The effects of irradiation on alaryngeal voice of totally laryngectomized patients.

The effects of radiation therapy on the ability of totally laryngectomized patients to produce voice and speech were examined using objective non-invasive methods. Moderate to severe losses were noted in patients producing voice with all types of alaryngeal modalities: tracheoesophageal, esophageal, and electrolaryngeal. Voice and speech losses were related to the impaired motility and vibratory capability of the esophageal wall and mucosa, to fibrosis of the submandibular region and to trismus. Tracheoesophageal and esophageal voice was recovered some weeks after completion of irradiation. No voice losses were observed in alaryngeal speakers who did not undergo voice restoration until after irradiation. All irradiated patients also showed various degrees of dysphagia during the treatment.

Pain-induced vocalization in the rat and its modification by pharmacological agents.

Vocalization was induced in rats by electrical stimulation of the tail (pain-induced vocalization), and its components were characterized in terms of latency, duration, frequency spectrum and energy. Noxious stimuli at threshold elicit a single vocalization component (V1). Increases in stimulus intensity produce additional discrete vocalization components (V2-Vn) with successively longer latencies, termed the vocalization afterdischarge (AD). The AD components are acoustically similar to each other but differ significantly from the V1 component. The duration, the specific acoustic measures and the sound energy of both V1 and AD components are positively correlated with intensity of the stimulus. The dependence of the V1 and AD components on the affective state of the rat was evaluated by comparing the acoustic characteristics of both components to those of stress-induced vocalizations, and by studying the effects of the anxiolytic drug diazepam and physical restraint on the threshold of V1 and AD. The AD components were markedly more dependent on the affective state of the rat then was the V1 component. A moderately low dose of morphine (3.0 mg/kg) also preferentially affected the AD component, suggesting that a significant portion of the action of morphine on pain-induced vocalization is mediated through its action on the affective state of the rat.

Voice quality following laryngeal reinnervation by ansa hypoglossi transfer.

Recurrent laryngeal nerve injury resulting in chronic unilateral vocal fold paralysis has been treated traditionally by implantation of various materials into the paralyzed vocal fold. Although the usage of these techniques, especially Teflon-glycerin paste injection, has been clinically established, they do not restore full functionality to the larynx (abduction, adduction, and vibratory synchronization of the vocal folds). Restoration of these functions, necessary for improved phonation, has been achieved at least on an experimental basis by reinnervation techniques previously described. This study demonstrates excellent human voice quality following reinnervation of the vocal folds in two cases using ansa hypoglossi-recurrent laryngeal nerve anastomosis. Although the reinnervated vocal fold neither abducted nor adducted, it presented itself in the midline for precise apposition with the nonparalyzed cord. Voice data were analyzed within a single subject experimental design at the following intervals; preoperatively, immediately postoperatively, midterm, and long-term (3 and 6 years). The data was analyzed by subjective and objective means, including acoustics and electroglottography. Patient selection, surgical techniques, results, and implications are reviewed.

Intermediate results of 306 recurrent laryngeal nerve sections for spastic dysphonia.

Recurrent laryngeal nerve section for spastic dysphonia was first performed in 1975 because prior forms of treatment had failed. Virtually every patient has had a detailed postoperative follow-up which includes a tape recording and a self-assessment questionnaire. The majority of patients remain free of spasticity at this medium-term follow-up. In some, spasticity recurred with less than preoperative severity. A small percentage of patients have a persistent breathy phonation. The first group is treated with vocal fold lateralization procedure using the CO2 laser; the second, with Teflon. When needed, voice therapy is also given. This paper provides a basis for diagnosis, indications for surgery, primary and secondary surgical techniques, encountered problems, and medium-term follow-up results.

Problems with surgical (RLN section) treatment of spastic dysphonia.

For over a century spastic dysphonia--a disorder of phonation--remained enigmatic and highly resistant to treatment. Recurrent laryngeal nerve surgery provides patients with elimination of their spastic dysphonia symptoms. Maintenance of long-term surgical results has been a problem in some cases. Management of this problem and of problems in the diagnosis and treatment of patients with spastic dysphonia are discussed. The observations and conclusions are based on almost 300 patients examined and/or treated for this disorder.

Fungal colonization of tracheoesophageal voice prosthesis.

Laryngectomized patients fitted with tracheoesophageal (TE) puncture voice prosthesis may experience frequent failures in adequate production of neophonation. In some cases, these phonatory problems result from obstruction of the voice prosthesis with various deposits. The nature of these deposits was studied with mycologic techniques and by light and scanning electron microscopy. Candida albicans and other fungal species were identified.

Nerve transfer versus Teflon injection for vocal cord paralysis: a comparison.

