Obstrucción laríngea inducible (OLI): una revisión actualizada de la literatura / Induced laryngeal obstruction (ILO): an updated literature review

La obstrucción laríngea inducible se ha descrito como un trastorno de la respiración que se presenta, habitualmente, como dificultad respiratoria aguda por aducción anormal de los pliegues vocales, típicamente, durante la inspiración. Es más frecuente en mujeres y adultos, que en adolescentes. Es difícil estimar la incidencia exacta dada la heterogeneidad de los criterios diagnósticos y nomenclatura, asociado al frecuente subdiagnóstico de esta entidad. Por ello, en la literatura se ha reportado la prevalencia de acuerdo con las subpoblaciones de pacientes, describiendo que alrededor de un 2,8% de los pacientes que consultan en el servicio de urgencia por disnea podría corresponder a esta patología. El diagnóstico es eminentemente clínico, con confirmación mediante laringoscopia flexible. Se apoya en exámenes de función respiratoria, especialmente para descartar otras patologías pulmonares que expliquen el cuadro. El tratamiento es sencillo y, suele ser exitoso, tanto en situaciones agudas como crónicas. Sin embargo, se ha descrito, frecuentemente, un retraso en el diagnóstico, debido a desconocimiento de esta patología.

Induced laryngeal obstruction has been described as a respiratory disorder, usually presenting as an acute respiratory distress due to abnormal adduction of the vocal folds, typically during inspiration. It is more frequent in women and adults, than adolescents. It is difficult to estimate its exact incidence given the heterogeneity of the diagnostic criteria and nomenclature, together with its common underdiagnosis. Hence, studies have reported its prevalence according to the subpopulations within this entity, with a prevalence of 2.8% in patients who consult in the emergency room for dyspnea. The diagnosis is based upon clinical presentation, confirmed by flexible laryngoscopy, and supported by respiratory function exams to rule out other pulmonary diseases with similar symptoms. Its treatment is simple and usually successful, in both acute and chronic situations. However, a delay in the diagnosis has been frequently described, due to unawareness of this disorder.

Vocal fold paralysis and cauda equina syndrome following spinal-epidural anesthesia: A case report.

RATIONALE: Vocal fold paralysis and cauda equina syndrome are very rare neurologic deficits. This report describes the case of a patient who simultaneously developed both after uneventful spinal-epidural anesthesia with 0.5% hyperbaric bupivacaine. PATIENT CONCERNS: We report the case of a 45-year-old female, who underwent surgery for bilateral hallux valgus developed cauda equina syndrome and unilateral vocal fold paralysis after uneventful spinal-epidural anesthesia was administered. There was no pain or paresthesia during needle placement or drug injection. Surgery was performed uneventfully. DIAGNOSES: Right vocal fold paralysis was diagnosed with flexible laryngoscopy. INTERVENTIONS: Patient was started on the treatment with a surgery for bilateral hallux valgus, who developed cauda equina syndrome and unilateral vocal fold paralysis after uneventful spinal-epidural anesthesia was administered. OUTCOMES: Postoperatively, she had difficulty in urination and defecation. In addition, she developed unilateral vocal fold paralysis characterized by hoarseness, effortful voice production, and choking with liquids. Magnetic resonance imaging performed on the lumbosacral area and computed tomography of the neck, the chest, and the skull revealed entirely normal results. However, flexible laryngoscopy revealed a right vocal fold paralysis. Although cauda equina syndrome can occur due to neurotoxicity of local anesthetics, the exact etiology of vocal fold paralysis is uncertain. LESSONS: The case highlights that 2 rare and serious complications of spinal-epidural anesthesia can even occur in the same patient after uneventful surgery and block performance.

Disfonía por tensión muscular: concepto y criterios diagnósticos / Muscle tension dysphonia: concept and diagnostic criteria

