Value and utility of 532 nanometre pulsed potassium-titanyl-phosphate laser in endoscopic laryngeal surgery.

OBJECTIVES: Recently, the 532 nm pulsed potassium-titanyl-phosphate laser has emerged as an effective angiolytic laser for treating mucosal lesions of the larynx in the operating theatre and clinic. We sought to assess the current impact of potassium-titanyl-phosphate laser on our laryngeal surgery practice. STUDY DESIGN: Retrospective review of 710 patients undergoing endoscopic laryngeal surgery over a one-year period. METHODS: Medical records of the endoscopic laryngeal procedures were reviewed; 386/710 had been performed in the clinic and 324/710 in the operating theatre under general anaesthesia. Indications for the procedures were classified by pathology. RESULTS: Pulsed potassium-titanyl-phosphate laser was used in 209/386 clinic procedures. The indications for these procedures were: dysplasia (114/209 procedures), papillomatosis (89/209), varices or ectasia (three of 209), and 'other' (three of 209). Pulsed potassium-titanyl-phosphate laser was used in 178/324 operating theatre endoscopic laryngeal procedures. The indications for these procedures were: cancer (54/178 procedures), dysplasia (52/178), papillomatosis (38/178), varices or ectasia (13/178), polyps (six of 178), nodules (six of 178), stenosis (five of 178), granulation (three of 178), and amyloid (one of 178). CONCLUSIONS: Due to its versatility, the 532 nm pulsed potassium-titanyl-phosphate laser is our most commonly utilised instrument for performing endoscopic laryngeal surgery.

Essential versus complex autism: definition of fundamental prognostic subtypes.

Heterogeneity within the autism diagnosis obscures the genetic basis of the disorder and impedes our ability to develop effective treatments. We found that by using two readily available tests, autism can be divided into two subgroups, "essential autism" and "complex autism," with different outcomes and recurrence risks. Complex autism consists of individuals in whom there is evidence of some abnormality of early morphogenesis, manifested by either significant dysmorphology or microcephaly. The remainder have "essential autism." From 1995 to 2001, 260 individuals who met DSM-IV criteria for autistic disorder were examined. Five percent (13/260) were microcephalic and 16% (41/260) had significant physical anomalies. Individually, each trait predicted a poorer outcome. Together they define the "complex autism" subgroup, comprising 20% (46/233) of the total autism population. Individuals with complex autism have lower IQs (P=0.006), more seizures (P=0.0008), more abnormal EEGs (46% vs. 30%), more brain abnormalities by MRI (28% vs. 13%). Everyone with an identifiable syndrome was in the complex group. Essential autism defines the more heritable group with higher sib recurrence (4% vs. 0%), more relatives with autism (20% vs. 9%), and higher male to female ratio (6.5:1 vs. 3.2:1). Their outcome was better with higher IQs (P=0.02) and fewer seizures (P=0.0008). They were more apt to develop autism with a regressive onset (43% vs. 23%, P=0.02). Analysis of the features predictive of poor outcome (IQ<55, functionally non-verbal) showed that microcephaly was 100% specific but only 14% sensitive; the presence of physical anomalies was 86% specific and 34% sensitive. The two tests combined yielded 87% specificity, 47% sensitivity, and an odds ratio of 4.8:1 for poor outcome. Separating essential from complex autism should be the first diagnostic step for children with autism spectrum disorders as it allows better prognostication and counseling. Definition of more homogeneous populations should increase power of research analyses.

Efficacy of a behaviorally based voice therapy protocol for vocal nodules.

The aim of this study was to assess the effects on vocal function of voice therapy for vocal nodules. Perceptual and physiological progressive changes were examined during a strictly structured, behaviorally based voice therapy protocol in which 11 women with vocal nodules participated. Randomized audio recordings from pretherapy and from each of the therapy approaches (vocal hygiene, respiration, direct facilitation, carryover) were used for perceptual evaluations. Six speech-language pathologists rated ten voice quality parameters. Two evaluation procedures were performed and compared. Interlistener reliability was sufficiently high in both tests. Significant effects of therapy were found for decreased overall dysphonia, press, instability, gratings, roughness, vocal fry, and "scrape." Nonsignificant group effects were found for breathiness, aphonic instances, and lack of sonority. No significant parameter changes occurred between baseline assessment and the completion of the initial (vocal hygiene) phase of therapy. Significant changes were found following the direct facilitation and respiration phases of therapy. Videostroboscopic evaluations made by two laryngologists showed that in no case were the nodules completely resolved. However, the nodules had decreased in size and edema was reduced after therapy for all clients, but one. Combined results suggest: (1) Alterations in vocal function were reflected in perceptual parameters, and (2) the voice therapy had a positive effect on voice quality, vocal status, and vocal function for the majority of the vocal nodule clients.