Teflon injection for unilateral vocal cord paralysis frequently produces an improved yet breathy voice. Ansa hypoglossi-recurrent laryngeal nerve anastomosis has been performed in five patients. In the four patients discussed in this paper, excellent phonatory quality has been achieved. Electroacoustic analysis indicates that this technique may produce normal phonatory function in paralyzed larynges. There have been no serious side effects or complications in our first five patients. Denervation of the sternothyroid muscle, which results from sectioning its nerve in preparation for suture to the RLN, appears to further improve the voice by medially positioning the vocal cord. Gelfoam paste is injected at the time of nerve transfer to rehabilitate the voice during the 2 months required for nerve regeneration. For younger patients, or those with professional use of their voices, this technique offers superior speech results when compared with Teflon injection.

Ventricular dysphonia: a profile of 40 cases.

Ventricular dysphonia is a poorly understood disorder involving ventricular fold participation during phonation. A population of ventricular dysphonia patients was evaluated using phonatory function studies such as laryngovideostroboscopy, advanced acoustic analysis, and electroglottography to identify shared epidemiologic characteristics and to discuss possible neuromuscular mechanisms and causes. Forty patients with ventricular dysphonia were studied and epidemiologic, acoustic, and histologic data were analyzed. In almost all cases, the authors found abnormalities affecting the glottis caused by a related medical condition. The abnormalities included true vocal cord (TVC) aperiodicity in 100% of the patients, TVC asymmetry in 65%, a laryngeal mass or foreign body (usually Teflon) in 35%, TVC erythema or edema in 32.5%, and TVC bowing in 22.5%. Ventricular dysphonia seems to be primarily a compensatory mechanism for glottic dysfunction. Therapy is based on identifying and correcting the underlying abnormalities. Laryngovideostroboscopy is a particularly important tool in examining chronic dysphonia.

Problems with tracheoesophageal fistula voice restoration in totally laryngectomized patients. A review of 95 cases.

OBJECTIVES: Tracheoesophageal fistula (TEF) construction, performed during or after total laryngectomy, is used for voice and speech restoration but has been associated with mild to severe complications. Our goal was to study the successes and complications in the application of this technique to restore voice function after laryngectomy in 95 consecutive patients. RESEARCH DESIGN: Retrospective cohort study with a mean follow-up time of 3.5 years. SETTING: Five medical facilities in northern California: the Veterans Affairs Medical Centers in San Francisco and Martinez, the Kaiser Permanente Medical Center in Oakland, and private practice offices in San Francisco and Pinole. PATIENTS: Ninety-five patients (90 men and five women) who had undergone total laryngectomy with subsequent or primary TEF construction. Patients' ages ranged from 35 to 80 years. INTERVENTIONS: Three- or two-layer closure was used, depending on whether TEF construction was done as a secondary or a primary procedure. Most patients underwent radiation therapy, and most used surface or intraoral electrolarynx devices before TEF construction. Insufflation tests were performed by clinicians, or self-insufflation tests were performed by the patient. Patients' voices were recorded and analyzed. In many cases, respiratory and pulmonary function studies were performed before and after total laryngectomy or TEF. Blom-Singer and Groningen voice prostheses were used. MAIN OUTCOME MEASURES: Voice restoration was considered successful when the patient was able to communicate effectively via the TEF. RESULTS: Approximately 92% of patients who underwent TEF construction and had voice prostheses placed were considered to be successfully rehabilitated. Complications ranged from mild to severe and included problems with predictive values obtained during insufflation, fistula retention, TEF angulation shifts, fungal colonization of the prosthesis, valve retention problems, difficulty with digital occlusion, pressure necrosis, postradiation necrosis, dysphagia, phonatory gagging, emesis, gastric distention, pouching, stenosis, infection, hypertrophy, shunt insufficiency, persistent spasm, myotomy, inadvertent fistula closure, and aspiration of the prosthesis. CONCLUSIONS: Acoustic measures indicate that speech produced with the TEF compares better with normal laryngeal speech than does esophageal or electronic speech. Thus, TEF should remain the preferred procedure to rehabilitate patients undergoing total laryngectomy.

Practical techniques of office voice recording.

Advances in restoration and preservation of voice necessitate adequate documentation of changes in patients' voices. Magnetic sound recording currently offers the best means for such documentation, and it can be performed in an office setting. An outline of equipment needs and recording protocols is given.

Postoperative and follow-up studies of spastic dysphonia patients treated by recurrent laryngeal nerve section.

Long-term results of surgical treatment of spastic dysphonia by RLN section are evaluated by means of perceptual psychophysical scaling and by the patients themselves. It is found that a significant reduction in spastic dysphonia symptoms occurs as a result of surgery, and that these results are maintained after long-term follow-up in the majority of patients. These experimental observations are in agreement with the subjective assessment of postsurgical communication by the patients involved in the study.

Evaluation and treatment of recurrent spasticity after recurrent laryngeal nerve section. A preliminary report.

