Supraglottic activity: evidence of vocal hyperfunction or laryngeal articulation?

False vocal fold (FVF) adduction and compression of the arytenoid cartilages to the petiole of the epiglottis in an anterior to posterior (A-P) direction have been thought to characterize voice disorders with abnormally increased muscle tension or effort, often termed hyperfunctional voice disorders. To further evaluate the association between hyperfunctional voice disorders and supraglottic activity, we compared the incidence of static and dynamic supraglottic activity in individuals with normal laryngeal mucosa, normal voice quality, and no voice complaints to two populations: subjects with vocal fold nodules and subjects with complaints of dysphonia without visible vocal fold lesions, glottal incompetence, or impairment of arytenoid cartilage motion ("hyperfunctional" group). Thirty-two subjects were assigned to one of these three groups (10 control, 12 nodule, and 10 hyperfunctional). Laryngeal movements were recorded using flexible videoendoscopy while a subject was performing speech tasks such as sustained phonation, syllable repetitions, sentence imitations, and conversation. Samples were randomized by subject and task and rated for presence or absence of A-P and FVF compression. Statistically significant group differences were found for FVF compression across speech tasks (chi-square, p<0.001). The control group had the smallest incidence (45%), nodule patients the next larger incidence (68%), and hyperfunctional patients the largest incidence (80%). Statistically significant group differences were found for A-P compression across speech tasks (chi-square, p<.05). The control group had the smallest incidence (74%), nodule patients the next larger incidence (78%), and hyperfunctional patients the largest incidence (92%). Statistically significant task differences were found for the presence of FVF compression in control subjects (chi-square, p<.005), hyperfunctional patients (chi-square, p<.025), and nodule patients (chi-square, p<.001), but not for A-P compression for any of the groups. A higher incidence of FVF compression was present for the speech tasks that included glottal stops. This context-specific variation in supraglottic activity suggested a dynamic component to FVF compression and also explained the high proportion of FVF compression in the control group. Each video sample was also rated for consistency of FVF or A-P compression to explore the static and dynamic nature of supraglottic activity. For samples on which raters agreed, A-P compression was typically present consistently, suggesting a static component, and FVF compression inconsistently, suggesting a dynamic component, for all three groups (chi-square, p<.001). These findings do not support previous suggestions that supraglottic activity may be a precursor to developing vocal fold nodules, as the nodule patients did not exhibit a higher incidence or consistency of A-P or FVF compression than patients with hyperfunctional voicing patterns in this study. Subjects in the hyperfunctional voice group were found to have static components of FVF and A-P compression. The presence of FVF compression in speech tasks that included glottal stops in the control group suggests an articulatory function at the laryngeal level.

Experimental approaches to vocal fold alteration: introduction to the minithyrotomy.

Treatment of challenging laryngeal disorders, such as lamina propria loss or neuromuscular dysfunction, may require novel approaches and techniques. This paper discusses an evolution of experimental techniques for treatment of lamina propria loss and use of the minithyrotomy. These techniques have been used for surgical access for lamina propria substitution, as well as placement of stimulating electrodes. The minithyrotomy is tolerated well by patients, provides access for microscopic instruments with the surgeon's hand close to the tissue of interest, avoids intralaryngeal mucosal incisions, and lines up the direction of dissection in an anterior-to-posterior orientation. This orientation is favorable for particular situations herein discussed. We present anatomic and physiologic concepts relevant to the surgical treatment of lamina propria dysfunction, as well as presenting our clinical experience. This paper is not intended to state how these difficult problems should be handled, but rather, to present our experience in techniques that may prove useful through further development.

Surgical dimensions of the facial recess in adults and children.

The facial recess approach permits surgical access to the round window area. This route is used in patients who are undergoing cochlear implantation. To evaluate the feasibility of this procedure in children as compared with adults, serial sections of temporal bones were used to measure the surgical dimensions of the facial recess. No statistically significant differences in the dimensions of the facial recess or the extended facial recess approaches were found between children and adults. The relationship of the facial and chorda tympani nerves to the annular plane exhibited no change with postnatal growth. These structures translate posteriorly and laterally toward the annular plane as they descend within the temporal bone. Therefore, the facial recess approach represents no greater hazard in a child than in an adult.