Introducción. La disfonía por tensión muscular fue definida, desde 1983, como un desorden que ocasiona un desbalance en las fuerzas de tensión muscular laríngea sin evidencia de patología estructural o neurológica. Denominado también disfonía por tensión muscular, tipo 1, este desorden aún no tiene estandarizadas las características que en la práctica han sido consideradas parte de su diagnóstico.Objetivo. Revisar la información actual, no mayor a cinco años, sobre disfonía por tensión muscular para unificar criterios y diagnósticos actuales.Metodología. Se realizó una búsqueda sistemática a través de las bases de datos PubMed, Google Scholar y Cochrane. Los términos MESH utilizados fueron: dis-fonía por tensión muscular, disfonía funcional, disfonía hipercinética y fatiga vocal. Criterios de inclusión: artículos publicados en revistas arbitradas, sin importancia del diseño y antigüedad no mayor a cinco años. Criterios de exclusión: artículos cuyo enfoque principal no fuera disfonía por tensión muscular y con idioma diferente al inglés o español.Resultados. Dos estudios refieren mayor patología en mujeres que hombres; cuatro investigaciones reportan presión subglótica aumentada (>90 mmHg); tres trabajos reportaron medidas fonatorias; un trabajo propone video de alta resolución como demostración de hiperfunción vocal; una investigación evaluó onda mucosa por elec-troglotografía; una investigación estudió el uso de resonancia magnética funcional; otro trabajo propuso un estudio piloto de evaluación de flujo sanguíneo de músculos infrahioideos. Otro trabajo hace una revisión del uso de métodos diagnósticos.Conclusiones. Los parámetros de mayor peso fueron pico cepstral y presión sub-glótica. Aún es necesario ampliar el conocimiento con nuevas investigaciones que permitan criterios universales

Introduction. Muscle tension dysphonia has been defined since 1983 as a disorder in which there is an imbalance in laryngeal muscle tension forces, without evidence of structural or neurological pathology; it has also been called type I muscle tension dysphonia. The characteristics that in practice have been considered part of the di-agnosis are not standardized.Objective. To review current information, not older than 5 years, on muscle tension dysphonia, unifying current diagnostic criteria.Methodology. A systematic search was carried out through the Pub Med, Google scholar and Cochrane databases. The MESH terms used were: muscle tension dys-phonia, functional dysphonia, hyperkinetic dysphonia, and vocal fatigue. Inclusion criteria: articles published in peer-reviewed journals, regardless of design and pub-lished no more than 5 years before. Exclusion criteria: articles whose main focus was not muscle tension dysphonia and with a language other than English or Spanish.Results. Two studies report more pathology in women than men; four investiga-tions report increased subglottic pressure (> 90 mmHg); three studies reported pho-natory measures; a work proposes high resolution video as a demonstration of vo-cal hyperfunction; an investigation evaluated mucosal wave by electroglottography; an investigation studied the use of functional magnetic resonance imaging; another work proposed a pilot study of infrahyoid muscle blood flow assessment: another work reviews the use of diagnostic methods.Conclusions. The parameters of greater weight were cepstral peak and subglottic pressure. It is still necessary to expand the knowledge with new research that allows universal criteria

Prenatal diagnosis of laryngo-tracheo-esophageal anomalies in fetuses with congenital diaphragmatic hernia by ultrasound evaluation of the vocal cords and fetal laryngoesophagoscopy.

BACKGROUND: To evaluate the incidence of laryngeal ultrasound (US) abnormalities in fetuses with congenital diaphragmatic hernia (CDH) and to assess the utility of fetal laryngoesophagoscopy for prenatal diagnosis of laryngo-tracheo-esophageal anomalies. STUDY DESIGN: A cohort of CDH fetuses with laryngeal ultrasound abnormalities were selected for diagnostic fetal laringoesophagoscopy in a single fetal surgery center at Queretaro, Mexico. RESULTS: During the study period, 210 CDH fetuses were evaluated. US examination of the vocal cords was successfully performed in all fetuses, and abnormal ultrasound findings were observed in four cases (1.9%). Fetal laringoesophagoscopy was successfully performed in all four cases at a median gestational age of 29.5 (range, 28.1-30.6) weeks. During fetal intervention, a laryngo-tracheo-esophageal cleft (TEC) extending from the larynx to the carina (type IV) was endoscopically visualized in three cases, and laryngeal atresia coexisting with TEC was confirmed in the remaining case. Fetal karyotype was normal in all cases, but abnormal chromosomal microarray analysis was reported in two cases (50%). All cases were delivered liveborn with severe respiratory failure presenting cardiac arrest and immediate neonatal death. CONCLUSIONS: Laryngeal anomalies in CDH fetuses can be presumed by ultrasound evaluation of the vocal cords and confirmed by fetal laryngoesophagoscopy during pregnancy.

Congenital and iatrogenic laryngeal and vocal abnormalities in patients with 22q11.2 deletion.

