimal vocal usage, vocal hygiene, and an appropriate period of vocal rest.

Made available in DSpace on 2020-12-12T02:17:39Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-01-01 Objective: to determine the sectorial concentration of fibrous matrix along the vocal folds of the elderly. Methods: Thirteen fresh vocal folds were removed from 13 cadavers. The subjects were divided into two groups: control group (CG) – age range 25–40 years (n = 5), and elderly group (EG), aged ≥70 years (n-8). The vocal folds were separated according to regions in: anterior macula flava (AMF), posterior macula flava (PMF), medial region (M) and lateral region of the membranous vocal fold (L). The material was examined using a scanning electron microscope and 10 pictures per region were obtained at 1200x magnification. The area of fibrous matrix was quantified in both groups using the AVSOFT Biovew Program. Results: Percentage (%) of fibrous matrix per region (%): AMF (EG = 86.78%; CG = 81.63%); PMF (EG = 88.19%; CG = 81.52%); M (EG = 84.92%; CG = 77.96%); L (EG = 83.93%; CG = 78.91%). Irregular distribution of a dense fibrous matrix was also more evident in the elderly's larynges in a qualitative assessments. Conclusion: A higher concentration of fibrous matrix was observed in the vocal folds of the elderly when compared to the control at all the studied regions. The greatest increase in the concentration of fibers in the medial portion of the body of the vocal folds is probably due to the phonatory stimulation. The macula flava remains functional even in the senile larynx. Department of Ophthalmology Otorhinolaryngology and Head and Neck Surgery Univ. Estadual Paulista Botucatu Medical School (Unesp) Institute of Bioscience Department of Morphology Univ. Estadual Paulista (Unesp) Department of Ophthalmology Otorhinolaryngology and Head and Neck Surgery Univ. Estadual Paulista Botucatu Medical School (Unesp) Institute of Bioscience Department of Morphology Univ. Estadual Paulista (Unesp)

Injection laryngoplasty (IL) is performed to reduce the gap between vocal folds induced by unilateral vocal fold paralysis (UVFP). Voice quality after IL may be different due to other factors that influence voice quality. Voice therapy has been reported to improve voice quality after IL in patients with UVFP. This study evaluated the efficacy of voice therapy combined with IL.Patients with UVFP who underwent IL as primary therapy from March 2017 to June 2019 were evaluated. The enrolled patients were divided into two groups, those who did and did not receive voice therapy after IL. Voice quality was evaluated using perceptual, acoustic, and aerodynamic parameters, and voice handicap index-30 scores one month after IL and after completing each treatment.Of 261 patients who underwent IL during the study period, 40 were enrolled, including 21 who did and 19 who did not receive voice therapy. Voice parameters one month after IL did not differ between these two groups. Jitter, shimmer, noise-to-harmonic ratio, and mean flow rate decreased, while maximum phonation time increased after voice therapy (both P0.05). In the absence of voice therapy, improved voice parameters were maintained for six months after IL. Total voice handicap index-30 scores decreased, from 35.6 to 19.1 (P0.05), in patients who received voice therapy.Voice therapy following IL is beneficial to patients with UVFP. Combined treatment can help to maintain improved voice quality more than six months after IL.

Ideally, an analysis method for laryngeal high-speed videoendoscopy (LHSV) based on the glottal area waveforms (GAW) requires images of a complete view of the glottis to ensure findings that are representatives of the vibratory behaviors of the whole vocal folds. However, in practice, the preferred images may not be obtained at all times. Often, the only available images that a clinician has to work with consist of a partial view of the glottis. This study aims to examine the effects of using images of a partial view of the glottis (ie, posterior-middle, anterior-middle, or middle) on the LHSV-based measures (ie, fundamental frequency (F0GAW), frequency perturbation (jitterGAW), amplitude perturbation (shimmerGAW), open quotient (OQGAW), and Nyquist plot). The participants consisted of 9 young normophonic females. The procedures involved LHSV recording of the vibration of the vocal folds. The images of the complete view of the glottis were analyzed to obtain the LHSV-based measures. The same images were used to simulate the images of partial views of the glottis by changing the outline of the region of interest to include only either the posterior-middle, anterior-middle, or middle parts of the glottis. The LHSV-based measures from the images of the partial views were then compared to those with the complete view . The results showed that all LHSV-based measures from the images of the posterior-middle view were similar to those of the complete view. However, only the F0GAW, jitterGAW, and shimmerGAW from the images of the anterior-middle and middle views were similar to those of the complete view. Lower OQGAW and different Nyquist plots than those of the complete view were generated by the images of the anterior-middle and middle views. In conclusion, all LHSV-based measures from the images of the posterior-middle view of the glottis, and only the F0GAW, jitterGAW, and shimmerGAW from the images of the anterior-middle and middle views of the glottis reflect the vibratory behaviors of the whole vocal folds. The same conclusion could not be applied to the OQGAW and Nyquist plots of the images of the anterior-middle and middle views of the glottis. A possible effect of the presence or absence of a posterior glottal gap on the findings warrants further confirmation.

Introduction A challenge in phonosurgery is achieving good vocal quality with minimal vocal fold fibrosis. Fibrin glue can be applied to minimize fibrosis; however, its use in the larynx is based primarily on clinical experience, particularly in extensive lesions. Objective The objective of this study was to evaluate the effect of application of fibrin glue on collagen concentration at the late phase of the healing process after detaching a pedicled flap of the vocal fold cover in rabbits. Methods In this prospective animal study, twelve adult male rabbits underwent laryngeal microsurgery, in which an incision was made along the entire length of both vocal folds, followed by extensive mucosal detachment and section of the incision ends. Fibrin glue was applied in the left vocal fold, and the mucosa was repositioned. In the right vocal fold, the mucosa was repositioned without treatment with fibrin glue. After 3-months, the rabbits were euthanized. Histological analyses were performed, and the data collected were subjected to statistical analysis. Results Vocal folds treated with fibrin glue presented higher collagen concentration in Masson trichrome staining and significantly higher (p< 0.05) collagen concentration in picrosirius red staining compared to control vocal folds. Conclusion Treatment with fibrin glue led to greater vocal fold fibrogenesis in the present study. Nonetheless, further studies are necessary to determine the prophylactic effect of sealants in laryngeal surgeries that require extensive detachment of the vocal fold cover. Resumo Introdução Um desafio na fonocirurgia é conseguir uma boa qualidade vocal com o mínimo de fibrose das pregas vocais. A cola de fibrina pode ser aplicada para minimizar a fibrose; porém, seu uso na laringe é baseado principalmente na experiência clínica, particularmente em lesões extensas. Objetivo Avaliar o efeito da aplicação da cola de fibrina na concentração de colágeno na fase tardia do processo de cicatrização, após o descolamento do retalho pediculado da cobertura da prega vocal em coelhos. Método Neste estudo prospectivo com animais, 12 coelhos adultos machos foram submetidos à microcirurgia de laringe, na qual uma incisão foi feita em toda a extensão de ambas as pregas vocais, seguida de extenso descolamento da mucosa e secção das extremidades da incisão. A cola de fibrina foi aplicada na prega vocal esquerda e a mucosa foi reposicionada. Na prega vocal direita, a mucosa foi reposicionada sem tratamento com cola de fibrina. Após três meses, os coelhos foram sacrificados. Análises histológicas foram feitas e os dados coletados foram submetidos à análise estatística. Resultados As pregas vocais tratadas com cola de fibrina apresentaram maior concentração de colágeno na coloração tricrômica de Masson e concentração significativamente maior de colágeno (p < 0,05) na coloração com picrosirius red comparadas às pregas vocais controle. Conclusão O tratamento com cola de fibrina resultou em maior fibrogênese das pregas vocais no presente estudo. Contudo, novos estudos são necessários para determinar o efeito profilático dos selantes em cirurgias de laringe que requerem extenso descolamento da cobertura das pregas vocais.

