Presbilaringe: revisión de la literatura / Presbylarynges: literature review

La voz senil o presbifonía es una condición que se produce por cambios fisiológicos que se generan con los años y que alteran el sistema fonatorio, a nivel de cartílagos, músculos, vías nerviosas y otras alteraciones estructurales lo que, en su conjunto, se denomina presbilaringe. El diagnóstico de presbifonía es un diagnóstico de exclusión, debiendo previamente descartarse causas patológicas de disfonia. En el presente artículo se realiza una revisión de presbilaringe, enfocándose en epidemiología, anatomía, fisiología, histología, diagnóstico y manejo.

The senile voice or presbyphonia it is a condition that is produced by physiological changes that affects the fonatory system in the cartilage, muscles, nerves and other structural alterations, the latter is what is called presbylarynx. Presbyphonia is a diagnosis of exclusion, other pathological causes of dysphonia must be previously ruled out. In this article we made a review of the literature on presbylarynx, focusing on epidemiology, anatomy, physiology, histology, diagnosis and treatment.

Computerized Tomography Measures During and After Artificial Lengthening of the Vocal Tract in Subjects With Voice Disorders.

PURPOSE: The present study aimed to observe the effect of two types of tubes on vocal tract bidimensional and tridimensional images. METHODS: Ten participants with hyperfunctional dysphonia were included. Computerized tomography was performed during production of sustained [a:], followed by sustained phonation into a drinking straw, and then repetition of sustained [a:]. A similar procedure was performed with a stirring straw after 15 minutes of vocal rest. Anatomic distances and area measures were obtained from computerized tomography midsagittal and transversal images. Vocal tract total volume was also calculated. RESULTS: During tube phonation, increases were measured in the vertical length of the vocal tract, oropharyngeal area, hypopharyngeal area, outlet of the epilaryngeal tube, and inlet to the lower pharynx. Also, the larynx was lower, and more closure was noted between the velum and the nasal passage. CONCLUSION: Tube phonation causes an increased total vocal tract volume, mostly because of the increased cross-sectional areas in the pharyngeal region. This change is more prominent when the tube offers more airflow resistance (stirring straw) compared with less airflow resistance (drinking straw). Based on our data and previous studies, it seems that vocal tract changes are not dependent on the voice condition (vocally trained, untrained, or disordered voices), but on the exercise itself and the type of instructions given to subjects. Tube phonation is a good option to reach therapeutic goals (eg, wide pharynx and low larynx) without giving biomechanical instructions, but only asking patients to feel easy voice and vibratory sensations.

Efficacy of Water Resistance Therapy in Subjects Diagnosed With Behavioral Dysphonia: A Randomized Controlled Trial.

PURPOSE: The purpose of the present study was to determine the efficacy of water resistance therapy (WRT) in a long-term period of voice treatment in subjects diagnosed with voice disorders. METHODS: Twenty participants, with behavioral dysphonia, were randomly assigned to one of two treatment groups: (1) voice treatment with WRT, and (2) voice treatment with tube phonation with the distal end in air (TPA). Before and after voice therapy, participants underwent aerodynamic, electroglottographic, acoustic, and auditory-perceptual assessments. The Voice Handicap Index and self-assessment of resonant voice quality were also performed. The treatment included eight voice therapy sessions. For the WRT group, the exercises consisted of a sequence of five phonatory tasks performed with a drinking straw submerged 5 cm into water. For the TPA, the exercises consisted of the same phonatory tasks, and all of them were performed into the same straw but the distal end was in air. RESULTS: Wilcoxon test showed significant improvements for both groups for Voice Handicap Index (decrease), subglottic pressure (decrease), phonation threshold pressure (decrease), and self-perception of resonant voice quality (increase). Improvement in auditory-perceptual assessment was found only for the TPA group. No significant differences were found for any acoustic or electroglottographic variables. No significant differences were found between WRT and TPA groups for any variable. CONCLUSIONS: WRT and TPA may improve voice function and self-perceived voice quality in individuals with behavioral dysphonia. No differences between these therapy protocols should be expected.

Comparison of Supraglottic Activity and Spectral Slope Between Theater Actors and Vocally Untrained Subjects.