Carrier detection and rapid newborn diagnostic test for the common Y393N maple syrup urine disease allele by PCR-RFLP: culturally permissible testing in the Mennonite community.

The turnaround time for diagnosis of maple syrup urine disease (MSUD) by classic serum amino acid analyses often requires 3-4 days. This is due to the need for branched-chain amino acids (BCAA) to accumulate in the serum of the newborn before testing. The accumulation of BCAAs in infants with MSUD during this time increases the risk of the infant becoming clinically symptomatic. We have developed a noninvasive DNA-based mismatch PCR-RFLP assay for the Y393N BCKDHA allele (E1alpha gene of the branched chain alpha-keto acid dehydrogenase complex), the primary cause of MSUD in Old Order Mennonite communities. The homozygosity and high frequency of this mutation in the Mennonite community and its prevalence in compound heterozygote non-Mennonite MSUD patients is of significance. We describe carrier testing, present the results of nine newborns diagnostically evaluated for the Y393N BCKDHA allele, and demonstrate the efficacy of this PCR-RFLP assay for determining clinical status within 24 h after birth. Analyses within the first 24 h of life allow for immediate diagnosis and treatment of infants homozygous for the Y393N MSUD defect. This is a significant improvement over the time required by current serum amino acid analysis methods.

Stroboscopic assessment of vocal fold keratosis and glottic cancer.

Disruption of the normal viscoelastic properties of the superficial lamina propria (SLP) results in aberrant vocal fold vibration and mucosal wave propagation. Therefore, an investigation was performed to determine whether stroboscopy is a reliable method for 1) differentiating invasive glottic carcinoma from intraepithelial atypia or 2) determining the depth of cancer invasion. An analysis was done on the preoperative vocal fold vibration characteristics of 62 keratotic (intraepithelial, 45; cancer, 17) lesions that were subsequently resected by means of microlaryngoscopy. Histopathology and intraoperative mapping were used to specify the depth of invasion. A panel of 4 blinded judges was used to assess the amplitude of vocal fold vibration and the magnitude of mucosal wave activity in the region of the lesion from videostroboscopic recordings. The final comparative data set comprised only those ratings that achieved at least 75% interjudge agreement. Of the 28 intraepithelial lesions that could be reliably evaluated for amplitude of vocal fold vibration, only 2 were normal, with the amplitude reduced in 24 and absent in 2. Of the 30 intraepithelial lesions in which mucosal wave activity could be reliably assessed, only 2 were normal, with the wave reduced in 24 and absent in 4. Furthermore, amplitude of vocal fold vibration and magnitude of mucosal wave propagation were absent in 2 of 4 carcinomas in which the depth of microinvasion did not reach the vocal ligament. According to the findings herein, reduced amplitude of vocal fold vibration and/or mucosal wave propagation associated with keratosis did not reliably predict the presence of cancer or the depth of cancer invasion into the laminae propriae. However, the presence of a flexible mucosal wave probably indicates that there is not extensive vocal ligament invasion. Reductions in the amplitude of vocal fold vibration and in mucosal wave magnitude were usually noted in intraepithelial atypia, despite the fact that there was no invasion into the SLP. The reduced epithelial pliability could be due to bulky keratosis and/or alteration of the SLP occurring as a result of inflammation or fibrovascular scarring.

Recurrent laryngeal nerve transposition in guinea pigs.

