Evidence of Long-Term Voice Therapy Effectiveness in Patients With Presbylarynges.

Evidence for long-term effectiveness of voice therapy (>2 years from previous clinic visit) is lacking from patients over 60 years who initially presented with voice complaints and subsequently demonstrated videostroboscopic signs of aging leading to voice therapy recommendations. Over the telephone, a certified speech-language pathologist enquired from those compliant and non-compliant, whether their voices were better, stable, or worse since their previous clinic visit, and asked them to rate Voice-Related Quality of Life, voice satisfaction, and Glottal Function Index to compare with their previous clinic visit ratings. Further questions focused on current voice satisfaction, and for those who were compliant, therapeutic experiences including home exercises. Twenty-four participated (16 complied; eight non-compliant), with a mean of 3.7 ± 1.2 years since the previous clinic visit. For those compliant, 0% reported better voices, 69% stable, and 31% worse. Most compliant participants (56%) attended between two and five therapy sessions. The most frequently reported therapy techniques were repeating nasal sounds/words; straw phonation; fewer words/breath group; and increasing pitch range. Eighty-one percent of compliant participants were given home exercises. They stopped regular practice a few months post-therapy but continued using them as rescue techniques. For those non-compliant, 88% reported better voices, 0% stable, and 12% worse. Most non-compliant participants (43%) reported lack of time as their reason for non-compliance. Most compliant participants reported stable voices, supporting voice therapy's role in maintaining voice function over time in the context of progressive aging. However, non-compliant participants were not associated with poorer voice quality over time.

Predicting Airflow from Measures Sensitive to Mid-cord Glottal Gap During the COVID-19 Pandemic.

OBJECTIVES: To determine if trans-laryngeal airflow, important in assessing vocal function in paresis/paralysis and presbylarynges patients with mid-cord glottal gaps, could be predicted by other measures sensitive to mid-cord glottal gap size but with smaller risks of spreading COVID-19, and if any patient factors need consideration. METHODS: Four populations were: unilateral vocal fold paresis/paralysis (UVFP, 148), aging and UVFP (UVFP plus aging, 22), bilateral vocal fold paresis/paralysis without airway obstruction (BVFP, 49), and presbylarynges (66). Five measures were selected from the initial clinic visit: mean airflow from repeated /pi/ syllables, longer of 2 /s/ and 2 /z/ productions, higher of 2 cepstral peak prominence smoothed for vowel /a/ (CPPSa), and Glottal Function Index (GFI). S/Z ratios were computed. Stepwise regression models used 3 measures and 5 patient factors (age, sex, etiology, diagnosis, and potentially impaired power source for voicing) to predict airflow. RESULTS: Log-transformations were required to normalize distributions of airflow and S/Z ratio. The final model revealed age, sex, impaired power source, log-transformed S/Z ratio, and GFI predicted log-transformed airflow (R2 = .275, F[5,278] = 21.1; P < .001). CONCLUSIONS: The amount of variance explained by the model was not high, suggesting adding other predictive variables to the model might increase the variance explained.

Long-Term Voice Change in Presbylarynges Patients With and Without Intervention.

PURPOSE: To explore long-term patient experience of treated and untreated presbylarynges patients two or more years after their previous clinic visit by their responses to a probe about the changes in voice (better, stable, or worse) and standardized rating scales either by phone or from clinic records. Congruences of rating differences between visits and probe responses were assessed. METHODS: Thirty-seven participated prospectively and seven retrospectively. Better, stable, or worse probe responses and treatment follow-through were obtained. Self-rating scales, completed verbally or obtained from charts, were compared to the previous visit so differences between visits could be converted to be congruent with probe responses. RESULTS: After a mean of 4.6 years, 44% (63% untreated) reported stable, 36% (38% untreated) worse, and 20% (89% untreated) better. Significantly greater proportions of untreated reported better/stable probe responses while treated reported worse (χ2; P = 0.038). Significantly better means for all ratings were found at follow-up for those with better probe responses, but mean ratings were not significantly worse for those with worse probe response. No significant congruences of rating differences between visits and probe responses were found. In untreated reporting stable probe response, a significantly greater proportion of those with previous clinic ratings within normal limits (WNL) maintained ratings WNL at follow-up (z-statistic; P = 0.0007). CONCLUSIONS: Ratings WNL at the initial evaluation, especially voice-related quality of life and effort, were found to still be WNL after several years. Little congruence was found between rating differences and probe responses, especially for worse, suggesting need for developing more sensitive rating scales.

Objective Laryngoscopic Measures From Older Patients With Voice Complaints and Signs of Aging.

