Recovery Related to Vocalization and Swallowing After Tracheostomy

Tracheostomy refers to a surgical incision created in the neck to allow direct air entry into the trachea bypassing the upper respiratory tract including the oral and nasal cavities. Normal vocalization and swallowing are limited immediately postoperatively; however, gradual recovery of vocalization and swallowing function can be initiated, following improvement in the causative condition that necessitated the tracheostomy. Duration of the tracheostomy depends upon the patient’s condition, and the degree of vocalization and swallowing function recovery after tracheostomy tube removal varies widely across patients. In this review, we investigated the changes associated with vocalization and swallowing function in patients who underwent tracheostomy and have discussed the various approaches and voice rehabilitation treatments to aid with normal recovery.

Differences in Patient Characteristics between Spasmodic Dysphonia and Vocal Tremor

Spasmodic dysphonia, essential tremor, and vocal tremor related with Parkinson’s disease are different disorders showing fairly similar symptoms such as difficulty in the speech onset, and tremble in the voice. However, the cause and the resulting treatment of these diseases are different. Spasmodic dysphonia is a vocal disorder characterized by spasms of the laryngeal muscles during a speech, invoking broken, tense, forced, and strangled voice patterns. Such difficult- to-treat dysphonia disease is classified as central-origin-focal dystonia, of a yet unknown etiology. Its symptoms arise because of intermittent and involuntary muscle contractions during speech. Essential tremor, on the other hand, is characterized by a rhythmic laryngeal movement, resulting in alterations of rhythmic pitch and loudness during speech or even at rest. Severe cases of tremor may cause speech breaks like those of adductor spasmodic dysphonia. In the case of hyper-functional tension of vocal folds and accompanying tremors, it is necessary to distinguish these disorders from muscular dysfunction. A diversified assessment through the performance of specific speech tasks and a thorough understanding for the identification of the disorder is necessary for accurate diagnosis and effective treatment of patients with vocal tremors.

Real-Time Light-Guided Vocal Fold Injection: an In Vivo Feasibility Study in a Canine Model

Objectives@#. The transcutaneous approach is a good option for office-based vocal fold injection (VFI). However, precise localization requires extensive experience because the needle tip is invisible in small and complex laryngeal spaces. Recently, real-time light-guided VFI (RL-VFI) was proposed as a new technique that allows simultaneous injection under precise needle localization by light guidance. Herein, we aimed to verify the feasibility of RL-VFI in an in vivo canine model and explored its clinical usefulness. @*Methods@#. The device for RL-VFI comprised a light source (light-emitting diode modules [10 W] of red color [650 nm]) and injectors (1.5 inches, 23 gauge). An adult male beagle was used for the experiment. After tracheostomy, a rigid laryngoscope was inserted and suspended to expose the larynx. A flexible naso-laryngoscopy system was used to visualize the vocal folds. @*Results@#. RL-VFI was performed using various transcutaneous approaches, including the cricothyroid, transthyroid, and transhyoid approaches. Light guidance helped identify the path of the needle and prevent inadvertent penetration. The location of the needle tip was accurately indicated by the light. The illuminated needle could be easily placed at the intended points in the vocal fold with real-time visual-motor feedback. Hyaluronic acid could be simultaneously injected lateral to the vocal process under light guidance without manipulation of the device. @*Conclusion@#. RL-VFI was found to be safe and feasible in an in vivo canine model, providing precise localization and visualmotor feedback. The clinical application of RL-VFI is expected to improve the safety and precision of VFI.

Differences in Patient Characteristics between Spasmodic Dysphonia and Vocal Tremor

Spasmodic dysphonia, essential tremor, and vocal tremor related with Parkinson’s disease are different disorders showing fairly similar symptoms such as difficulty in the speech onset, and tremble in the voice. However, the cause and the resulting treatment of these diseases are different. Spasmodic dysphonia is a vocal disorder characterized by spasms of the laryngeal muscles during a speech, invoking broken, tense, forced, and strangled voice patterns. Such difficult- to-treat dysphonia disease is classified as central-origin-focal dystonia, of a yet unknown etiology. Its symptoms arise because of intermittent and involuntary muscle contractions during speech. Essential tremor, on the other hand, is characterized by a rhythmic laryngeal movement, resulting in alterations of rhythmic pitch and loudness during speech or even at rest. Severe cases of tremor may cause speech breaks like those of adductor spasmodic dysphonia. In the case of hyper-functional tension of vocal folds and accompanying tremors, it is necessary to distinguish these disorders from muscular dysfunction. A diversified assessment through the performance of specific speech tasks and a thorough understanding for the identification of the disorder is necessary for accurate diagnosis and effective treatment of patients with vocal tremors.