BACKGROUND: Voice abnormalities often go unrecognized in patients with 22q11.2 deletion because speech abnormalities become the focus of evaluation. OBJECTIVE: To analyze voice and vocal fold abnormalities in patients with 22q11.2 deletion by examining voice, not speech. METHODS: This is a case series with chart review from 2009 to 2016. Records of both a velocardiofacial syndrome (VCF) clinic and pediatric otolaryngology clinic at a tertiary pediatric hospital were reviewed. All patients with confirmed 22q11.2 deletion were identified. Cardiac, otolaryngological, speech, and voice characteristics were recorded along with surgical history. Main outcomes included voice characteristics based on speech therapy assessment, along with vocal fold or laryngeal abnormalities. Co-morbidities and surgical history were also recorded. RESULTS: 109 patients were identified with 22q11.2 deletion by genetic testing. Eighteen percent (n = 20) displayed a vocal fold or laryngeal abnormality, either congenital or iatrogenic. The most common congenital abnormalities were laryngeal web (n = 10) and subglottic stenosis (n = 7). The most common iatrogenic abnormality was paralyzed left vocal fold (n = 4). Perceptual analysis by speech therapy showed 65% (n = 71) with a voice within normal limits while 17% (n = 19) were not within normal limits. Of the 20 patients with a vocal fold abnormality, 15% (n = 3) presented a voice within normal limits, while 65% (n = 13) were not within normal limits. Of the 19 patients with a voice outside normal limits, 68% (n = 13) had a diagnosed vocal fold abnormality. Sixteen percent (n = 3) of these patients had an abnormal voice as a result of other issues. CONCLUSION: Out of 109 patients with 22q11.2 deletion, 18% displayed a laryngeal abnormality and 17% had abnormal vocal quality. This suggests that voice and vocal fold abnormalities are important to consider in this population. Distinguishing between speech and voice abnormalities in patients with 22q11.2 deletion can help ensure appropriate intervention.

Shear Wave Elastography to Assess False Vocal Folds in Healthy Adults: A Feasibility Study.

OBJECTIVES: The aim of the study was to investigate the feasibility of using ultrasound shear wave elastography to quantify mechanical properties and movement symmetry of false vocal folds positioned in adduction and abduction. METHODS: We prospectively measured the shear wave velocity (SWV) within the bilateral false vocal folds in 10 healthy adults using acoustic radiation force impulse imaging. From a transcutaneous approach at the level of thyroid cartilage, 5 SWV measurements were obtained within each side of the false vocal folds twice in adduction and again in abduction for each participant. Configuration-related differences in the SWV within false vocal folds were compared between adduction and abduction, in addition to differences between the right and left false vocal folds and between men and women, by a paired t test. We developed an SWV index [(SWVgreater - SWVlesser )/SWVgreater ] to assess movement symmetry between the right and left false vocal folds. Intraobserver agreement on repeated measures was examined by the intraclass correlation coefficient. RESULTS: The 10 participants included 5 men and 5 women. We observed that the SWV within false vocal folds was significantly higher in adduction than in abduction (P < .001). The SWV within false vocal folds in adduction was also significantly higher in women compared to men (P < .001). There was no significant difference in the SWV between the right and left false vocal folds in adduction or in abduction or between men and women in abduction (P > .05). The mean SWV index was 0.05 (range, 0.03-0.07). The intraclass correlation coefficient for intraobserver agreement was 0.89 (P < .001). CONCLUSIONS: Shear wave elastography seems to be feasible to quantify mechanical properties and evaluate the symmetry of false vocal folds in healthy adults.

Effect of voice therapy in sulcus vocalis: A single case study.

BACKGROUND: Sulcus vocalis is a structural deformity of the vocal ligament. It is the focal invagination of the epithelium deeply attaching to the vocal ligament. There is a dearth of literature on the outcome of voice therapy in sulcus vocalis condition. OBJECTIVE: The primary objective of this study was to document voice characteristics of sulcus vocalis and the secondary objective was to establish the efficacy of voice therapy in a patient with sulcus vocalis. METHOD: A trial of voice therapy was given to the client who was diagnosed as having sulcus vocalis. Boon's facilitation techniques were used in voice therapy along with other techniques such as breath holding and push and pull approach prior to surgery. Acoustic, aerodynamic, perceptual, quantitative measures of voice quality and self-rating measurements were performed before and after voice therapy. RESULTS: Improvement was noticed in 10/10 acoustic, 4/4 aerodynamic, perceptual, dysphonia severity index and voice handicap index scores, which hinted that voice therapy can be an option critically for clients with sulcus vocalis in the initial stage. CONCLUSION: Voice therapy showed promising improvement in the study and it must be recommended as the initial treatment option before any surgical management.

Estimation of vocal fold plane in 3D CT images for diagnosis of vocal fold abnormalities.