PURPOSE: The purpose of this study was to use objective measures of glottal gap, bowing, and supraglottic compression from selected images of laryngoscopic examinations from adults over 60 years of age with voice complaints and signs of aging to test current hypotheses on whether degree of severity impacts treatment recommendations and potential follow-through with treatment. METHOD: Records from 108 individuals 60 years or older with voice complaints and signs of aging were reviewed. Three objective measures (normalized glottal gap area [NGGA], total bowing index, and normalized true vocal fold width) were derived. Each measure was subsequently divided into three categories by severity: absence, small degree, or large degree. Nonparametric statistics tested associations between severity and treatment recommendations as well as potential follow-through. RESULTS: Noninvasive treatments (observation/voice therapy) were marginally associated with no glottal gap (p = .09). More invasive treatments (injection/bilateral thyroplasty) were associated with glottal gaps being present (p = .026), but bilateral thyroplasty recommendations were not significantly associated with the largest gaps. Treatment modalities were not characterized by specific severity categories for any of the objective measures. No significant differences were found for any of the three objective measures between those who followed through with recommended treatment and those who did not. DISCUSSION: Results demonstrated some support for current hypotheses on how degrees of severity of objective measures relate to treatment recommendations. Of the three measures, NGGA appears to be more informative regarding treatment recommendations and follow-through, but due to low power, larger sample sizes are needed to confirm clinical relevance.

Surgical Management in Tracheobronchopathia Osteochondroplastica: A Case Study.

Tracheobronchopathia Osteochondroplastica is a benign condition characterized by osseous and cartilaginous submucosal growths of the tracheobronchial tree. This is a case report of an individual that was to undergo elective surgery using general anesthesia with endotracheal tube intubation. However, the anesthesiologist encountered a large osseous mass of the precricoid region and could not be intubated. This case report describes the technique for removal of the obstructing lesion using a Sonopet ultrasonic aspirator. Laryngoscope, 131:E911-E913, 2021.

The Role of Choral Singing in Speaking Voice Preservation of Aging Adults.

Purpose This descriptive cohort pilot study, using a convenience sample, examined whether evidence from vocal function measures, auditory-perceptual ratings, and/or endoscopic signs of aging supported singing in senior chorales as a possible intervention to preserve the speaking voice in aging adults. Method Thirteen singers and five nonsinging controls, all over 65 years of age, participated. They were assessed at two visits, 15-20 months apart. Vocal function measures and auditory-perceptual ratings of estimated age and the presence of voice disorders were compared across singing status and visit. Changes in the presence and degree of laryngeal signs of aging between visits were compared across singing status. Results Using an alpha of .2, deemed acceptable for pilot studies, vocal function measures supported choral singing as an intervention to preserve the speaking voice as less noise energy between 2 and 3 kHz (p = .01) and lower phonation threshold pressures (PTPs) were present (p = .09) for singers compared to nonsinging controls. Greater flows at comfortable pitch (p = .04) and high pitch (p = .06) as well as lower cepstral peak prominence smoothed (CPPS) for the vowel /a/ (p < .01) were found at Visit 2 for both groups, but singers demonstrated lower flows at Visit 2 than nonsinging controls at comfortable pitch (p = .06). Auditory-perceptual ratings did not support preservation of speaking voice, although a larger percentage of listeners rated nonsinging controls as voice disordered at Visit 2. Endoscopic ratings supported preservation, as singers were more likely than nonsinging controls to be rated as having laryngeal signs of aging absent at both visits (p = .02). Conclusion The findings from this pilot study provide evidence that regular singing in senior chorales may assist in preserving older adults' speaking voices.

Unilateral versus bilateral botulinum toxin injections in adductor spasmodic dysphonia in a large cohort.

OBJECTIVES/HYPOTHESIS: The primary treatment of adductor spasmodic dysphonia is repeated injections of botulinum toxin type A (Botox) into the thyroarytenoid muscles. Dosing can be performed into either one or both thyroarytenoid muscles. The objective of this study was to evaluate the treatment effect and side effect profile across a large number of injections. This study was performed previously in 2002 on 45 patients. STUDY DESIGN: Individual cohort study. METHODS: This is retrospective study of all patients with adductor spasmodic dysphonia with and without tremor treated by the senior laryngologist at George Washington University. In the current study, 272 patients (214 females and 58 males) were included in the current analysis. Duration of effects and side effects (vocal weakness and liquid dysphagia) were recorded into a database for each patient after each injection. These data were analyzed using χ2 analysis. RESULTS: A total of 4,023 injections (2,708 bilateral and 1,315 unilateral) were evaluated in this study. Optimal effect duration (≥3 months) was more commonly seen in the bilaterally injected patients (55%) compared to the unilaterally injected patients (47%) (P = .0001). Optimal side effect duration (≤2 weeks) was better for the unilaterally injected patients (77%) compared to the bilaterally injected patients (73%) (P = .023). Having both optimal effect and side effect in the same injection was more commonly seen in the bilaterally injected patients (36%) compared to the unilaterally injected patients (33%) (P = .0228). CONCLUSIONS: This study shows that bilateral injections of Botox are more effective in producing optimal effect/side effect profiles. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:2659-2662, 2020.