Improved control of prosthetic voice aids for laryngectomees might be possible to obtain with residual laryngeal motor nerve signals. We were able to recover motor signals from the recurrent laryngeal nerve (RLN) by transposing it into the ipsilateral denervated sternohyoid muscle (SH) in 8 guinea pigs. Reinnervation was monitored by electromyographic recordings from surface and intramuscular needle electrodes in awake animals. Within 4 to 14 weeks after surgery, all animals demonstrated laryngeal-like motor activity in the reinnervated SH, including activity during respiration, sniffing, swallowing, and/or vocalizing. After 3 to 6 months, the animals were reanesthetized, and nerve stimulation and section experiments confirmed the RLN as the source of reinnervation in all cases. In several animals, activity of the RLN-innervated SH was demonstrated to be correlated with that of contralateral laryngeal muscles. Histochemical analysis of the SH indicated a unilateral transformation from mostly fatigable to mostly fatigue-resistant fiber types ipsilateral to the RLN transposition, a phenotype more typical of laryngeal muscles. Thus, RLN transposition at the time of laryngectomy may be a method for salvaging laryngeal control signals that could be used to control prosthetic voice devices.

Prevalence of autism in Missouri: changing trends and the effect of a comprehensive state autism project.

To assess change in autism prevalence in Missouri from 1988 until 1995, computerized client registries from the Regional Diagnostic Centers were analyzed. In the five to nine year age group, the prevalence rose thirty fold from 0.15 to 4.8 per 10,000. The study period coincides with the establishment of the Missouri Autism Project suggesting that provision of services will increase the apparent prevalence figures and that autistic disorders were previously underdiagnosed in Missouri.

Value of a clinical morphology examination in autism.

In an effort to delineate more homogeneous autism subgroups for genetic study, we evaluated 133 consecutive individuals referred to the University of Missouri Autism Center. Each index case underwent a diagnostic evaluation, including a clinical morphology examination, laboratory studies, brain MRI, EEG, and collection of historical, medical, and family data. The 71% (94/133) who fulfilled DSM-IV and CARS autism diagnostic criteria were included in this study. Six of 94 were diagnosed with a known genetic disorder. Of the remaining 88 with apparently "idiopathic autism," 58% (51/88) were phenotypically normal, 22% (19/88) were clearly abnormal, and for 20% (18/88) the clinical morphology examination was equivocal. The percentage of phenotypically abnormal individuals is higher than generally thought and disagrees with the perception that children with autism are usually normally formed. The phenotypically abnormal individuals were 10 times more likely to be diagnosed with a known genetic syndrome (21% vs. 2%) and were more than twice as likely (29% vs. 14%) to have structurally abnormal brain MRIs than the phenotypically normal propositi. Moreover, the male to female ratio correlated with the presence of physical anomalies. The total study group had a male to female ratio of 4.2:1; the morphologically normal subgroup, defined on the basis of a normal physical examination, had a sex ratio of 7.5:1 and the normal subgroup, defined on the basis of both a normal physical examination and a structurally normal brain by MRI had a 23:1 sex ratio. For the phenotypically abnormal subgroup, the sex ratio was 1.7:1. Since differences in sex ratio are presumably a reflection of differences in genetic constitution, we postulate that the phenotypically normal subgroup of individuals with "idiopathic autism" is genetically different from the phenotypically abnormal individuals and that differences in the sex ratio in different autism populations is one indicator of a population's genetic heterogeneity.

Montgomery Thyroplasty Implant for vocal fold immobility: phonatory outcomes.

Forty-three patients with a diagnosis of unilateral vocal fold immobility underwent thyroplasty type I with the Montgomery Thyroplasty Implant System. Preoperative and postoperative evaluations were completed by means of videostroboscopic, acoustic, and aerodynamic measures. Clinicians' perceptions of vocal quality and patients' satisfaction with the surgery and vocal quality were determined. Improvements after surgery were observed for glottal closure, vocal fold amplitude, mucosal wave activity, average intensity, maximum intensity range, maximum phonation time, glottal airflow, average sound pressure, and subglottal pressure. Average postsurgical fundamental frequency values fell within normal limits and did not display significant changes relative to presurgical values. The clinicians' perceptual evaluations indicated an improvement in voice quality for most patients. A majority of patients expressed satisfaction with the surgery and resulting voice quality. The results of the present study, in combination with the surgical advantages that have been described for the Montgomery Thyroplasty Implant System, support the view that this approach offers an attractive alternative for treating unilateral vocal fold immobility.

Head circumference is an independent clinical finding associated with autism.