Real-Time Light-Guided Vocal Fold Injection: an In Vivo Feasibility Study in a Canine Model

Objectives@#. The transcutaneous approach is a good option for office-based vocal fold injection (VFI). However, precise localization requires extensive experience because the needle tip is invisible in small and complex laryngeal spaces. Recently, real-time light-guided VFI (RL-VFI) was proposed as a new technique that allows simultaneous injection under precise needle localization by light guidance. Herein, we aimed to verify the feasibility of RL-VFI in an in vivo canine model and explored its clinical usefulness. @*Methods@#. The device for RL-VFI comprised a light source (light-emitting diode modules [10 W] of red color [650 nm]) and injectors (1.5 inches, 23 gauge). An adult male beagle was used for the experiment. After tracheostomy, a rigid laryngoscope was inserted and suspended to expose the larynx. A flexible naso-laryngoscopy system was used to visualize the vocal folds. @*Results@#. RL-VFI was performed using various transcutaneous approaches, including the cricothyroid, transthyroid, and transhyoid approaches. Light guidance helped identify the path of the needle and prevent inadvertent penetration. The location of the needle tip was accurately indicated by the light. The illuminated needle could be easily placed at the intended points in the vocal fold with real-time visual-motor feedback. Hyaluronic acid could be simultaneously injected lateral to the vocal process under light guidance without manipulation of the device. @*Conclusion@#. RL-VFI was found to be safe and feasible in an in vivo canine model, providing precise localization and visualmotor feedback. The clinical application of RL-VFI is expected to improve the safety and precision of VFI.

Practical Issue of Botulinum Toxin use Liquid Type, Storage and Reuse

Botulinum toxin (BTX) has been widely used to treat muscle spasms in many voice disorders. Most commercially available forms of BTX require reconstitution before use, which may increase the risk of contamination and requires careful titration. Recently, a liquid-type BTX type A (BTX-A) has been developed, which should simplify the procedure and enhance its efficacy. In this session, I will discuss about the differences of BTX-A from existing types and the practical issues associated with it.

The Effect of Voice Therapy Applying Self-Regulation Concepts on Dysphonia Patients

BACKGROUND AND OBJECTIVES: The goal of this study is to present a strategy for improving the self-regulation (SR) ability and facilitating the change of vocal behavior by applying voice therapy using the SR concept to the patients with vocal cord nodule and muscle tension dysphonia. MATERIALS AND METHOD: The subjects were 80 patients and 80 patients who were diagnosed with muscle tension dysphonia and vocal nodules. As a control group, the results were compared among patients with the same dysphonia without using SR strategies. The concept of SR before voice therapy was explained to the patients, and the treatment was divided into three stages according to the goal of voice therapy. The treatment stages consist of 1) skill acquisition, 2) habit formation, and 3) habit changes. voice therapy was performed by applying SR strategies such as goal implementation intentions and a less routine behavior. Patient's dropout rates were measured to compare the adherence of voice therapy. RESULTS: Significant improvement was seen in all groups receiving voice therapy. However, in the group using the SR strategy, the voice analysis results showed a relatively low dropout rate of voice therapy. In the generalization confirmation stage, patients who applied SR concept showed better results. SR strategy did no longer be necessary to maintain newly adopted vocal behavior. CONCLUSION: The results of this study show that SR is one of the cognitive factors that can have a significant impact on the outcome of voice therapy, and also has a positive impact on the acquisition and generalization of new skills. A better understanding of SR and the development of therapeutic strategies using it will play an important role in solving voice problems in clinical settings.

