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.

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.

[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.

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.

Unilateral vocal fold agenesis: an unusual cause of dysphonia.

Unilateral vocal fold agenesis: an unusual cause of dysphonia. Unilateral vocal fold agenesis is a rare congenital laryngeal anomaly. To our knowledge, there have been no published reports about this clinical entity to date. A 6-year-old female patient was referred to our practice for persistent hoarseness of voice since birth. On physical examination, her voice was hoarse and reduced in volume. She had facial features typical of Down syndrome and macroglossia. Laryngeal examination revealed the absence of the right vocal fold. She had no further evaluation or treatment.

[Incidence of structural vocal fold abnormalities associated with vocal fold polyps.

UNLABELLED: Phonotrauma is considered the main cause of vocal fold polyps (VFP). However, the authors believe that an underlying anatomical deviation could render the vocal folds more susceptible to such trauma. AIM: To prove this hypothesis a retrospective chart review was carried out to correlate the surgical findings of patients with VFP. MATERIAL AND METHODS: The charts of thirty-three patients who underwent surgery for excision of VFP were reviewed: 21 had right VFP, 10 had left VFP and 2 had bilateral lesions. RESULTS: Associated lesions were reported in 27 patients (14 lesions on the opposite VF and 13 on the ipsilateral VF): 10 opposite nodules, 12 sulcus vocalis, 3 cysts, and 2 capillary engorgement. DISCUSSION AND CONCLUSIONS: The high incidence of associated anatomical lesions to the VF (63%) suggests that patients with these minor underlying anatomical deviations are more vulnerable to vocal abuse, probably because they present abnormal glottic closure and an irregular vibratory margin.

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.

Voice handicap evaluation of patients with pathologic sulcus vocalis.

OBJECTIVES: The purpose of this study was to characterize the psychosocial impact of dysphonia on patients with pathologic sulcus vocalis by use of the Voice Handicap Index (VHI). METHODS: The VHI was administered to 15 patients (11 women and 4 men) with pathologic sulcus vocalis. The VHI subscale and total scores were compared with previously published data from individuals with no history of dysphonia and from patients with vocal fold scar. Additional comparisons were performed for patients with unilateral sulcus versus bilateral sulci, type II sulcus versus type III sulcus, and sulcus with concomitant vocal fold scar versus sulcus without concomitant scar. RESULTS: The VHI scores for patients with pathologic sulcus vocalis were significantly greater than those for individuals with no history of dysphonia and for patients with vocal fold scar. In addition, significantly greater VHI scores were observed for patients with sulcus vocalis with concomitant scar versus those with sulcus alone. CONCLUSIONS: These data suggest that pathologic sulcus vocalis can be a severely handicapping condition, particularly in the presence of concomitant scar.

Tracheal anomalies complicating ventilation of an infant with Apert syndrome.

Apert syndrome is a rare autosomal dominant disorder characterized by severe syndactyly of the feet and hands, craniofacial abnormalities, and craniosynostosis. A 7-month-old male infant with Apert syndrome who underwent direct bronchoscopy and tracheotomy during general anesthesia is presented. Early rigid bronchoscopy is important in these patients when there are problems with the airway, as they have a relatively high incidence of airway anomalies.

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.

Upper airway asymmetry in velo-cardio-facial syndrome.

OBJECTIVE: Various forms of asymmetry have been recognized as a feature of velo-cardio-facial syndrome (VCFS). This study was implemented to determine the frequency of anatomic and functional asymmetry of the velum, pharynx and larynx in children with VCFS. METHODS: Individuals with VCFS underwent prospective, blinded analysis by an expert panel who assessed the velum, pharynx and larynx with multi-view videofluoroscopy (MVF) and nasopharyngolaryngoscopy (NPL). The VCFS group was compared to an age-matched group of normal individuals. Eight different parameters were assessed in both groups for functional and anatomic symmetry including: velar elevation, adenoid size, posterior pharyngeal wall size, carotid pulsations, epiglottis size and shape, arytenoid size, true vocal cord size and true vocal cord motion. RESULTS: One hundred and twenty-one subjects with VCFS and 20 normal individuals underwent examination. Children with VCFS showed significantly more asymmetry compared to the normal group (69% versus 20%, P=0.01) with greatest differences seen with palatal motion, posterior pharyngeal wall size and epiglottis shape. On average, subjects with VCFS had three asymmetric parameters versus one parameter in the normal group. CONCLUSION: Asymmetric development of the pharynx and larynx in children with VCFS appears to be a distinct clinical feature of this syndrome. This finding may provide an important diagnostic clue for patients presenting with subtle features of the 22q11.2 microdeletion. These developmental abnormalities may increase the risk of speech impairment, aspiration and airway obstruction in affected individuals.