Treatment effectiveness for aging changes in the larynx.

OBJECTIVES: To compare the effectiveness of injection augmentation and bilateral thyroplasty surgery in managing age-related changes of the larynx. STUDY DESIGN: Retrospective chart review of patients treated with bilateral thyroplasty and/or injection augmentation. METHODS: We evaluated 22 patients before and after treatment using: 1) normalized glottal gap area and normalized true vocal fold width from endoscopic images; 2) patient self-rating questionnaires; and 3) acoustic and aerodynamic measures. RESULTS: Thyroplasty surgery resulted in 38% of patients demonstrating less bowing compared to 33% after injection, and 63% demonstrated less supraglottic activity compared to 43% after injection (P = 0.09). Change in mean Voice-Related Quality of Life (V-RQOL) scores was 25.5 after thyroplasty compared to -16.4 after injection (P < 0.05). Those exhibiting a greater than 20 change in V-RQOL after treatment were significantly more likely to report swallowing symptoms pretreatment. CONCLUSION: Patients postinjection did not rate themselves on any questionnaires as significantly better compared to pretreatment, whereas patients post-thyroplasty rated themselves as significantly improved on all questionnaires. Patients post-thyroplasty rated their voices as significantly closer to their best voice than patients postinjection. Likewise, 64% of patients who had thyroplasty surgery reported a significant treatment effect compared to 33% for injection augmentation. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2572-2577, 2017.

Medullary thyroid carcinoma presenting as a supraglottic mass.

We report a rare case of medullary thyroid carcinoma that presented as a metastasis to the supraglottic larynx. A 92-year-old man with a 3-month history of voice change and airway obstruction was diagnosed with medullary thyroid carcinoma metastatic to the supraglottis. Excision of the mass, total thyroidectomy, and elective neck dissection were recommended, but the patient declined because of his advanced age. Medullary carcinoma of the thyroid gland is a rare neuroendocrine tumor with a poor prognosis when associated with a distant metastasis. To the best of our knowledge, this is the first case of a medullary carcinoma of the thyroid presenting as a supraglottic mass. Total thyroidectomy, neck dissection, and surgical excision of the entire tumor comprise the treatment of choice.

Computational study of effects of tension imbalance on phonation in a three-dimensional tubular larynx model.

OBJECTIVES: The present study explores the use of a continuum-based computational model to investigate the effect of left-right tension imbalance on vocal fold (VF) vibrations and glottal aerodynamics, as well as its implication on phonation. The study allows us to gain new insights into the underlying physical mechanism of irregularities induced by VF tension imbalance associated with unilateral cricothyroid muscle paralysis. METHODS: A three-dimensional simulation of glottal flow and VF dynamics in a tubular laryngeal model with tension imbalance was conducted by using a coupled flow-structure interaction computational model. Tension imbalance was modeled by reducing by 20% the Young's modulus of one of the VFs, while holding VF length constant. Effects of tension imbalance on vibratory characteristic of the VFs and on the time-varying properties of glottal airflow as well as the aerodynamic energy transfer are comprehensively analyzed. RESULTS AND CONCLUSIONS: The analysis demonstrates that the continuum-based biomechanical model can provide a good description of phonatory dynamics in tension imbalance conditions. It is found that although 20% tension imbalance does not have noticeable effects on the fundamental frequency, it does lead to a larger glottal flow leakage and asymmetric vibrations of the two VFs. A detailed analysis of the energy transfer suggests that the majority of the energy is consumed by the lateral motion of the VFs and the net energy transferred to the softer fold is less than the one transferred to the normal fold.

Subject-specific computational modeling of human phonation.