PURPOSE: The present study aimed to assess supraglottic activity in theater actors and to observe whether they present differences compared with subjects with no voice training. Acoustic and perceptual analyses were also performed. METHODS: A total of 20 participants were divided into two groups: an experimental group of trained theater actors, and a comparative group of subjects with no voice training. Absence of laryngeal pathology was confirmed by rigid videostroboscopy. Flexible laryngoscopy was performed to assess supraglottic activity during speaking phonatory tasks. Voice recording was also carried out. Four blinded judges were asked to assess laryngoscopic and perceptual variables using a visual analog scale. A comparison between groups, phonatory tasks, and loudness levels was performed. RESULTS: Multivariate linear regression showed that trained participants had a higher degree of both laryngeal and pharyngeal activities compared with untrained participants. Moreover, phonatory tasks at high intensity showed higher activity than those at medium and low intensities for most phonatory tasks and laryngoscopic parameters. Vocally trained participants evidenced higher values for all spectral variables compared with untrained participants. CONCLUSION: Actors have a greater degree of both laryngeal and pharyngeal activities than vocally untrained subjects. Apparently, this higher activity is associated to speaking voice training and not to a hyperfunctional vocal behavior. Anterior-posterior laryngeal compression is greater than medial compression. Intensity and phonatory tasks have an effect on all laryngoscopic variables. Supraglottic activity during professional speaking voice may be not necessarily a hyperfunctional behavior, but a strategy to avoid vocal fold damage while producing the desired voice quality.

Air Pressure and Contact Quotient Measures During Different Semioccluded Postures in Subjects With Different Voice Conditions.

OBJECTIVE: The purpose of this study was to investigate the effect of phonation into tubes in air and tubes submerged in water on air pressure variables and vocal fold adduction in subjects with different voice conditions. METHODS: Forty-five participants representing four vocal conditions were included: (1) subjects diagnosed with normal voice and without voice training, (2) subjects with normal voice with voice training, (3) subjects with muscle tension dysphonia, and (4) subjects with unilateral vocal fold paralysis. Participants phonated into different kinds of tubes (drinking straw, 5 mm in inner diameter; stirring straw, 2.7 mm in inner diameter; silicon tube, 10 mm in inner diameter) with the free end in air and in water. Aerodynamic, acoustic, and electroglottographic signals were captured simultaneously. Mean values of the following variables were considered: glottal contact quotient (CQ) measured by electroglottograph, fundamental frequency, subglottic pressure (Psub), oral pressure (Poral), and transglottal pressure. RESULTS: All exercises had a significant effect on Psub, Poral, transglottal pressure, and CQ (P < 0.05). Phonation into a 55-cm silicon tube submerged 10 cm in water and phonation into a stirring straw resulted in the highest values for CQ, Psub, and Poral compared with baseline (repetition of syllable [pa:]) for all vocal status. Poral and Psub correlated positively. CONCLUSION: During semioccluded exercises, most variables behaved in a similar way (same trend with a quite large individual variation) regardless of the vocal status of the participants.

Do Different Semi-Occluded Voice Exercises Affect Vocal Fold Adduction Differently in Subjects Diagnosed with Hyperfunctional Dysphonia?

OBJECTIVE: To observe the possible differential effects of 8 different semi-occluded vocal tract exercises on glottal contact quotient (CQ) as a measure of vocal fold impact stress. PATIENTS AND METHODS: Eighty participants were divided into two groups: an experimental group with hyperfunctional dysphonia and a control group of vocally healthy subjects. The participants were recorded before, during and after the exercises. Electroglottographic samples were analyzed to obtain CQ. RESULTS: For the experimental group, all exercises, except lip trills and tongue trills, had an overall significant effect when conditions before, during and after the exercises were compared. The CQ presented differently across the 8 semi-occluded postures during exercise for both groups. For the experimental group, most exercises increased the CQ during practice. Only lip and tongue trills demonstrated lower CQ during exercise. CONCLUSIONS: Different semi-occluded exercises differentially affect vocal fold adduction. Lip and tongue trills produced the lowest CQ. Therefore, they may be recommended for decreasing glottal adduction. A straw submerged 10 cm below the water surface presented the greatest CQ. A shallower depth led to a lower CQ, while deeper submersion produced a higher CQ.

Laryngoscopic and spectral analysis of laryngeal and pharyngeal configuration in non-classical singing styles.

PURPOSE: The present study aimed to assess three different singing styles (pop, rock, and jazz) with laryngoscopic, acoustic, and perceptual analysis in healthy singers at different loudness levels. Special emphasis was given to the degree of anterior-posterior (A-P) laryngeal compression, medial laryngeal compression, vertical laryngeal position (VLP), and pharyngeal compression. STUDY DESIGN: Prospective study. METHODS: Twelve female trained singers with at least 5 years of voice training and absence of any voice pathology were included. Flexible and rigid laryngeal endoscopic examinations were performed. Voice recording was also carried out. Four blinded judges were asked to assess laryngoscopic and auditory perceptual variables using a visual analog scale. RESULTS: All laryngoscopic parameters showed significant differences for all singing styles. Rock showed the greatest degree for all of them. Overall A-P laryngeal compression scores demonstrated significantly higher values than overall medial compression and VLP. High loudness level produced the highest degree of A-P compression, medial compression, pharyngeal compression, and the lowest VLP for all singing styles. Additionally, rock demonstrated the highest values for alpha ratio (less steep spectral slope), L1-L0 ratio (more glottal adduction), and Leq (more vocal intensity). Statistically significant differences between the three loudness levels were also found for these acoustic parameters. CONCLUSIONS: Rock singing seems to be the style with the highest degree of both laryngeal and pharyngeal activity in healthy singers. Although, supraglottic activity during singing could be labeled as hyperfunctional vocal behavior, it may not necessarily be harmful, but a strategy to avoid vocal fold damage.