Changes in Oral Microbiota in Patients Receiving Radical Concurrent Chemoradiotherapy for The Head and Neck Squamous Cell Carcinoma

Radiotherapy (RT) is a mainstay in the treatment of head and neck squamous cell carcinoma (HNSCC). For locally advanced HCSCC, concurrent chemoradiotherapy (CCRT) benefits HCSCC patients in terms of better survival and loco-regional control. In this study, we evaluated changes in oral microbiota in patients, who received CCRT for head and neck cancer. Oral rinsed samples were weekly collected before and during CCRT and at 4 weeks following treatment from HNSCC patients, who had received 70 Gy of radiation delivered to the primary sites for over 7 weeks and concurrent chemotherapy. Oral microbiota changes in three patients were analyzed by next-generation sequencing using 16S rRNA 454 pyrosequencing. On an average, 15,000 partial 16S rRNA gene sequences were obtained from each sample. All sequences fell into 11 different bacterial phyla. During early CCRT, the microbial diversity gradually decreased. In a patient, who did not receive any antibiotics during the CCRT, Firmicutes and Proteobacteria were the most abundant phylum. During the early CCRT, proteobacteria gradually decreased while Firmicutes increased. During the late CCRT, firmicutes gradually decreased while Bacteroides and Fusobacteria increased. In all the patients, yellow complex showed a gradual decrease, while orange and red complex showed a gradual increase during the CCRT. At 4 weeks after CCRT, the recovery of oral microbiota diversity was limited. During CCRT, there was a gradual increase in major periodontopathogens in association with the deterioration of the oral hygiene. Henceforth, it is proposed that understanding oral microbiota shift should provide better information for the development of effective oral care programs for patients receiving CCRT for HNSCC.

Aerodynamic Evaluation of Voice Changes in Thyroid Surgery Extent

BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate the impact of surgical extent on voice using acoustic and aerodynamic measurements in a serially followed thyroidectomy patients. MATERIALS AND METHOD: From October 2015 to January 2017, 108 patients who had undergone thyroid surgery and voice test for preoperative, 2, 3, and 6 months postoperatively were classified into five operative types. The radiological stage preoperatively and histopathological stage postoperatively were classified according to the invasion of thyroid capsule and surrounding tissue. For each classification, the results of the voice analysis according to the period were compared and analyzed. RESULTS: The difference of voice according to surgical extent, radiological stage, and histopathologic stage showed significant difference only with Maximal phonation time (MPT) over time. However, in the analysis of interaction between each classification and period, Phonation threshold pressure (PTP) only showed significant results. CONCLUSION: Differences in imaging and histopathologic stages have no significant effect on recovery of voice symptoms after thyroid surgery. As the extent of operation increases, the pressure to start vocalization is relatively higher, which also varies with time after surgery.

Glomangiopericytoma of the Spinal Cord

Glomangiopericytoma, also referred to as a hemangiopericytoma-like tumor or sinonasal type hemangiopericytoma, is a rare tumor of the nasal cavity and paranasal sinus that has never been reported in the spinal cord. Here, we report a case of a 47-year-old man who developed glomangiopericytoma in the thoracic spine. This lesion showed a heterogeneous high signal intensity compared to the spinal cord on a T2-weighted image and an easily enhanced isointense signal on a T1-weighted image.

Usefulness of Cepstral Peak Prominence (CPP) in Unilateral Vocal Fold Paralysis Dysphonia Evaluation

BACKGROUND AND OBJECTIVES: The purpose of this study was to compare the usefulness of Cepstral peak prominence (CPP) with parameter of Multiple Dimensional Voice Program (MDVP) in evaluating unilateral vocal fold paraylsis patients with subjective voice impairment. MATERIALS AND METHODS: From July 2014 to August 2016, 37 patients with unilateral vocal fold paralysis who had been diagnosed with unilateral vocal fold paralysis and had received two or more voice tests before and after the diagnosis were evaluated for maximum phonation time (MPT), MDVP and CPP. Respectively. Voice tests were performed with short vowel /a/ and paragraph reading. RESULTS: The CPP-a (CPP with vowel /a/) and CPP-s (CPP with paragraph reading) of the Cepstrum were statistically negatively correlated with G, R, B, and A before the voice therapy. Jitter, Shimmer, and NHR of MDVP were positively correlated with G, R, B. Jitter, Shimmer, and NHR of the MDVP were significantly correlated with the Cepstrum index. G, B, A and CPP-a and CPP-s showed a statistically significant negative correlation and a somewhat higher correlation coefficient between 0.5 and 0.78. On the other hand, in MDVP index, there was a positive correlation with G and B only with Jitter of 0.4. CONCLUSION: CPP can be an important evaluation tool in the evaluation of speech in the unilateral vocal cord paralysis when speech energy changes or the cycle is not constant during speech.