Occipitofrontal circumference (OFC) is one of the few physical findings in autism that varies significantly from the norm and is distinct and measurable. As part of a study of genetic heterogeneity of autism, we scrutinized data from a large sample of patients with idiopathic autism (N = 137), using OFC as the categorizing variable. The OFC standard deviation (OFCSD) values of the autistic propositi (0.61+/-1.6) varied significantly from that of the normal population (0.0+/-1.0), (P<0.001). Comparison of the macrocephalic (OFCSD > 2.0, N = 32) with the normocephalic individuals (-2 SD < OFCSD < +2 SD, N = 95) showed no significant differences in sex ratio, morphological status, IQ, seizure prevalence, or recurrence risks. The macrocephalic individuals were slightly less apt than those with normocephaly to have a family history of Attention Deficit Hyperactivity Disorder (ADHD) (P<0.05). Each clinical subgroup of autism propositi, defined on the basis of phenotypic status, type of onset, seizure history, or IQ, had a higher than normal mean OFC indicating that macrocephaly is an independent clinical trait in autism. As in the non-autistic population, macrocephaly was highly familial with 45% of the macrocephalic and 37% of the normocephalic propositi having at least one macrocephalic parent. Microcephaly, however, was an independent significant variable that predicted the presence of other phenotypic or genetic traits and outcome. The microcephalic patients were more likely to have abnormal physical morphology, structural brain malformations, lower IQ, and seizures. Their sex ratio was closer to normal, and their relatives had a higher incidence of seizures.

Cricothyroid subluxation: a new innovation for enhancing the voice with laryngoplastic phonosurgery.

Laryngoplastic phonosurgery has evolved to become a dominant treatment modality for paralytic dysphonia. Current surgical procedures have addressed primarily the position of the musculomembranous vocal fold and the arytenoid in the axial and vertical planes. However. dynamic range capabilities and vocal flexibility have been limited secondary to the flaccid, denervated vocal fold tissue. Therefore. a new procedure was conceived to enhance the acoustic vocal outcome from operations that reposition the vocal edge. Cricothyroid (CT) subluxation was designed as a technique to increase the distance between the cricoarytenoid joint and the insertion of the anterior commissure ligament. Cricothyroid subluxation was done without complication in 9 patients who underwent combined adduction arytenopexy and medialization laryngoplasty, and in 4 patients with medialization laryngoplasty alone. Postoperative stroboscopic assessment was done in all of the 13 patients, while complete analysis of vocal function was available in 10 of the 13 patients; this revealed improvement (as a group) on almost all objective measures over the preoperative state. All patients who underwent CT subluxation had a normal maximum frequency range (pitch variation of more than 2 octaves), as compared with 22% of a prior similar cohort of patients who did not undergo CT subluxation. All patients who underwent CT subluxation had normal glottal airflow and a normal noise-to-harmonics ratio. Cricothyroid subluxation is a relatively easily adjustable procedure that increases the length and viscoelastic tension of the denervated vocal fold. The modified biomechanical properties resulted in improved vocal outcome in all of our patients, which was most remarkable in terms of maximal range capabilities. Cricothyroid subluxation enhanced the postoperative voice of patients regardless of whether they required medialization laryngoplasty alone or whether they also required adduction arytenopexy.

Electroglottography in the pediatric population.

OBJECTIVE: To establish normative electroglottography (EGG) data in the pediatric population. DESIGN: Clinical study with EGG data gathered on children with normal voices. SETTING: Major children's hospital and specialty eye and ear hospital. PATIENTS: A total of 164 children, 79 girls and 85 boys, aged 3 to 16 years. METHODS: Children with normal voices, determined through subjective evaluation and a voice use history questionnaire, underwent EGG recording. The EGG data were analyzed with commercially available software for fundamental frequency, jitter, open quotient, closing quotient, and opening quotient. RESULTS: Normative EGG data were established for children aged 3 to 16 years. Jitter, open quotient, closing quotient, and opening quotient were all found to have no significant dependence on age. CONCLUSIONS: Children as young as 3 years can easily tolerate EGG, making it possible to establish this initial set of normative pediatric EGG data. These preliminary results suggest that EGG may have potential to assist clinicians with noninvasive documentation of vocal function in the pediatric population. This maybe particularly important for tracking treatment-related changes in the vocal function of children who are difficult to examine endoscopically.

Ectasias and varices of the vocal fold: clearing the striking zone.