Vocal folds are the key body structures that are responsible for phonation and regulating air movement into and out of lungs. Various vocal fold disorders may seriously impact the quality of life. When diagnosing vocal fold disorders, CT of the neck is the commonly used imaging method. However, vocal folds do not align with the normal axial plane of a neck and the plane containing vocal cords and arytenoids does vary during phonation. It is therefore important to generate an algorithm for detecting the actual plane containing vocal folds. In this paper, we propose a method to automatically estimate the vocal fold plane using vertebral column and anterior commissure localization. Gray-level thresholding, connected component analysis, rule based segmentation and unsupervised k-means clustering were used in the proposed algorithm. The anterior commissure segmentation method achieved an accuracy of 85%, a good estimate of the expert assessment.

Anatomical study of minor alterations in neonate vocal folds.

INTRODUCTION: Minor structural alterations of the vocal fold cover are frequent causes of voice abnormalities. They may be difficult to diagnose, and are expressed in different manners. Cases of intracordal cysts, sulcus vocalis, mucosal bridge, and laryngeal micro-diaphragm form the group of minor structural alterations of the vocal fold cover investigated in the present study. The etiopathogenesis and epidemiology of these alterations are poorly known. OBJECTIVE: To evaluate the existence and anatomical characterization of minor structural alterations in the vocal folds of newborns. METHODS: 56 larynxes excised from neonates of both genders were studied. They were examined fresh, or defrosted after conservation via freezing, under a microscope at magnifications of 25× and 40×. The vocal folds were inspected and palpated by two examiners, with the aim of finding minor structural alterations similar to those described classically, and other undetermined minor structural alterations. Larynges presenting abnormalities were submitted to histological examination. RESULTS: Six cases of abnormalities were found in different larynges: one (1.79%) compatible with a sulcus vocalis and five (8.93%) compatible with a laryngeal micro-diaphragm. No cases of cysts or mucosal bridges were found. The observed abnormalities had characteristics similar to those described in other age groups. CONCLUSION: Abnormalities similar to sulcus vocalis or micro-diaphragm may be present at birth.

Anatomical study of minor alterations in neonate vocal folds / Estudo de alterações anatômicas menores em pregas vocais de neonatos

INTRODUCTION: Minor structural alterations of the vocal fold cover are frequent causes of voice abnormalities. They may be difficult to diagnose, and are expressed in different manners. Cases of intracordal cysts, sulcus vocalis, mucosal bridge, and laryngeal micro-diaphragm form the group of minor structural alterations of the vocal fold cover investigated in the present study. The etiopathogenesis and epidemiology of these alterations are poorly known. OBJECTIVE: To evaluate the existence and anatomical characterization of minor structural alterations in the vocal folds of newborns. METHODS: 56 larynxes excised from neonates of both genders were studied. They were examined fresh, or defrosted after conservation via freezing, under a microscope at magnifications of 25× and 40×. The vocal folds were inspected and palpated by two examiners, with the aim of finding minor structural alterations similar to those described classically, and other undetermined minor structural alterations. Larynges presenting abnormalities were submitted to histological examination. RESULTS: Six cases of abnormalities were found in different larynges: one (1.79%) compatible with a sulcus vocalis and five (8.93%) compatible with a laryngeal micro-diaphragm. No cases of cysts or mucosal bridges were found. The observed abnormalities had characteristics similar to those described in other age groups. CONCLUSION: Abnormalities similar to sulcus vocalis or micro-diaphragm may be present at birth. .

INTRODUÇÃO: As alterações estruturais mínimas (AEM) da cobertura das pregas vocais são causas frequentes de alterações vocais. Podem ser de diagnóstico difícil, e expressam-se de modo variável. O cisto intracordal, o sulco vocal, a ponte de mucosa e o microdiafragama laríngeo constituem o grupo das AEM da cobertura das pregas vocais pesquisadas neste estudo. Sua etiopatogenia e epidemiologia não são bem conhecidas. OBJETIVO: Avaliar a existência e a caracterização anatômica das AEM em prega vocal de neonatos. MÉTODOS: Foram estudadas 56 laringes excisadas de neonatos, de ambos os sexos. As laringes foram examinadas a fresco ou descongeladas após conservação por congelação, sob microscopia com aumento de 25 e 40×. As pregas vocais foram inspecionadas e palpadas por dois examinadores, com o intuito de encontrar AEM semelhantes às classicamente descritas e outras indeterminadas. As laringes com alterações foram submetidas a exame histológico. RESULTADOS: Foram encontradas seis alterações em laringes distintas: uma (1,79%) compatível com sulco vocal e cinco (8,93%) compatíveis com microdiafragma laríngeo. Não foram encontrados cistos e pontes de mucosa. As alterações presentes apresentavam características semelhantes às descritas em outras faixas etárias. CONCLUSÃO: Alterações semelhantes ao sulco vocal e ao microdiafragma laríngeo podem estar presentes ao nascimento. .