PURPOSE OF REVIEW Sulcus vocalis is a benign condition of the vocal folds that, according to its severity, can affect the quality of the voice of those who have it. Voice symptoms can range from mild to severe, affecting the quality of life of patients with this condition. Although different surgical and no surgical options have been described, no gold standard treatment has been described. RECENT FINDINGS New evidence supports congenital, inflammatory, and acquired theories for sulcus vocalis. Also, recent literature demonstrated the role of the epithelium in the pathogenesis, which makes the absence of superficial lamina propria no longer the only accepted hypothesis. Technological developments improved the in-office diagnostics capabilities for this condition, but vocal fold palpation remains the gold standard. Different benign laryngeal conditions are associated with sulcus vocalis and knowing when to treat those is very important. Different treatment options are available for sulcus vocalis, however, results are diverse and no strong recommendations for one over the other can be made. SUMMARY Progress continues to be made in our understanding of sulcus vocalis from diagnosis to treatment. Novel and promising therapeutic strategies have been recently developed for this condition; however, more data and investigations are needed to improve their accuracy and reproducibility.

Summary The greatest rate of change in the glottal flow rate during phonation is a rapid decrease that occurs during the latter part of the glottal closing. Previous works showed that intraglottal flow separation vortices form in a divergent glottis, produce negative gauge pressures (below atmospheric) during closing. It is hypothesized here that flow separation vortices contribute to the rapid closing mechanism of the true vocal folds during phonation. Four idealized static models (M5) of the human larynx were investigated using large eddy simulation: 2 models featured parallel folds that did not enable flow separation in the glottis and 2 models involved a divergent glottis. The influence of the ventricular gap (narrow/wide) is evaluated. An unsteady pressure inlet representing a voicing cycle was applied to the sub-glottal region to mimic the time-varying glottal flow. Intraglottal vortex structures formed downstream of the separation point in a divergent glottis. Their existence caused a higher closing force that was applied onto the vocal folds. A narrow ventricular gap strengthens this effect. Strength of the intraglottal vortices increased with the maximum flow declination rate. Therefore, a more divergent shape of the glottis during glottal closing will be one of the main contributors to the voice quality.

Sound generation during voiced speech remains an open research topic because the underlying process within the human larynx is hardly accessible for direct measurements. In the present study, harmonic sound generation during phonation was investigated with a model that replicates the fully coupled fluid-structure-acoustic interaction (FSAI). The FSAI was captured using a multi-modal approach by measuring the flow and acoustic source fields based on particle image velocimetry, as well as the surface velocity of the vocal folds based on laser vibrometry and high-speed imaging. Strong harmonic sources were localized near the glottis, as well as further downstream, during the presence of the supraglottal jet. The strongest harmonic content of the vocal fold surface motion was verified for the area near the glottis, which directly interacts with the glottal jet flow. Also, the acoustic back-coupling of the formant frequencies onto the harmonic oscillation of the vocal folds was verified. These findings verify that harmonic sound generation is the result of a strong interrelation between the vocal fold motion, modulated flow field, and vocal tract geometry.

The perceived pitch of human voices is highly correlated with the fundamental frequency (f0) of the laryngeal source, which is determined largely by the length and mass of the vocal folds. The vocal folds are larger in adult males than in adult females, and men’s voices consequently have a lower pitch than women’s. The length of the supralaryngeal vocal tract (vocal-tract length; VTL) affects the resonant frequencies (formants) of speech which characterize the timbre of the voice. Men’s longer vocal tracts produce lower frequency, and less dispersed, formants than women’s shorter vocal tracts. Pitch and timbre combine to influence the perception of speaker characteristics such as size and age. Together, they can be used to categorize speaker sex with almost perfect accuracy. While it is known that domestic dogs can match a voice to a person of the same sex, there has been no investigation into whether dogs are sensitive to the correlation between pitch and timbre. We recorded a female voice giving three commands (‘Sit’, ‘Lay down’, ‘Come here’), and manipulated the recordings to lower the fundamental frequency (thus lowering pitch), increase simulated VTL (hence affecting timbre), or both (synthesized adult male voice). Dogs responded to the original adult female and synthesized adult male voices equivalently. Their tendency to obey the commands was, however, reduced when either pitch or timbre was manipulated alone. These results suggest that dogs are sensitive to both the pitch and timbre of human voices, and that they learn about the natural covariation of these perceptual attributes.

Objective Fibrotic changes in the vocal fold mucosa have been observed in patients with vocal fold scarring, aged vocal fold, and sulcus vocalis, which often lead to severe voice disorders. Previous research suggests that the basic fibroblast growth factor (b FGF) improves variations in vocal fold properties [1 , 2] . Although clinical studies on b FGF treatments have been conducted [3 , 4 , 5] , these studies only demonstrated the efficacy of this drug over a short period. The present study is the first to investigate the long-term efficacy of b FGF treatment. Methods b FGF injections were performed in six patients from January of 2016 to December of 2017 at our institution. Patient follow-up continued for at least two years after the last injection. Three patients had vocal fold scarring, two had aged vocal fold atrophy, and one patient had sulcus vocalis. Each vocal fold was injected with 10 µg of b FGF four times. Voice and stroboscopic examinations were performed after surgery (at one month, three months, six months, one year, two years). Fundamental frequency, maximum phonation time (MPT), mean flow rate (MFR), amplitude perturbation quotient (APQ), pitch perturbation quotient (PPQ), and noise-to-harmonic ratio (NHR), and voice handicap index-10 (VHI-10) were examined and compared statistically between the pretreatment time and at each posttreatment time point. Results The speaking F0 had an obvious decreasing tendency, with significant differences suggesting the increase in volume in the vocal folds. Aerodynamic parameters also showed small improvements. The most remarkable improvement was observed in the acoustic parameters, indicating that the treatment could improve the vocal fold to make vibrations symmetrically and regularly for a long period. Achievement of symmetry and regularity on vocal fold vibrations suggested the property changes had happened in the vocal folds. Consequently, the score of VHI-10 had improved, indicating high patient satisfaction with this treatment. Conclusion b FGF injections could be a reliable treatment option for diseases that deteriorate the property of vocal fold.

Objective The slow spatial encoding of MRI has precluded its application to rapid physiologic motion in the past. The purpose of this study is to introduce a new fast acquisition method and to demonstrate feasibility of encoding rapid two-dimensional motion of human vocal folds with sub-millisecond resolution. Method In our previous work, we achieved high temporal resolution by applying a rapidly switched phase encoding gradient along the direction of motion. In this work, we extend phase encoding to the second image direction by using single-point imaging with rapid encoding (SPIRE) to image the two-dimensional vocal fold oscillation in the coronal view. Image data were gated using electroglottography (EGG) and motion corrected. An iterative reconstruction with a total variation (TV) constraint was used and the sequence was also simulated using a motion phantom. Results Dynamic images of the vocal folds during phonation at pitches of 150 and 165 Hz were acquired in two volunteers and the periodic motion of the vocal folds at a temporal resolution of about 600 µs was shown. The simulations emphasize the necessity of SPIRE for two-dimensional motion encoding. Discussion SPIRE is a new MRI method to image rapidly oscillating structures and for the first time provides dynamic images of the vocal folds oscillations in the coronal plane.