Vascular malformations such as ectasias and varices (Es and Vs) are frequently encountered in patients who present with recurrent vocal fold hemorrhage and/or other traumatic vocal fold lesions. This study examined Es and Vs with regard to their anatomic presentation, phonomicrosurgical management, and treatment outcome. Forty-two patients (39 of them singers) were treated for a total of 87 Es and Vs: 67 of 87 (77%) were on the superior surface of the vocal fold and 20 of 87 (23%) were on the medial surface of the vocal fold. Eighty-three percent were located in the middle musculomembranous region (the striking zone), where the greatest aerodynamically induced shearing stresses occur during phonation. Treatment was performed with carbon dioxide laser cauterization (13 patients), or a new technique utilizing cold instrument excision by means of epithelial cordotomies (23 patients), while a combined approach was employed in 6 patients. Comparisons of preoperative and postoperative stroboscopy revealed improvement or no significant change in all patients in whom the cold instrument technique was used, and increased epithelial stiffness was noted in 4 of 19 patients in whom the carbon dioxide laser was used. Clearing the striking zone appears to have halted further hemorrhages by removing the the fragile Es and Vs from this injury-prone region of the vocal fold. Interpretations of stroboscopic examinations were directed at providing new insights into the biomechanical forces of vocal fold vibration that probably contribute to the genesis of Es and Vs in the vocal folds.

Adduction arytenopexy: a new procedure for paralytic dysphonia with implications for implant medialization.

Arytenoid adduction was designed to enhance posterior glottal closure in patients with paralytic dysphonia by reproducing lateral cricoarytenoid muscle function. However this procedure can exaggerate normal medial rotation of the vocal process, because the agonist-antagonist function of the interarytenoid, lateral thyroarytenoid, and posterior cricoarytenoid muscles is not simulated. Therefore, a new adduction procedure (adduction arytenopexy) was devised to affix the arytenoid on the cricoid facet in a more optimal position for glottal sound production. The adduction arytenopexy procedure was designed on fresh cadavers. In this technique, the lateral aspect of the cricoarytenoid joint is opened widely and the body of the arytenoid is manually medialized along the cricoid facet. A specially designed single suture is then placed through the posterior cricoid and the body or the muscular process of the arytenoid to achieve 2-point fixation. This draws the arytenoid posteriorly, superiorly, and medially for precise positioning. The arytenoid is rocked internally on the cricoid facet, and suture tension is adjusted appropriately to simulate normal cricoarytenoid adduction. In the first study, the adduction arytenopexy was compared with the classic arytenoid adduction in 10 fresh cadaver larynges. The new arytenopexy procedure resulted in an average increase of 2.1 mm (p < .01) in the length of the musculomembranous vocal fold, whereas the classic arytenoid adduction did not reveal a significant change in length. Additionally, the adduction arytenopexy resulted in a consistently higher vocal fold and a more normally contoured arytenoid than the classic adduction procedure. The second study consisted of a clinical trial in which 12 patients, who presented with a widely patent posterior glottis, underwent adduction arytenopexy in conjunction with implant medialization. The procedure was successful in all patients, and there were minimal complications. In the third study, preoperative and postoperative vocal assessment measures (stroboscopic, aerodynamic, acoustic, and perceptual) were analyzed in 9 of the 12 patients. The most striking preoperative stroboscopic observation was that 8 of the 9 patients presented with an aperiodic vibrational flutter during phonation due to severe valvular incompetence. Postoperatively, all patients developed complete closure of the glottal chink and effective entrained oscillation of the vocal folds. This visual improvement in function was commensurate with comparable changes in most of the other objective and subjective measures of vocal function. The new adduction arytenopexy procedure closely simulates the biomechanics underlying normal glottal closure and cricoarytenoid adduction. In turn, complex implant design shapes are not necessary to achieve proper alignment of the arytenoid and the vocal fold. Because the arytenoid is properly positioned prior to the medialization, implants can be sized more precisely and are unencumbered by an anterior thyroid lamina suture. These procedural innovations resulted in enhanced entrained oscillation of the glottal valve and, in turn, improved laryngeal sound production.

Assessment of vocal function using simultaneous aerodynamic and calibrated videostroboscopic measures.

Despite many attempts to model how vocal fold movements relate to the aerodynamic forces acting on them during phonation, there have been few simultaneous measurements of glottal area and transglottal air pressures and flows. A novel system is described that combines endoscopic measurement of glottal area with aerodynamic flow and pressure measures made during phonation. Results from bench top model tests and from one human subject are presented. For both tests, an aerodynamic model of airflow through a constriction was used to predict the area of the constriction (glottis), and these predictions were compared with endoscopic measurements. The results showed good correlation between predicted and observed areas; however, for small constrictions (<0.025 cm2), whether artificial or glottal, the errors in estimating areas with either optical or aerodynamic methods increase significantly. These results suggest that this measurement system has the potential to enhance the assessment of vocal function.