Of 365 spastic dysphonia patients treated by recurrent laryngeal nerve (RLN) section to date, 44 (12%) have experienced recurrence of the spastic dysphonia. Most of these 44 patients had moderately severe to very severe spastic dysphonia before the RLN section was performed. We believe, therefore, that preoperative severity is an important predictor of the likelihood of recurrence. Twenty-eight patients with recurrent spastic dysphonia following RLN section were further treated by one or more carbon dioxide laser thinnings of the paralyzed vocal fold. Following this procedure, 23 patients (50%) achieved eradication of spasticity, while a mild degree of spasticity remained in 17 (39%). These findings lead us to conclude that even though spastic dysphonia may recur following RLN section, a viable secondary surgical procedure is available.

Recurrent laryngeal nerve histopathology in spastic dysphonia: a preliminary study.

Spastic dysphonia is a severe voice disorder ordinarily described as psychogenic. Organic-neurologic changes secondary to central or peripheral nervous system involvement have also been postulated and led recently to the surgical treatment of spastic dysphonia by unilateral section of the recurrent laryngeal nerve (RLN). This study reports the histologic findings from these resections of the RLN from patients with an average 9.5 years duration of spastic dysphonia. Thirty percent of the RLNs examined demonstrated significant abnormalities as compared to age-matched controls. Although no reactive changes were noted by light microscopy, groups of fibers which did not stain for myelin or axons were found in RLNs from patients with spastic dysphonia. A preliminary ultrastructural study of these areas in one RLN revealed sheets of unmyelinated axons. These findings suggest an organic basis for spastic dysphonia at least in some patients.

Overpressure and breathiness in spastic dysphonia. An acoustic (LTAS) and perceptual study.

Pre- and postsurgical speech segments spoken by patients with spastic dysphonia were submitted to long-time-average-spectrum (LTAS) analysis and for perceptual assessment of breathiness and overpressure. Breathy phonation corresponded to a steep fall in the LTAS, while overpressured phonation produced higher spectral levels and a less steep fall. Mixed breathy-overpressured phonation produced a somewhat elevated spectrum. Post-surgical changes in overpressure are demonstrated by spectral shifts. Perceptual scores correlated well with the objective acoustic spectral measures.

The recurrent laryngeal nerve in spastic dysphonia. A light and electron microscopic study.

Sections of right or left recurrent laryngeal nerve (RLN), removed from patients with spastic dysphonia (SD) at the time of surgery, were studied using light and electron microscopy and were compared with control RLNs. In both groups, small, medium and large-sized myelinated nerve fibres were found in the RLN. Furthermore, numerous unmyelinated axons intermingled with the myelinated fibres were detected in the control group as well as in SD specimens. Slight morphometric differences were also found between the two groups, but these cannot explain the causation of spastic dysphonia.

Speech restoration post-pharyngolaryngoesophagectomy using tracheogastric fistula.

Restoration of voice and speech in patients with gastric pull-up presents a formidable challenge, and many of these patients are left at best with a poorly functional electrolaryngeal speech. To improve this condition, a tracheogastric puncture stented with a biflanged self-retaining Groningen voice button was accomplished, resulting in gastric mucosa vibrations during exhalatory phase. The biomechanical characteristics of gastric vibrations and tracheogastric puncture candidate selection criteria are discussed.

Current evidence for the existence of laryngeal macrotremor and microtremor.

To test for the existence of laryngeal "microtremors" two experiments were conducted on humans. The first analyzed the acoustic characteristics of observable tremors (macrotremors) in the voice of singers using vocal vibrato and in pathologic subjects producing vocal tremor. In both of these groups acoustic oscillations between 4 and 8 Hz were found. The second study, using a normal subject, sampled electromyographic (EMG) activity from laryngeal and arm muscles during isometric contraction to determine if a periodic component (microtremor) was present in either muscle's contraction pattern. A 9-Hz signal was detected in limb muscle contraction, whereas no periodicity was found in signals from laryngeal muscles. The application of these findings to the theory behind voice "stress" analyzers is discussed

Effects of prestimulus interval on phonation initiation reaction times.

Latencies for phonation initiation (from adducted, abducted, and a subject method, prephonatory vocal-fold- position) were studied in 30 young adults under an auditory reaction time paradigm as a function of random prestimulus intervals. Shortest latencies were obtained when the auditory stimulus was presented within a 1000- to 2000-millisecond frame. Stimulus delivery at intervals exceeding or preceding this time frame increases the latency of vocal reaction.

Magnetic sound recording in laryngology.

A laryngologist's documentation of patients' vocal behavior usually suffers from inadequacy of verbal description of the acoustic signals contained in voice speech. Because various phonosurgeries are by now well established, adequate documentation of the patient's vocal production must be obtained. Magnetic sound recording offers the best means for such documentation.