Summary Objectives The objective of this study was to present a novel surgical technique involving the use of a “bipedicled vocal fold mucosal flap” to repair a mucosal defect and to evaluate the outcomes of patients in whom it was used. Material and methods This was a retrospective study of 6 clinical cases. All patients underwent surgery between November 2000 and July 2018, and all procedures were performed by the same surgeon. For the auditory-perceptual assessment, the Grade-Roughness-Breathiness-Asthenia-Strain hoarseness scale was used. We based the stroboscopic evaluation on the European Laryngological Society protocol, analyzing the parameters glottal closure, mucosal wave, and phase symmetry. Results Ages at the time of surgery ranged from 10 to 52 years, and all of the patients were male. Preexisting vocal fold lesions included polyps, cysts, a sulcus, and mucosal bridges. Among the stroboscopic parameters, only the mucosal wave differed significantly between the preoperative and postoperative periods (P = 0.046). There were also significant postoperative improvements in the overall grade of dysphonia (P = 0.025) and in the degree of breathiness (P = 0.025). Conclusions The use of a bipedicled vocal fold mucosal flap appears to promote significant improvements in the mucosal wave and in voice quality. In the patients evaluated here, the technique was used without preoperative planning. However, it proved to be a safe and appropriate means of repairing mucosal defects in the vocal folds, with the potential to preserve rheological properties and promote healing with less chance of fibrosis.

Previous models have theorized that, during phonation, skewing of the glottal waveform (which is correlated with acoustic intensity) occurred because of inertance of the vocal tract. Later, we reported that skewing of the flow rate waveform can occur without the presence of a vocal tract in an excised canine larynx. We hypothesized that in the absence of a vocal tract, the skewing formed when dynamic pressures acted on the glottal wall during the closing phase; such pressures were greatly affected by formation of intraglottal vortices. In this study, we aim to identify how changes in false vocal folds constriction can affect the acoustics and intraglottal flow dynamics. The intraglottal flow measurements were made using particle image velocimetry in an excised canine larynx where a vocal tract model was placed above the larynx and the constriction between the false vocal folds was varied. Our results show that for similar values of subglottal pressures, the skewing of the glottal waveform, strength of the intraglottal vortices, and acoustic energy increased as the constriction between the false vocal folds was increased. These preliminary findings suggest that acoustic intensity during phonation can be increased by the addition of a vocal tract with false fold constriction.

OBJECTIVES/HYPOTHESIS Anterior glottic stenosis (AGS) results from surgical intervention, carcinoma, papillomatosis, congenital, or idiopathic causes. It may be present as elastic web or fibrotic scar. It impairs vocal function and glottic airway. Reconstructive options include resection and placement of a keel or glottic web-based mucosal flaps to prevent restenosis. These methods may not be sufficient for reconstructing a thick anterior scar and may require multiple interventions. The aim of the study was to describe the anterior subglottic mucosal flap (ASGMF), a one-stage, keel-free technique for AGS repair. STUDY DESIGN A retrospective cohort. METHODS Patients with AGS were operated using the ASGMF between 2017 and 2020. The stenotic segment was excised, and then an ASGMF was developed. A unilateral oblique incision was performed to allow rotation and advancement of the flap toward the contralateral vocal fold. The flap was sutured to the mucosal edge of the vocal fold to create mucosal continuity and prevent restenosis. Vocal fold length ratio (VFLR), which is between the free part and the total vocal fold length, as well as stroboscopic measures, were calculated before and after surgery. RESULTS Twelve patients were enrolled. Etiologies were iatrogenic, dysplasia, papillomatosis, carcinoma, and congenital. Average VFLR improved from 0.33 to 0.87 (P-value

Resumen Introducción: Los ejercicios de tracto vocal semiocluido (ETVSO) son herramientas utilizadas en la rehabilitación fisiológica de la voz. Los ETVSO son ejercicios vocales producidos por la semioclusión del tracto vocal, a través de una serie de posturas que buscan alargar y/o ocluir el tracto vocal, generando un cambio en el patrón vibratorio de los pliegues vocales, grado de aducción y el patrón respiratorio. Los ETVSO pueden dividirse, según el tipo de semioclusión, en sostenida, transitoria y oscilatoria, así como en ejercicios de mayor resistencia a menor resistencia. Objetivo: Describir los diferentes tipos de ejercicios de tracto vocal semiocluido, el tipo de semioclusión, el grado de resistencia y sus efectos en los pliegues vocales, patrón respiratorio y configuración del tracto vocal. Metodología: Se realizó una revisión de la literatura en las bases de datos PubMed, Medline y Science Direct, usando los siguientes términos: “Semi-Occluded Vocal Tract Postures”, "tract vocal semiocclude” y “ejercicios de tracto vocal semiocluido”. Se utilizaron operadores booleanos "AND" y "OR" para especificar la búsqueda. Resultados: Los beneficios de estos ejercicios impactan positivamente en variables aerodinámicas, en la función glótica y en la configuración del tracto vocal. Conclusiones: Los ejercicios de tracto vocal semiocluido son una familia de ejercicios vocales producidos por semioclusión sostenida, transitoria y oscilatoria del tracto vocal, a través de una serie de posturas que buscan alargar y/o ocluir el tracto vocal, cuyos beneficios impactan positivamente los pliegues vocales y el tracto vocal. Abstract Introduction: Semi-occluded vocal tract exercises (SOVTE) are tools used in physiologic voice rehabilitation. Semi-occluded vocal tract exercises are vocal exercises produced by the semi-occlusion of the vocal tract through a series of postures that seek to lengthen and/or occlude the vocal tract, generating a change in the vibratory pattern of vocal folds, degree of vocal folds adduction, and the respiratory pattern. SOVTE can be divided, according to the type of semi-occlusion, into sustained, transient and oscillatory, as well as exercises with high and low degree of airflow resistance. Objective: To describe the different types of semi-occluded vocal tract exercises, the type of semi-occlusion, the type of resistance, and their effects on the vocal folds, respiratory pattern, and configuration of the vocal tract. Methodology: A literature review was performed in the PubMed, Medline, and Science Direct databases, using the following terms: "Semi-occluded vocal tract postures", "Semi-occluded vocal tract" and "Semi-occluded vocal tract exercises”. Boolean operators "AND" and "OR" were used to specify the search. Results: The benefits of these exercises positively impact aerodynamic variables, glottal function, and configuration of the vocal tract. Conclusions: The semi-occluded vocal tract exercises are a family of vocal exercises produced by the sustained, transitory, and oscillatory semi-occlusion of the vocal tract, through a series of postures that seek to lengthen and/or occlude the vocal tract, whose benefits positively impact on vocal folds and vocal tract.