Functional outcomes following treatment for advanced laryngeal cancer. Part I--Voice preservation in advanced laryngeal cancer. Part II--Laryngectomy rehabilitation: the state of the art in the VA System. Research Speech-Language Pathologists. Department of Veterans Affairs Laryngeal Cancer Study Group.

This two-part investigation assessed functional outcomes related to communication (including amount of speech therapy), swallowing and eating, and employment status for patients who received one of the two treatment modalities for advanced laryngeal cancer (stage III or IV laryngeal squamous cell carcinoma) in Veterans Administration Cooperative Study #268. One hundred sixty-six patients were randomized to primary surgery (laryngectomy) and radiotherapy (RT), and 166 to induction chemotherapy (CT) and RT. The first investigation dealt with examining and comparing functional outcomes for patients in the two treatment arms of the main study. Results showed clearly that patients with advanced laryngeal cancer are better off from the standpoint of speech communication if they can be treated for this disease without removal of the larynx. In contrast, there were few significant differences between patient groups for other non-speech-related measures. The second investigation focused on communication-related outcomes associated with the rehabilitation of total laryngectomy patients. Results revealed that only relatively small percentages of total laryngectomy patients (6%) developed usable esophageal speech or remained nonvocal (8%), and that a majority of patients ended up as users of artificial electrolarynx (55%) or tracheoesophageal (31%) speech. The results from both investigations are discussed with respect to factors that can influence the rehabilitation process and long-term outcome status of patients who are treated for advanced laryngeal cancer with these two strategies.

Temporal and spectral estimations of harmonics-to-noise ratio in human voice signals.

The quantity, harmonic-to-noise ratio (HNR), has been used to estimate the level of noise in human voice signals. HNR estimation can be accomplished in two ways: (1) on a time-domain basis, in which HNR is computed directly from the acoustic waveform; and (2) on a frequency-domain basis, in which HNR is computed from a transformed representation of the waveform. An algorithm for computing HNR in the frequency domain was modified and tested in the work described here. The modifications were designed to reduce the influence of spectral leakage in the computation of harmonic energy, and to remove the necessity of spectral baseline shifting prescribed in one existing algorithm [G. de Krom, J. Speech Hear. Res. 36, 254-266 (1993)]. Frequency-domain estimations of HNR based on this existing algorithm and our modified algorithm were compared to time-domain estimations on synthetic signals and human pathological voice samples. Results indicated a highly significant, linear correlation between frequency- and time-domain estimations of HNR for our modified approach.

Reinke's edema: phonatory mechanisms and management strategies.

Reinke's edema (RE) has been associated typically with smoking and sometimes with vocal abuse, but aspects of the pathophysiology of RE remain unclear. To gain new insights into phonatory mechanisms associated with RE pathophysiology, we used an integrated battery of objective vocal function tests to analyze 20 patients (19 women) who underwent phonomicrosurgical resection. Preoperative stroboscopic examinations demonstrated that the superficial lamina propria is distended primarily on the superior vocal fold surface. Acoustically, these individuals have an abnormally low average speaking fundamental frequency (123 Hz), and they generate abnormally high average subglottal pressures (9.7 cm H2O). The presence of elevated aerodynamic driving pressures reflects difficulties in producing vocal fold vibration that are most likely the result of mass loading associated with RE, and possibly vocal hyperfunction. Furthermore, it is hypothesized that in the environment of chronic glottal mucositis secondary to smoking and reflux, the cephalad force on the vocal folds by the subglottal driving pressure contributes to the superior distention of the superficial lamina propria. Surgical reduction of the volume of the superficial lamina propria resulted in a significant elevation in fundamental frequency (154 Hz) and improvement in perturbation measures. In almost all instances, both the clinician and the patient perceived the voice as improved. However, these patients continued to generate elevated subglottal pressure (probably a sign of persistent hyperfunction) that was accompanied by visually observed supraglottal strain despite the normal-sized vocal folds. This finding suggests that persistent hyperfunctional vocal behaviors may contribute to postsurgical RE recurrence if therapeutic strategies are not instituted to modify such behavior.