A direct numerical simulation of flow-structure interaction is carried out in a subject-specific larynx model to study human phonation under physiological conditions. The simulation results compare well to the established human data. The resulting glottal flow and waveform are found to be within the normal physiological ranges. The effects of realistic geometry on the vocal fold dynamics and the glottal flow are extensively examined. It is found that the asymmetric anterior-posterior laryngeal configuration produces strong anterior-posterior asymmetries in both vocal fold vibration and glottal flow which has not been captured in the simplified models. It needs to be pointed out that the observations from the current numerical simulation are only valid for the flow conditions investigated. The limitations of the study are also discussed.

Perceived vocal fatigue and effort in relation to laryngeal functional measures in paresis patients.

OBJECTIVES/HYPOTHESIS: To determine if differences in objective measures of laryngeal function can meaningfully explain different levels of self-perceptions of effort or fatigue in patients with vocal fold paresis. STUDY DESIGN: A retrospective chart review of 72 patients with vocal fold paresis diagnosed using laryngeal electromyography, who had either been observed (n=21), treated only by injection (n=24), or treated only by surgery (n=27). METHODS: Before and after treatment/observation, patients' subjective ratings of severity of vocal effort and fatigue were assessed using the Glottal Function Index. Laryngeal function was assessed using maximum phonation time and translaryngeal flow. RESULTS: None of the variables demonstrated a significant linear change across time. Post hoc Tukey analyses following analysis of variance (ANOVA) found significant differences in flow among three groups, those rating symptoms of effort as no problem, moderate problem, or severe problem. Post hoc Tukey analyses following ANOVA found significant differences in the amount that flow changed among three groups, those demonstrating no difference, minor differences, or major differences in ratings of effort before and after treatment. CONCLUSIONS: Changes in reported symptom severity of effort were related to changes in translaryngeal midvowel flow that were not explained by passage of time. LEVEL OF EVIDENCE: 4.

Toward a simulation-based tool for the treatment of vocal fold paralysis.

Advances in high-performance computing are enabling a new generation of software tools that employ computational modeling for surgical planning. Surgical management of laryngeal paralysis is one area where such computational tools could have a significant impact. The current paper describes a comprehensive effort to develop a software tool for planning medialization laryngoplasty where a prosthetic implant is inserted into the larynx in order to medialize the paralyzed vocal fold (VF). While this is one of the most common procedures used to restore voice in patients with VF paralysis, it has a relatively high revision rate, and the tool being developed is expected to improve surgical outcomes. This software tool models the biomechanics of airflow-induced vibration in the human larynx and incorporates sophisticated approaches for modeling the turbulent laryngeal flow, the complex dynamics of the VFs, as well as the production of voiced sound. The current paper describes the key elements of the modeling approach, presents computational results that demonstrate the utility of the approach and also describes some of the limitations and challenges.

Primary care perceptions of otolaryngology.

OBJECTIVE: To identify diseases of the head and neck for which primary care physicians may underappreciate the role of the otolaryngologist. STUDY DESIGN: Cross-sectional analysis. SETTING: With increasing subspecialization in the world of medicine, there is the potential for confusion about the scope of practice for different specialties by primary care physicians. These clinicians are often faced with patients who have disease processes in which otolaryngologist are trained but may end up referring patients to other specialists. SUBJECTS AND METHODS: A brief, web-based survey was administered via e-mail to resident physicians of family medicine, pediatrics, and internal medicine programs in the United States. The survey asked responders which specialist they believed was an expert for particular clinical entities: allergies, oral cancer, restoring a youthful face, sleep apnea, thyroid surgery, and tracheostomy. Respondents could choose from a dermatologist, general surgeon, ophthalmologist, oral maxillofacial surgeon, orthopedic surgeon, otolaryngologist, and plastic surgeon. The responder was able to choose more than one specialist for each question. RESULTS: A total of 1064 completed surveys were analyzed. The percentage of primary care residents who picked otolaryngologists as experts was 13.8 percent for allergies, 73.6 percent for oral cancer, 2.7 percent for restoring a youthful face, 32.4 percent for sleep apnea, 47.2 percent for thyroid surgery, and 72.5 percent for tracheostomy. CONCLUSION: This study demonstrates that many primary care residents are not aware of the scope of expertise that an otolaryngologist may offer. Increased exposure to otolaryngology during primary care residency training may increase understanding of the specialty among primary care physicians.

Using laryngeal electromyography to differentiate presbylarynges from paresis.