Resumen El presente artículo corresponde a una reflexión sobre las orientaciones filosóficas en la terapia vocal actual. Cuando existe alguna alteración o trastorno vocal, se habla comunmente de un desequilibrio entre los subsistemas involucrados en el proceso fonatorio, es decir, fuelle (sistema respiratorio), fuente (pliegues vocales) y filtro (tracto vocal). Si no hay un correcto balance, entonces el sistema no tiene un correcto funcionamiento y pueden aparecer síntomas como ronquera, sensación de cuerpo extraño, prurito, fatiga vocal o bien disfonía o incluso afonía. Como consecuencia de estas dificultades, se generan compensaciones que durante el proceso de la intervención fonoaudiológica el profesional debe volver a “equilibrar”. Para lograr este objetivo, se desarrollan y analizan las diversas herramientas que entregan las filosofías de pensamiento a lo largo de la historia de la rehabilitación vocal, donde se encuentran la orientación higiénica, psicológica, sintomatológica, fisiológica y ecléctica. En este mismo sentido, el profesional debe buscar lo que percibe como más idóneo para cada paciente o grupo a intervenir, centrado en mejorar la calidad vocal y las necesidades actuales de estos, basándose en el contexto mundial actual, con el objetivo de lograr un buen proceso de entrenamiento o rehabilitación y finalmente lograr el alta. Abstract The present article corresponds to a reflection about the philosophical orientations in the current vocal therapy. When there are some vocal alterations or disorders, we usually talk about an imbalance between the sub-sysmtems involved in the fonatory process, which are bellows (respiratory system), source (vocal folds) and filter (vocal tract). When there is not a correct balance, the system does not work properly and, as a consequence, it is possible to experiment symptoms such as hoarseness, foreign body sensation, pruritus, vocal fatigue, dysphonia or even aphonia. As a result of these difficulties, it is possible to generate compensations through the intervention of speech therapy. By virtue of this therapy the professional must ‘balance’. In order to achieve this, it is necessary to develop and analyze the different tools that philosophical studies offer through the history of vocal rehabilitation. Some of these tools are hygienic orientation, psychological, symptomatological, physiological and eclectic. Thinking on that, the professional must search what it is most suitable for every patient or group of people that he/she will be working with. This must be focus on improving vocal quality and the actual necessities of the patient, based on the current global context. The final purpose of the professional is to achieve a good and healthy process of training and/or rehabilitation to accomplish medical discharge.

Objectives The human adult vocal fold mucosa, especially, superficial layer of the lamina propria (Reinke's space) has attracted notice as an important vibrating structure. However, fine structures of the stratified squamous epithelium of the human adult vocal fold, which is another histological component of the mucosa, remain enigmatic. Methods Three normal human adult vocal folds and epiglottises and three newborn vocal folds were investigated. Observations using transmission electron microscopy and light microscopy including immunohistochemistry were performed. Results The most obvious feature of the epithelium of the human adult vocal folds was that the intercellular spaces between adjacent epithelial cells were large (984 ± 186 nm) compared with the stratified squamous epithelium of the human adult epiglottis and the human newborn vocal fold. Even though intercellular spaces between adjacent epithelial cells of the human adult vocal fold were large, desmosomes at the junctions of two adjacent epithelial cells made firm intercellular adhesion. Tonofilaments composed of the bundles of intermediate filaments anchored to the desmosomes. Desmosomes formed a continuous cytoskeletal network throughout the epithelial cells and epithelium of the human adult vocal fold. In addition, a great deal of E-cadherin (adhesive glycoprotein) was present between epithelial cells especially the lower half of the stratified squamous epithelium of the human adult vocal fold. Conclusions From the functional morphological point of view, stratified squamous epithelium of the human adult vocal fold seems to form a structural framework of tensile strength with pliability suitable structure for vibration.

Self-sustained oscillations of the vocal folds (VFs) during phonation are the result of the energy exchange between the airflow and VF tissue. Understanding this mechanism requires accurate investigation of the aerodynamic pressures acting on the VF surface during oscillation. A self-oscillating silicone VF model was used in a hemilaryngeal flow facility to measure the time-varying pressure distribution along the inferior-superior thickness of the VF and at four discrete locations in the anterior-posterior direction. It was found that the intraglottal pressures during the opening and closing phases of the glottis are highly dependent on three-dimensional and unsteady flow behaviors. The measured aerodynamic pressures and estimates of the medial surface velocity were used to compute the intraglottal energy transfer from the airflow to the VFs. The energy was greatest at the anterior-posterior midline and decreased significantly toward the anterior/posterior endpoints. The findings provide insight into the dynamics of the VF oscillation and potential causes of some VF disorders.

People who have undergone total laryngectomy typically have difficulties speaking and coughing. Coughing, the protective reflex action where air is rapidly expelled from the lungs to clear the airway, is crucial in everyday life. Insufficiency in coughing can lead to serious chest infections. In this research we present a bionic assistive coughing device (RoboCough) to improve coughing efficacy among laryngectomy patients by increasing pressure and flow rate. RoboCough was designed to mimic the function of the glottis and trachea in the upper respiratory system. Experimental results show a significant increase (t(64) = 4.9, p < 0.0001) in peak cough flow rate and peak cough pressure (t(64) = 12.6, p < 0.0001) among 33 control participants using RoboCough. A pilot study with a smaller cohort of laryngectomy patients shows improvement in peak cough pressure (p = 0.0159) using RoboCough. Preliminary results also show that post-laryngectomy coughs achieved similar peak cough flow (Z = -0.9933, p = 0.32) to the control group’s natural cough. Coughing capabilities could be improved through using RoboCough. Applications of RoboCough include simulation of vocal folds and respiratory conditions, rehabilitation of ineffective coughs from laryngeal and respiratory diseases and as a test-bed for the development of medical devices for respiratory support.

Summary Objectives Excessive or disharmonious activity of internal and external laryngeal muscles causes a type of dysphonia known as muscle tension dysphonia (MTD). MTD is often diagnosed based on laryngoscopic findings and clinical history. Several diagnostic and classification systems have so far been proposed based on increased supraglottic activity to determine MTD. Various studies have shown that increased supraglottic activity may also be observed in those with normal voice. The present study aimed to precisely examine the incidence of abnormal muscle tension pattern (aMTP) in those with normal voice in comparison with those with MTD. The secondary goal of this study was comparative examination of acoustic parameters and maximum phonation time (MPT) in the group with MTD and normal individuals. Material and Methods Participants were 75 people with MTD (41 women and 34 men) and 50 individuals with normal voice and no history of dysphonia (20 women and 30 men). Laryngoscopic evaluation was performed for all participants by considering four types of aMTP. Acoustic analyses, including cepstral peak prominence, jitter, shimmer and NHR, as well as MPT examination were performed. Results A significant difference between the MTD group and control group was observed in all MTPs except for MTP 2 (lateral-to-medial approximation of the false vocal folds) (P = 0.367, χ2(1) = 0.81). In other MTPs, a significant difference existed between the control and MTD groups in terms of aMTP incidence (P Conclusion On the four aMTPs, results revealed that one must exercise caution in diagnosing MTD based on MTP 2 (medial compression of ventricular folds), and this must not be the sole criterion for diagnosis. Moreover, cepstral peak prominence and MPT analyses are of high clinical significance.

The detection and description of pathological voice are the most important applications of voice profiling. Currently, techniques like laryngostroboscopy or surgical microlarynoscopy are popularly used for the diagnosis of voice pathologies but are invasive in nature. Disorders of vocal folds impact the quality of voice, and therefore, the accuracy of voice profiling is reduced. This paper presents a better solution to differentiate normal and pathological voices based on the glottal, physical, and acoustic and equivalent electrical parameters. These parameters have been correlated using mathematical equations and models. Results reveal that the glottal flow is strongly influenced by physical parameters like stiffness and viscosity of vocal folds in case of pathological voice. However, their direct measurement requires complex invasive medical procedures or costly and complex electronic hardware arrangements in case of non-invasive methods. Glottal parameters, on the other hand, facilitate much simpler estimation of vocal folds disorders. In this work, the authors have presented two non-invasive approaches for better accuracy and least complexity for differentiating normal and pathological voices: 1) by using correlation of glottal and physical parameters, 2)by using acoustic and equivalent electrical parameters.