Decanulación y evaluación de la deglución del paciente traqueotomizado en cuidados intensivos no-neurocríticos / Decannulation and assessment of deglutition in the tracheostomized patient in non-neurocritical intensive care

Las evaluaciones para la decanulación y los trastornos de la deglución son motivos frecuentes de interconsulta otorrinolaringológica para pacientes en cuidados intensivos. El objetivo de la traqueotomía es mantener una vía aérea permeable. No previene necesariamente los episodios de aspiración e incluso podría favorecerlos. Cuando la causa que motivó la traqueotomía se resuelve, puede plantearse la decanulación del paciente. La deglución es un acto complejo que involucra la interacción coordinada de diversas estructuras de la vía aereodigestiva. El estudio endoscópico con fibra óptica y la videofluoroscopia son herramientas útiles y complementarias en la evaluación de pacientes con trastornos de la deglución. Para el manejo de estos pacientes es necesario un conocimiento sobre la fisiología laríngea y de la deglución, y sobre las distintas alternativas terapéuticas disponibles. Aunque muchas veces coexisten trastornos de la deglución en los pacientes traqueotomizados, la evaluación para la decanulación no es sinónimo de evaluación de la deglución. Un paciente puede ser candidato a ser decanulado y tener un trastorno de la deglución asociado, o bien un paciente traqueotomizado puede lograr deglutir de manera adecuada. Conocer y comprender estos conceptos lleva a un manejo más eficiente, y ayuda a clarificar la comunicación entre el intensivista y el otorrinolaringólogo. Idealmente, debiera existir un equipo multidisciplinario especializado en la evaluación y tratamiento de estos pacientes (AU)

With intensive care patients, decannulation and deglutition disorders are frequent reasons for otorhinolaryngological assessment. The objective of a tracheostomy is to maintain a patent airway. It does not necessarily prevent episodes of aspiration and may even favour them. When the cause that led to the tracheostomy resolves, a decannulation may be proposed. Deglutition is a complex act involving the coordinated interaction of several structures of the aerodigestive tract. Fibre-optic endoscopy and videofluoroscopy are 2 useful, complementary tools for the evaluation of patients with swallowing disorders. In managing these patients, a thorough knowledge of laryngeal and swallowing physiology, as well as of the different therapeutic alternatives, is required. Although it is not uncommon for swallowing disorders to coexist in tracheostomy patients, decannulation evaluation is not synonymous with deglutition assessment. A patient could be a candidate for decannulation and have a swallowing disorder, or a tracheostomy patient could swallow adequately. Knowing and understanding these concepts will lead to more efficient management and help to clarify communication between the intensive care physician and the otorhinolaryngologist. Ideally, a multidisciplinary team should be formed to evaluate and manage these patients (AU)

Decannulation and assessment of deglutition in the tracheostomized patient in non-neurocritical intensive care.

With intensive care patients, decannulation and deglutition disorders are frequent reasons for otorhinolaryngological assessment. The objective of a tracheostomy is to maintain a patent airway. It does not necessarily prevent episodes of aspiration and may even favour them. When the cause that led to the tracheostomy resolves, a decannulation may be proposed. Deglutition is a complex act involving the coordinated interaction of several structures of the aerodigestive tract. Fibre-optic endoscopy and videofluoroscopy are 2 useful, complementary tools for the evaluation of patients with swallowing disorders. In managing these patients, a thorough knowledge of laryngeal and swallowing physiology, as well as of the different therapeutic alternatives, is required. Although it is not uncommon for swallowing disorders to coexist in tracheostomy patients, decannulation evaluation is not synonymous with deglutition assessment. A patient could be a candidate for decannulation and have a swallowing disorder, or a tracheostomy patient could swallow adequately. Knowing and understanding these concepts will lead to more efficient management and help to clarify communication between the intensive care physician and the otorhinolaryngologist. Ideally, a multidisciplinary team should be formed to evaluate and manage these patients.

Infecciones profundas del cuello en el niño / Deep neck infections in children

Las infecciones profundas cervicales, a excepción de los abscesos periamigdalianos, son poco frecuentes en pediatría. Sin embargo, cuando aparecen en esta edad muestran un elevado riesgo de presentar complicaciones graves, tales como la obstrucción de la vía aérea, con una morbilidad y mortalidad que justifican que el pediatra tenga un conocimiento general de esta patología así como de su tratamiento adecuado