[Evaluation of the use of hyaluronic acid in iatrogenic scars after phonosurgery (excluding surgical oncology) and ligamento-epithelial abnormalities of the vocal cords]. / Evaluation de l'usage de l'acide hyaluronique dans les cicatrices iatrogènes après phonochirurgie (chirurgie oncologique exclue) et les anomalies ligamento-épithéliales des cordes vocales.

Between January of 2007 and December of 2011, six patients underwent revision microphonosurgery because of scarring complicating the initial surgery. The technique consisted of detaching the scarred area, the insertion of fibrils of hyaluronic acid (Merogel), a microsuture and possibly intra-cordal fat injection. A pre-and post-operative phoniatric protocol assessed the results which appear encouraging.

Sulcus vocalis: evidence for autosomal dominant inheritance.

We found evidence of autosomal dominant hereditary transmission of sulcus vocalis. Four dysphonic patients from three generations of the same family were submitted to videolaryngoscopic examination (three patients) and to direct laryngoscopy (one patient) to diagnose the hoarseness. Sulcus vocalis was diagnosed in all four patients. The finding of four affected individuals in three generations, with vertical transmission affecting man and women, is more consistent with autosomal dominant inheritance pattern; it is an etiological model that we propose for the sulcus vocalis in this pedigree.

Laryngeal and respiratory patterns in patients with paradoxical vocal fold motion.

The purposes of this study were to determine the differences in spirometric measures obtained from patients with endoscopically-documented paradoxical vocal fold motion (PVFM) and to compare them to a group of normal subjects without endoscopically-documented paradoxical vocal fold motion during non-provocative breathing and following speech. Thirty eight subjects with documented paradoxical vocal fold motion using transnasal flexible laryngoscopy (TFL) and no history of asthma and 21 normal subjects with documented normal breathing patterns and normal findings on endoscopy underwent flow-volume loop studies. Endoscopic judgments of vocal fold motion from three breathing conditions were made by two observers. The results of the endoscopic judgments indicate that paradoxical motion occurs whether breathing through the nose or mouth in the PVFM subjects, mainly after speaking and inhalation. In addition, the spirometry results indicated that the inspiratory measure of FIVC%, FVC% and FIV(0.5)/FIVC were significantly lower in the PVFM group compared to the normal subjects. The data supports the hypothesis that in patients with PVFM, inspiratory spirometric values play a role in identifying patients with PVFM. The finding of vocal fold closure following a speech utterance in the majority of the PVFM subjects but not in the normal control group warrants further investigation.

Histopathological characteristics of sulcus vocalis.

OBJECTIVE: To describe the frequency of sulcus vocalis in a population and to establish its histopathological properties. STUDY DESIGN: A cadaver study. SETTING: Istanbul Training and Research Hospital and Ministry of Justice National Forensic Institute. SUBJECTS AND METHODS: One hundred (21 women, 79 men) fresh cadaver larynges were examined. Two hundred vocal folds were coronally sectioned and examined by light microscopy. Sulcus types, depths, degree of fibrosis in Reinke space, basement membrane thickness, and perisulcus degeneration were determined. RESULTS: Sulcus vocalis was found in 39 of 100 cases (39%), with a male preponderance of 41.8% compared with women at 28.6%. Twenty-one (54%) cases had unilateral and 18 (46%) cases had bilateral sulcus. Among 200 vocal folds, 57 had sulcus (28%). A total of 21 sulcus cases were type 1 (37%), 18 were type 2 (31.5%), and the remaining 18 cases were type 3 (31.5%). Of the 39 (30.7%) sulcus cases, 12 were confirmed by histopathological examination, although they looked morphologically normal following macroscopic evaluation. Vocal ligament involvement was found in 14 cases with type 2 (78%) and in 15 cases with type 3 sulcus (83%). CONCLUSION: Sulcus vocalis is a common pathology in the population and can be observed at all ages. The accuracy of diagnosis seems to depend on the measurement of the sulcus depth and the histological characteristics. For this reason, tools and strategies should be established in living subjects for effective management of this challenging disorder.