ObjectiveCells in the vocal fold of maculae flavae are likely to be tissue stem cells. Energy metabolism of the cells in newborn maculae flavae was investigated from the aspect of mitochondrial microstructure.MethodFive normal newborn vocal folds were investigated under transmission electron microscopy.ResultsMitochondria consisted of a double membrane bounded body containing matrices and a system of cristae. However, these membranes were ambiguous. In each mitochondrion, the lamellar cristae were sparse. Intercristal space was occupied by a mitochondrial matrix. Some mitochondria had fused to lipid droplets and rough endoplasmic reticulum, and both the mitochondrial outer and inner membranes had incarcerated and disappeared.ConclusionThe features of the mitochondria of the cells in the newborn maculae flavae showed that their metabolic activity and oxidative phosphorylation were low. The metabolism of the cells in the newborn maculae flavae seems to be favourable to maintain the stemness and undifferentiation of the cells.

Objective: The efficiency of laryngovideostroboscopy (LVS) in detecting premalignancies of the vocal fold and early glottic cancer was determined in a prospective monocentric study. In addition, the recovery rate of the mucosal membrane on the vocal fold after surgical intervention was determined by LVS. Methods: We included 159 patients with a leukoplakia of the vocal folds and 50 healthy controls. Clinicopathological data and LVS characteristics (amplitude, mucosal wave, nonvibratory segment, glottic closure, phase symmetry, periodicity) at the lesion site were obtained and compared with the histopathological results. LVS parameters were recorded before cordectomy and in a 12-month follow-up interval. Patients who had prior laryngosurgery, radiotherapy, or laryngeal scarring were excluded. Results: Absent or greatly reduced mucosal waves were found in all patients with an invasive carcinoma, in 94% with a severe intraepithelial neoplasia (SIN III), in 38% with a moderate squamous intraepithelial neoplasia (SIN II), in 32% with a mild squamous intraepithelial neoplasia (SIN I), and in 23% with a hyperkeratosis without dysplasia. The sensitivity and specificity of LVS in predicting an invasive carcinoma based on the absence or reduction of mucosal waves was 0.96 and 0.90, respectively. Following surgical intervention, the recovery rate of the mucosal wave and amplitude was 12% in the invasive carcinoma group, 36% in the SIN III group and up to 80% for both these parameters in the SIN I, SIN II, and hyperkeratosis groups. Conclusion: LVS is a valid tool to identify early glottic carcinoma and its high risk premalignancy carcinoma in situ (CIS). Even when there is no definitive differentiation between SIN I and II, the invasive character of a CIS and an invasive glottic carcinoma can be identified. Especially strobosopic signs of abnormal amplitude and/or mucosal waves, particularly phoniatric halt, are an early indication for a CIS or an invasive carcinoma.

Perpendicular vascular changes (PVC) are markers of tumor-induced neoangiogenesis at the vocal folds. Contact endoscopy with narrow-band imaging (CE-NBI) allows a detailed analysis of such vascular changes.This work intends to evaluate the potential of CE-NBI for diagnosis of benign, dysplastic, and malignant lesions of the vocal folds. In addition, it should be determined whether CE-NBI offers an additional benefit in detecting PVC compared to white-light endoscopy (WLE) and NBI alone.Three examiners evaluated histologically verified cases of benign, dysplastic, and malignant lesions of the larynx in WLE, NBI, and CE-NBI (n = 60). In each mode, they examined the lesion for PVC and assessed the lesion's dignity. The proportion of lesions with detected PVC, the statistical measures of performance in detecting high-grade dysplasia and carcinoma, and the interrater variability for each mode were calculated.CE-NBI proved superior to the other investigated diagnostic methods in terms of detecting PVC and in terms of sensitivity and accuracy in the diagnosis of high-grade dysplasia and carcinoma. A clear association of such pathologies with PVC was seen.CE-NBI detects PVC more frequently and reliably than the other methods investigated. The association of these vascular patterns to high-grade dysplasia and vocal fold carcinomas could be confirmed. Compared to WLE and NBI endoscopy, the diagnostic quality for detecting high-grade dysplasia and carcinoma is increased. Thus, CE-NBI can improve endoscopic differentiation between benign and malignant lesions of the vocal folds by enhancing the detection of PVC.HINTERGRUND: Perpendikuläre Gefäßveränderungen (PGV) sind Marker der tumorinduzierten Neoangiogenese der Stimmlippen. Die Kontaktendoskopie mit Narrow Band Imaging (KE-NBI) ermöglicht eine detaillierte Analyse solcher Gefäßveränderungen.In dieser Arbeit wurde das Potenzial der KE-NBI bei der Diagnostik benigner, dysplastischer und maligner Veränderungen der Stimmlippen untersucht. Außerdem sollte bei der Detektion von PGV die Aussagekraft des KE-NBI im Vergleich zur Weißlichtendoskopie (WLE) und zur alleinigen Narrow-Band-Imaging-Endoskopie (NBI) bestimmt werden.Dazu befundeten 3 Untersucher histopathologisch verifizierte benigne, dysplastische oder maligne Läsionen der Stimmlippen (n = 60) jeweils im Modus WLE, NBI und KE-NBI. Die Läsionen wurden auf PGV hin untersucht und ihre Dignität beurteilt. Ermittelt wurden der Anteil der Läsionen mit detektierten PGV sowie die diagnostische Güte für jeden Modus und die Interratervariabilität bei der Erkennung von höhergradigen Dysplasien und Karzinomen.Die KE-NBI zeigte sich den anderen Modi bei der Detektion von PGV und hinsichtlich Sensitivität und Genauigkeit bei der Erkennung von höhergradigen Dysplasien und Karzinomen überlegen. Die Autoren sahen eine deutliche Assoziation dieser pathologischen Veränderungen mit PGV.Mittels KE-NBI werden PGV häufiger und zuverlässiger als mit den anderen Methoden erkannt. Die Assoziation dieser Gefäßveränderungen mit höhergradigen Dysplasien und Karzinomen der Stimmlippen wurde bestätigt. Im Vergleich zu WLE und NBI zeigte sich eine erhöhte diagnostische Güte. Somit kann die KE-NBI durch bessere Detektion der PGV die endoskopische Differenzierung zwischen benignen und malignen Läsionen der Stimmlippen verbessern.

Background: The accent method (AM) of voice therapy is one of the holistic approaches for behavior readjustment technique (BRAT). Anatomic physiologic explanation for the accent method is the rhythmic pairing of timing with respiration and phonation which may promote motor learning of new phonatory behaviors that will enhance the Bernoulli's effect to restore the glottic wave. Hyperfunctional voice disorder is a non-physiological increase in tone of the vocal folds on phonation.Aim of the work: Is to evaluate the effects of the AM of voice therapy on acoustic measurements, in patients with hyperfunctional dysphonia.Patients and methods: This study was applied on 25 patients with age ranging from 20 - 60 years, from January 2018 to December 2020, diagnosed with Hyperfunctional dysphonia based on objective and clinical measures, recruited from the outpatient Phoniatric clinic at Ain Shams University Hospitals, underwent acoustic analysis (CSL) pre and post therapy.Results: Comparing pre and post therapy results, there was no statistically significant difference in fundamental frequency while there was statistically significant difference (reduction) in Jitter %, Shimmer% and Noise to harmonic ratio.Conclusion: The present study showed that the AM of voice therapy improved acoustic measurements suggestive of noise to the vocal production and positive effects on the closure of the vocal folds, therefore Smith Accent method of voice therapy is an effective voice line of rehabilitation in hyperfunctional dysphonia.