PURPOSE: Differential diagnosis of patients over 64 years of age reporting hoarseness is challenging. Laryngeal electromyography (LEMG) was used to determine the status of the recurrent and superior laryngeal nerves. The authors hypothesized that individuals with hoarseness but normal LEMG would have measures similar to those of patients from previous studies with presbylarynges and significantly different from those of patients with abnormal LEMG. METHOD: A retrospective chart review of acoustic, aerodynamic, endoscopic, and self-rating measures was completed for 52 individuals over 64 years of age reporting moderate to severe hoarseness. RESULTS: Individuals with normal LEMG had measures similar to those of patients from previous studies diagnosed with presbylarynges. The group with LEMG abnormalities was subcategorized by specific nerve(s) affected. Significant differences were found for measures between presbylarynges and unilateral but not bilateral paresis groups. Several endoscopic findings were observed more often than expected in the presbylarynges group. Using electromyography as a gold standard, the presence of any impairment in arytenoid movement had the most sensitivity (77%) in making the diagnosis of paresis, and the absence of any impairment had the most specificity (67%) in making the diagnosis of presbylarynges. CONCLUSION: LEMG may be useful in differentially diagnosing hoarseness in older patients, especially to distinguish between bilateral paresis and presbylarynges.

Evidence of return of function in patients with vocal fold paresis.

Unilateral vocal fold paresis (UVFP) patients were examined over time for achievement of partial or full functional return or no functional return in the extent of arytenoid movement, clarity of laryngeal articulation, maximum phonation time (MPT), and flow. Effects of treatment type and initial laryngeal electromyography (EMG) results were examined. A retrospective chart review was completed for patients a year or less after onset evaluated between April 1999 and December 2005 and treated between 2 and 20 months after onset. Twenty-one individuals were evaluated (11 males, age: 34-89 years) and subsequently treated (10 by injection and 11 by thyroplasty). Evidence of full functional return was found for the extent of arytenoid movement in 25% of individuals, for clarity of laryngeal articulation in 71%, for MPT in 58%, and for flow in 50%. No evidence of functional return was found for the extent of arytenoid movement in 33% of the individuals, for clarity of laryngeal articulation in 8%, for MPT in 32%, and for flow in 22%. All pairs of outcome measures showed poor agreement in the level to which they functionally returned. More individuals with signs of reinnervation demonstrated MPTs with full functional return than expected. Patients with UVFP, even after treatment and at least 12 months postinjury did not demonstrate full functional return for all measures. Differences across measures in the percentage of individuals demonstrating each level of function and the lack of agreement of function level between measures within individuals suggest the need to use multiple outcome measures.

Analysis of flow-structure interaction in the larynx during phonation using an immersed-boundary method.

A recently developed immersed-boundary method is used to model the flow-structure interaction associated with the human phonation. The glottal airflow is modeled as a two-dimensional incompressible flow driven by a constant subglottal pressure, and the vocal folds are modeled as a pair of three-layered, two-dimensional, viscoelastic structures. Both the fluid dynamics and viscoelasticity are solved on fixed Cartesian grids using a sharp-interface immersed boundary method. It is found that the vibration mode and frequency of the vocal fold model are associated with the eigenmodes of the structures, and that the transition of the vibration mode takes place during onset of the sustained vibration. The computed glottal waveforms of the volume flux, velocity, and pressure are reasonably realistic. The glottal flow features an unsteady jet whose direction is deflected by the large-scale vortices in the supraglottal region. A detailed analysis of the flow and vocal fold vibrations is conducted in order to gain insights into the biomechanics of phonation.

Granular cell tumors of the larynx: diagnosis and management.

In this case study, a retrospective review of chart and literature was done to discuss the presentation and treatment of granular cell tumors of the larynx. One patient was diagnosed and treated successfully with surgical resection of a laryngeal granular cell tumor. Excellent voice recovery was obtained and there is no evidence of recurrence 6 months after surgery. Granular cell tumors should be considered in the differential diagnosis of laryngeal masses, particularly in the posterior glottis.

Image guided medialization laryngoplasty.

Techniques that originate in computer graphics and computer vision have found prominent applications in the medical domain. In this paper, we have seamlessly developed techniques from computer graphics and computer vision together with domain knowledge from medicine to develop an image guided surgical system for medialization laryngoplasty. The technical focus of this paper is to register the preoperative radiological data to the intraoperative anatomical structure of the patient. With careful analysis of the real-world surgical environment, we have developed an ICP-based partial shape matching algorithm to register the partially visible anatomical structure to the preoperative CT data. We extracted distinguishable features from the human thyroid cartilage surface and applied image space template matching to find the initial guess for the shape matching. The experimental result shows that our feature-based partial shape matching method has better performance and robustness compared with original ICP-based shape matching method. Although this paper concentrates on the medialization laryngoplasty procedure, its generality makes our methods ideal for future applications in other image guided surgical areas.