Congenital bilateral vocal cord paralysis.

Congenital upper airway obstruction is a relatively rare but important cause of major respiratory problems in the neonatal period. Vocal cord paralysis is the second most common cause of congenital airway obstruction presenting with neonatal stridor. It is often the reason for the failure of neonates to wean from the respiratory support. A retrospective analysis of medical record review was conducted. There were seven paediatric patients diagnosed with bilateral vocal fold paralysis in the past three years, of which five were recently diagnosed. All patients underwent flexible with/without rigid bronchoscopes to confirm the diagnosis. This case series highlight our experience in managing the problem of bilateral vocal cord paralysis in the paediatric population, with particular emphasis on their clinical presentations, associated complications and both upper and lower airway abnormalities. The management options and outcome of these patients will also be discussed.

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

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.

Exercise-induced stridor due to abnormal movement of the arytenoid area: videoendoscopic diagnosis and characterization of the "at risk" group.

We evaluated 4 patients who developed severe, symptomatic stridor during maximal cardiopulmonary exercise testing, all referred due to exercise-related dyspnea. All underwent resting, unsedated transnasal fiberoptic laryngoscopy and had normal findings. Four patients performed repeat maximal exercise testing with fiberoptic laryngoscopy, and they form the basis of this report. They had normal vocal cord motion during exercise, but developed abnormal anterior motion of the arytenoid and aryepiglottic folds only at peak exercise, leading to partial airway obstruction and severe stridor. This report details the workup and characterizes patients at risk for this unusual phenomenon.

Radiophonosurgery of benign superficial vocal fold lesions.

OBJECTIVE: To conduct a prospective randomized controlled trial describing and investigating the efficacy and safety of radiosurgical excision of benign superficial vocal fold lesions. MATERIALS AND METHODS: Fifty patients with benign superficial vocal fold lesions (20 vocal nodules, 27 vocal polyps and three Reinke's oedema) who failed conservative therapy were included in the study. They were equally randomized into cold knife or radiosurgical excision. Clinical and voice assessments were done pre-operatively and after surgery. Voice analysis included a subjective visual analogue scale (VAS) and a perceptual assessment with a simplified version of the GRBAS scale (GRB) consisting of G (grade), R (roughness), and B (breathiness). Acoustic voice evaluation included jitter and shimmer. Post-operative voice therapy was provided for all patients. Complications, smoothness of post-operative recovery, and administration of analgesia were reported. RESULTS: Both groups experienced significant improvement in VAS, perceptual evaluation and acoustic analysis after surgery, with no evidence of significant differences between the cold knife and radiofrequency groups. The radiofrequency group showed a decrease of 17 per cent in the mean operative time when compared with the cold knife group, but this was not statistically significant. No evidence of a significant difference was noticed in the smoothness of post-operative recovery, administration of analgesia and complication rate. CONCLUSION: Radiophonosurgery opens a new therapeutic approach for patients with benign superficial vocal fold lesions. It combines the advantages of both cold knife and laser phonosurgery, being easy, safe, precise and effective, and having excellent tactile and haemostatic properties.

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.

Autosomal recessive multiple pterygium syndrome: a new variant?

Multiple pterygium syndromes include at least 15 different entities characterized by multiple pterygia or webs of the skin and multiple congenital anomalies. We describe a female infant who presented with a distinct constellation of multiple anomalies consisting of pterygia of the inguinal, intercrural and popliteal areas, flexion contractures and arthrogryposis of some joints, craniofacial anomalies including ectropion, medial canthal web, blepharophimosis, hypoplasia of nose, oral and nasopharyngeal cavities, vocal cords and tongue, micrognathia, orolabial synechiae secondary to pterygia, low set ears, alopecia, sad and expressionless face, short neck, asymmetric nipples, anal stenosis, rectal polyp, hypoplastic labia majora, complete syndactyly of all fingers and toes, pes equinovarus, bandlike web between feet, and absence of the nails and phalangeal-palmar creases. Radiological examination showed synostosis, absence or hypoplasia of metacarpal, metatarsal and phalangeal bones on feet and hands, and hypoplasia of pelvic bones and scapulae. This pattern of anomalies does not fit entirely any of the known multiple pterygium syndromes. Autosomal recessive inheritance is most likely due to the presence of three similarly affected siblings and normal parents.