The development of larynx simulators as platforms for clinical investigations has been identified as a useful tool for understanding the pathophysiology of vocal folds. The primary goal of this study was the realization of electrically conductive silicone vocal folds able to replicate an electroglottography (EGG) signal under pathophysiological conditions, in order to provide a quantitative method for monitoring the vocal folds vibratory characteristics. Both simulators showed an oscillatory behavior similar to human counterpart, thanks to the materials used for their realization. In addition, the synthetic simulators are made conductive by a silicone-based conductive solution applied to the surface of the synthetic vocal folds, in order to acquire an electrical signal to be compared to an EGG signal. Results showed a direct correlation between conductance variation and the occurrence of vocal folds contact, as it happens for the real EGG signal. In addition, results suggested that both simulators are able to replicate the vibratory characteristics of healthy and pathological vocal folds and to reproduce an electrical signal that is comparable to a real EGG. This will represent a powerful tool to characterize and cluster different vocal folds pathologies, which can lead to a significant improvement of prevention programs and an early diagnosis for laryngeal diseases.

Introduction Postoperative dysphonia is mostly caused by vocal fold scarring, and careful management of vocal fold surgery has been reported to reduce the risk of scar formation. However, depending on the vocal fold injury, treatment of postoperative dysphonia can be challenging. Objective The goal of the current study was to develop a novel prophylactic regenerative approach for the treatment of injured vocal folds after surgery, using biodegradable gelatin hydrogel microspheres as a drug delivery system for basic fibroblast growth factor. Methods Videoendoscopic laryngeal surgery was performed to create vocal fold injury in 14 rabbits. Immediately following this procedure, biodegradable gelatin hydrogel microspheres with basic fibroblast growth factor were injected in the vocal fold. Two weeks after injection, larynges were excised for evaluation of vocal fold histology and mucosal movement. Results The presence of poor vibratory function was confirmed in the injured vocal folds. Histology and digital image analysis demonstrated that the injured vocal folds injected with gelatin hydrogel microspheres with basic fibroblast growth factor showed less scar formation, compared to the injured vocal folds injected with gelatin hydrogel microspheres only, or those without any injection. Conclusion A prophylactic injection of basic fibroblast growth factor -containing biodegradable gelatin hydrogel microspheres demonstrates a regenerative potential for injured vocal folds in a rabbit model. Resumo Introdução A disfonia pós-operatória é causada principalmente por cicatrizes nas pregas vocais. Tem sido relatado que o manejo cuidadoso da cirurgia das pregas vocais reduz o risco de formação de cicatriz. No entanto, a depender da lesão da prega vocal, o tratamento da disfonia pós-operatória pode ser desafiador. Objetivo Desenvolver uma nova abordagem regenerativa profilática para o tratamento de pregas vocais lesionadas após a cirurgia, com microesferas biodegradáveis de hidrogel de gelatina como sistema de administração de medicamentos para o Fator Básico de Crescimento de Fibroblastos (bFGF). Método A cirurgia laríngea videoendoscópica foi feita para criar lesão nas pregas vocais em 14 coelhos. Imediatamente após esse procedimento, microesferas biodegradáveis de hidrogel de gelatina com bFGF foram injetadas na prega vocal. Duas semanas após a injeção, as laringes foram excisadas para avaliação da histologia das pregas vocais e do movimento da mucosa. Resultados A presença de função vibratória deficiente foi confirmada nas pregas vocais lesionadas. A histologia e a análise de imagem digital demonstraram que as pregas vocais lesionadas injetadas com microesferas de hidrogel de gelatina com bFGF apresentaram menor formação de cicatriz, em comparação com as pregas vocais lesionadas injetadas apenas com microesferas de hidrogel de gelatina ou aquelas sem injeção. Conclusão Uma injeção profilática de microesferas biodegradáveis de hidrogel de gelatina com bFGF demonstra um potencial regenerativo para pregas vocais lesionadas em um modelo de coelho.

Background/aim: This study aimed to assess the inflammatory adverse reactions of vocal fold injection laryngoplasty with hyaluronic acid. Materials and methods: This study was a retrospective chart review of patients who underwent vocal fold injection augmentation with HA injection from January 2005 to September 2016 in nine different institutions. Demographic data, indication for injection, injection techniques, types of injection material, settings of procedure, and complications were reviewed. The types of complication, onset time, and management of complications were also noted. Results: In all, 467 patients were identified. The majority of patients had been injected under general anesthesia (n = 382, 84.7%). For injection material, two different types of hyaluronic acid were used: hyaluronic acid alone or hyaluronic acid with dextranomer. Complications occurred in nine patients (1.9%). The majority of complications were inflammatory reactions (n = 7, 1.47%). Main symptoms were dysphonia and/or dyspnea with an onset of 0 h to 3 weeks after the hyaluronic acid injection. Three patients were hospitalized, one of which was also intubated and observed in the intensive care unit for 24 h. Systemic steroids and antibiotics were the main medical treatment in the majority of cases. There was no statistical difference in complication rates between patients who received hyaluronic acid and those who received hyaluronic acid with dextranomer (P = 0.220). Conclusion: Hyaluronic acid can be considered as a safe substance for the injection of vocal folds with a low risk of inflammatory reaction.

Sulcus vocalis is an indentation parallel to the edge of vocal fold, which may extend into the cover and ligament layer of the vocal fold or deeper. The effects of sulcus vocalis depth d on phonation and the vocal cord vibrations are investigated in this study. The three-dimensional laryngeal models were established for healthy vocal folds (0 mm) and different types of sulcus vocalis with the typical depth of 1 mm, 2 mm, and 3 mm. These models with fluid-structure interaction (FSI) are computed numerically by sequential coupling method, which includes an immersed boundary method (IBM) for modelling the glottal airflow, a finite-element method (FEM) for modelling vocal fold tissue. The results show that a deeper sulcus vocalis in the cover layer decreases the vibrating frequency of vocal folds and expands the prephonatory glottal half-width which increases the phonation threshold pressure. The larger sulcus vocalis depth makes vocal folds difficult to vibrate and phonate. The effects of sulcus vocalis depth suggest that the feature such as phonation threshold pressure could assist in the detection of healthy vocal folds and different types of sulcus vocalis.

The process of voice production is a complex process and depends on the correct interaction of the vocal folds and the glottal airstream inducing the primary voice source, which is subsequently modulated by the vocal tract. Due to the restricted access to the glottis, not all aspects of the three-dimensional process can be captured by measurements without influencing the measurement object. Hence, the application of a numerical tool capturing the physical process of phonation can provide an extended database for voice treatment and, therefore, can contribute to an increased effectiveness of voice treatment. However, such numerical models involve complex and demanding procedures to model the material behavior and the mechanical contact of the vocal folds and to realize moving boundaries of the involved physical domains. The present paper proposes a numerical model called simVoice, which circumvents these computational expenses by prescribing the experimentally obtained vocal fold motion within the simulation. Additionally, a hybrid approach for sound computation further enhances the computational efficiency and yields good agreement with acoustic measurements. An analysis of the computational workloads suggests that the key factor for a further increase in efficiency is an optimized flow simulation and source term computation.

Zusammenfassung Hintergrund Trotz erheblicher Fortschritte in der laryngologischen Forschung gibt es eine Reihe von (benignen) Stimmlippenerkrankungen, die kausal nicht therapierbar sind. Das liegt an der eingeschränkten Zugänglichkeit sowie der sensiblen Mikroarchitektur der Stimmlippen, die nicht auf zellulärer Ebene erforscht werden können. Das pathophysiologische Verständnis endet dadurch häufig in der makroskopischen Ebene, die Folgen von Interventionen werden großteils endoskopisch oder mit indirekten Methoden evaluiert. Fragestellung Im nachfolgenden Beitrag stellen die Autor(inn)en biotechnologische State-of-the-Art-Methoden vor, die in der laryngologischen Forschung Anwendung finden, verbunden mit praktischen Beispielen. Ergebnisse Tierversuche und Zellkulturexperimente haben in den letzten Jahren zu einer signifikanten Wissenserweiterung beigetragen, dies insbesondere in den Bereichen Stimmlippeninflammation und -narbenbildung. Dem Stimmlippenfibroblasten, als wichtigstem zellulärem Bestandteil der Lamina propria, kommt dabei eine zentrale Rolle zu. Schlussfolgerungen Mittlerweile besteht bei einigen Krankheitsbildern ein tieferes Verständnis von Makroanatomie und Makropathophysiologie als je zuvor. In-vitro-Versuche zeigten beispielsweise, dass Stimmlippenfibroblasten in einem inflammatorischen Setting weniger profibrotische und proinflammatorische Zytokine sezernierten, wenn sie Vibrationen ausgesetzt sind. Umgesetzt auf die Klinik könnte das bedeuten, dass eine frühe Stimmaktivierung nach operativen Eingriffen an den Stimmlippen zu besserer Heilung und besseren stimmlichen Ergebnissen führt. Unsere Vision lautet, dass die molekulare Laryngologie ein gesichertes Fundament an Wissen bereitstellen soll, auf das in weiterer Folge klinische Studien aufgebaut werden können.

The acoustic measure, relative fundamental frequency (RFF), has been proposed as an objective metric for assessing vocal hyperfunction; however, its underlying physiological mechanisms have not yet been fully characterized. This study aimed to characterize the relationship between RFF and vocal fold kinematics. Simultaneous acoustic and high-speed videoendoscopic (HSV) recordings were collected as younger and older speakers repeated the utterances /ifi/ and /iti/. RFF values at voicing offsets and onsets surrounding the obstruents were estimated from acoustic recordings, whereas glottal angles, durations of voicing offset and onset, and a kinematic estimate of laryngeal stiffness (KS) were obtained from HSV images. No differences were found between younger and older speakers for any measure. RFF did not differ between the two obstruents at voicing offset; however, fricatives necessitated larger glottal angles and longer durations to devoice. RFF values were lower and glottal angles were greater for stops relative to fricatives at voicing onset. KS values were greater in stops relative to fricatives. The less adducted vocal folds with greater KS and lower RFF at voicing onset for stops relative to fricatives in this study were in accordance with prior speculations that decreased vocal fold contact area and increased laryngeal stiffness may decrease RFF.

Diseases can affect organs such as the heart, lungs, brain, muscles, or vocal folds, which can then alter an individual’s voice. Therefore, voice analysis using artificial intelligence opens new opportunities for healthcare. From using vocal biomarkers for diagnosis, risk prediction, and remote monitoring of various clinical outcomes and symptoms, we offer in this review an overview of the various applications of voice for health-related purposes. We discuss the potential of this rapidly evolving environment from a research, patient, and clinical perspective. We also discuss the key challenges to overcome in the near future for a substantial and efficient use of voice in healthcare.

Purpose The goal of this study was to present vocal aerodynamic measurements from pediatric and adult participant pools. There are a number of anatomical changes involving the larynx and vocal folds that occur as children age and become adults. Data were collected using two methods of noninvasive aerodynamic assessment: mechanical interruption and labial interruption. Method A total of 154 participants aged 4–24 years old took part in this study. Ten trials were performed for both methods of airway interruption. To perform mechanical interruption, participants phonated /α/ for 10 s trials while a balloon valve interrupted phonation 5 times. For labial interruption, participants said /pα/ 5 times at comfortable and quiet volumes. Aerodynamic measures included subglottal pressure, phonation threshold pressure, mean airflow, laryngeal resistance, and others. Results One hundred one participants (51 females) successfully completed testing with both methods. Eight out of 20 measurements were found to have a statistically significant effect of participant age on measurements. Sex alone had a significant effect on vocal efficiency for the labial quiet method. Conclusions The data discussed here can be used to view age and sex trends in vocal aerodynamic measurements. When using either method of mechanical or labial interruption, participant age needs to be taken into account to properly interpret several aerodynamic parameters. A participant's sex is not as important when using these methods.

Glottic insufficiency (GI) is most often caused by vocal fold atrophy, immobility, hypomobility, or scar. Injection laryngoplasty (IL), the injection of a filler material into the vocal folds to improve glottic closure, has been used to improve clinical outcomes in patients with GI. This paper will provide a review of contemporary practices and injection materials in IL. Most ILs are now performed in an office setting, through a per oral, transnasal, or percutaneous approach. Today, most short-term injections are performed using carboxymethylcellulose. Most intermediate injections are done with hyaluronic acid gels. Long-term injections are done with autologous fat, calcium hydroxyapatite, or polydimethylsiloxane. Silk-hyaluronic acid is a newer material being used for long-term injections. Novel materials under investigation include fibroblast growth factor and autologous fibroblasts. Within the past 15 years, the landscape of injected materials for IL has changed greatly. Newer materials are more similar in composition to native vocal fold tissue and are less likely to migrate from the site of injection and elicit low rates of inflammatory responses.

In the clinic, many diagnostic and therapeutic procedures focus on the oscillation patterns of the vocal folds (VF). Dynamic characteristics of the VFs, such as symmetry, periodicity, and full glottal closure, are considered essential features for healthy phonation. However, the relevance of these individual factors in the complex interaction between the airflow, laryngeal structures, and the resulting acoustics has not yet been quantified. Sustained phonation was induced in nine excised porcine larynges without vocal tract (supraglottal structures had been removed above the ventricular folds). The multimodal setup was designed to simultaneously control and monitor key aspects of phonation in the three essential parts of the larynx. More specifically, measurements will comprise (1) the subglottal pressure signal, (2) high-speed recordings in the glottal plane, and (3) the acoustic signal in the supraglottal region. The automated setup regulates glottal airflow, asymmetric arytenoid adduction, and the pre-phonatory glottal gap. Statistical analysis revealed a beneficial influence of VF periodicity and glottal closure on the signal quality of the subglottal pressure and the supraglottal acoustics, whereas VF symmetry only had a negligible influence. Strong correlations were found between the subglottal and supraglottal signal quality, with significant improvement of the acoustic quality for high levels of periodicity and glottal closure.

Summary Background Paradoxical vocal fold motion (PVFM) is a disorder in which the vocal folds adduct inappropriately during inspiration resulting in episodic dyspnea and sometimes respiratory distress. Diagnosis is obtained through careful history, physical examination, flexible laryngoscopic examination with provocative maneuvers, and laryngeal electromyography. The pathogenesis and clinical findings of this disorder are not known. Objectives To determine characteristics of patients with confirmed PVFM and to evaluate efficacy of current treatments. Methods A retrospective chart review of the patients with PVFM who presented at a quaternary care laryngology office between January 1, 2007 and August 31, 2019 was performed. Comorbidities, laboratories tests, imaging, 24-hours pH impedance testing, and laryngeal EMG results were analyzed. Dyspnea Index questionnaire before and after treatment was used to evaluate the efficiency of treatments for PVFM. Results The average age of the 40 patients was 30.25 years. Forty-five percent of patients were under the age of 18, and 80% were female. Twenty-five percent of patients were serious athletes, and 40% of patients were students. Sixty-five percent had a previous diagnosis of asthma. One third of patients had concurrent psychiatric diagnosis. There was no family history of PVFM in the cohort. There were no other common findings. Treatment for laryngopharyngeal reflux (LPR) was used only when there was evidence of LPR; and 93% of our 40 patients received LPR treatment. Ninety percent of patients who received botulinum toxin, voice therapy (VT), and LPR treatment had subjective improvement. Patients with just VT and LPR treatment had a 43% subjective improvement rate; and the difference was statistically significant at P of 0.021. There was no statistical difference between VT and LPR treatment versus VT or LPR treatment alone. Conclusion Botulinum toxin, VT, and LPR treatment regimen is currently the most effective management for patients with paradoxical vocal fold movement disorder. More research is needed to determine the etiology of this disorder.

Objectives: This study aimed to identify vocal fold leukoplakia (VFL) lesions on the inferior surface as a risk factor for recurrence. Methods: This was a retrospective study with data collected from 2001 to 2018. The study comprised 37 patients with VFL, divided into the nonrecurrent and recurrent groups. We examined the clinicopathological characteristics and the surgical procedures performed in each patient. Results: Among the 37 patients, 15 (40.5%) had residual (3) or recurrent (12) VFL. Of those patients with and without recurrence, 8 of 12 (66.7%) and 6 of 22 (27.3%), respectively, had inferior surface lesions of the vocal fold at the initial operation ( P = .036). Recurrences were significantly higher in patients with inferior surface lesions. Other evaluated factors did not show significance for recurrence. Conclusion: The presence of VFL lesions on the inferior surface is a significant risk factor for recurrence.

Background Glottal insufficiency results in glottal gap between the two vocal folds, which in turn might cause dysphonia, dysphagia, and breathing problems. Vocal fold injection is considered a safe, reliable, and highly effective method of treatment. The purpose of the present study was to assess voice outcomes and complication rates in patients with glottal insufficiency undergoing injection laryngoplasty (IL) under local versus general anesthesia before, 1 week then 1 month after IL. Results Examined patients were 13 males and 12 females, suffering from dysphonia due to glottal insufficiency with mean age 43.68 ± SD 14.55. Unilateral vocal fold paralysis (UVFP) was diagnosed in seventeen cases, vocal fold scarring in six cases, presbylarynx in one case, and sulcus vocalis in one case. IL was performed in 18 cases under local anesthesia, and 7 under general anesthesia. Hyaluronic acid was injection material in 23 cases and calcium hydroxylapatite in two cases. IL by either local or general anesthesia has improved the patients’ auditory perceptual analysis of voice quality as assessed by “GRBAS” scale and Voice Handicap Index (VHI). There were four (16% of all injections) minor and self-limited complications (12% under local and 4% under general anesthesia). Conclusion Injection laryngoplasty performed under local and general anesthesia offers similar voice outcomes, but with slightly higher self-limited complications in IL under local anesthesia.

Dysphagia may occur after a prolonged intubation due to COVID‐19 but it is usually mild. Case reports on severe dysphagia following COVID‐19 are infrequent. Diagnosis can be difficult because international indications recommend avoiding instrumental assessments as far as possible because of the infection risk. An early rehabilitation treatment is recommended., This case report describes the clinical history of a COVID‐19 patient with a non‐immediate diagnosis of severe dysphagia that required a gastrostomy positioning. A vocal folds paresis was observed for the first time in the course of a Sars‐CoV‐2 infection. Thanks to intensive rehabilitation treatment, the outcome was favorable.

Objectives In our previous studies, the features of the mitochondria of tissue stem cells in the maculae flavae of the human vocal fold suggested that their metabolic activity and oxidative phosphorylation was low. This study investigated the metabolic activity, especially glycolysis of the tissue stem cells in the maculae flavae of the human adult vocal fold. Study Design Histologic analysis of the human vocal folds. Methods Three normal human adult vocal folds obtained from autopsy cases were investigated using immunohistochemistry. Results Among the three phenotypes of cells in the human adult maculae flavae, the vocal fold stellate cell‐like cells strongly expressed glucose transporter‐1. Three phenotypes of cells in the human adult maculae flavae expressed glycolytic enzymes (hexokinase II, glyceraldehyde‐3‐phosphate dehydrogenase and lactate dehydrogenase A) indicating the tissue stem cells in the maculae flavae relied more on glycolysis. The cells did not express phosphofructokinase‐1 but did express glucose‐6‐phosphate dehydrogenase indicating the cells relied more on the pentose phosphate pathway. The cells expressed lactate dehydrogenase A indicating the maculae flavae of the human adult vocal fold was likely to be an anaerobic microenvironment. Conclusions The present study is consistent with the hypothesis that the tissue stem cells in the maculae flavae of the human vocal fold seem to rely more on anaerobic glycolysis, especially by the pentose phosphate pathway, for energy supply. The metabolism of the tissue stem cells in the maculae flavae of the human adult vocal fold is likely to prevent toxic reaction oxygen species and be favorable to maintaining the stemness and undifferentiated states of the tissue stem cells in the stem cells system. Level of Evidence NA.

Educate the reader on common benign vocal fold lesions and update on new findings, which are primarily in the area of diagnosis. Benign elevated lesions of the vocal folds have varying nomenclature despite having anatomic differences in location. New imaging evaluations may aid in further understanding of best diagnosis. Benign elevated lesions in children are common and voice therapy remains the primary treatment modality. Diagnostic methods are expanding, though have not become widely used in practice. Future research should seek to further standardize these diagnostic methods. There is a paucity of literature on results in surgical intervention in children.

Smart healthcare systems for the internet of things (IoT) platform are cost-efficient and facilitate continuous remote monitoring of patients to avoid unnecessary hospital visits and long waiting times to see practitioners. Presenting a smart healthcare system for the detection of dysphonia can reduce the suffering and pain of patients by providing an initial evaluation of voice. This preliminary feedback of voice could minimize the burden on ENT specialists by referring only genuine cases to them as well as giving an early alarm of potential voice complications to patients. Any possible delay in the treatment and/or inaccurate diagnosis using the subjective nature of tools may lead to severe circumstances for an individual because some types of dysphonia are life-threatening. Therefore, an accurate and reliable smart healthcare system for IoT platform to detect dysphonia is proposed and implemented in this study. Higher-order directional derivatives are used to analyze the time–frequency spectrum of signals in the proposed system. The computed derivatives provide essential and vital information by analyzing the spectrum along different directions to capture the changes that appeared due to malfunctioning the vocal folds. The proposed system provides 99.1% accuracy, while the sensitivity and specificity are 99.4 and 98.1%, respectively. The experimental results showed that the proposed system could provide better classification accuracy than the traditional non-directional first-order derivatives. Hence, the system can be used as a reliable tool for detecting dysphonia and implemented in edge devices to avoid latency issues and protect privacy, unlike cloud processing.