Comparison of Initial Therapeutic Effects of Voice Therapy and Injection Laryngoplasty for Unilateral Vocal Cord Paralysis Patients

BACKGROUND AND OBJECTIVES: The purpose of this study was to classify patients with unilateral vocal fold paralysis according to their fixed location and to analysis the effects of two treatment methods by early voice therapy and injection laryngoplasty. MATERIALS AND METHODS: Twenty patients who were classified as full abduction and slight abduction according to the position of paralysis were treated injection laryngoplasy, and 23 patients were treated by voice therapy. Twenty patients were treated injection laryngoplasy and 23 patients were treated voice therapy. Results were evaluated by acoustic analysis, electroglottography, cepstrum analysis before and after therapy. The voice therapy was conducted by improving the larynx movement and glottal contact, whilst removing hypertension of the supraglottic and use the breathing. RESULTS: Significant improvement was found in the acoustic parameter, cepstrum parameter, and EGG before and after treatment in both groups. There was no significant difference between the two groups when compared before and after treatment to compare the effects of injection laryngoplasty and voice therapy. CONCLUSION: The initial treatments for unilateral vocal cord paralysis are injection laryngoplasty and voice therapy. however, there is no precise standard about which method should be applied first. Therefore, in this study, we tried to classify patients according to their paralysis position and then apply two methods. The results of this study suggest that voice therapy and Injection laryngoplasty at the initial stage is a very useful method to improve voice quality of vocal fold paralysis and improve laryngeal function.

The Effect of Voice Therapy in Unilateral Vocal Fold Paralysis

BACKGROUND AND OBJECTIVES: This study aims to conduct post-voice therapy to patients with unilateral vocal fold paralysis for vocal improvement, motility recovery and analyze the results. MATERIALS AND METHODS: Voice therapy was conducted to 13 patients who had shown response to voice therapy amongst 98 patients diagnosed with unilateral vocal fold paralysis. In order to be able compare before and after perceptual, acoustic and aerodynamic evaluations were conducted after voice therapy. Also, by using dysphagia checklist, we have verified whether if the patient had dysphagia prior to voice therapy. The therapy was conducted by improving the larynx movement and glottal contact, whilst removing hypertension of the supraglottic. RESULTS: All 13 patients who underwent voice therapy had shown improvements that are statistically significant from 4 scales excluding the S scale from auditory perception evaluation (p<0.05), with enhanced glottal contact. In acoustic evaluation, Jitter, Shimmer and NHR had shown significant improvement after voice therapy. MPT was also notably improved among aerodynamical evaluation (p<0.001). All 11 patients had with dysphagia prior to voice therapy reported to have improved swallowing functions. CONCLUSION: Application of adequate voice therapy to patients with unilateral vocal fold paralysis, is an effective method that might be employed in the initial phase. Especially, the voice therapy proposed in this study is expected to be useful for patients in hypertension status due to secondary compensation after initial paralysis, since it focuses on improving vocal symptoms in a calm state with the supraglottis sufficiently relaxed. Also, the therapy is expected to be effective for improving swallowing functions.

Effectiveness of an i-PTH Measurement in Predicting Post Thyroidectomy Hypocalcemia: Prospective Controlled Study

PURPOSE: Hypocalcemia is the most common complication after total thyroidectomy. The purpose of this study was to determine whether measurement of intact parathyroid hormone (i-PTH) level in thyroidectomy patients could predict hypocalcemia. MATERIALS AND METHODS: We performed a prospective study of patients undergoing total thyroidectomy. Serum concentration of i-PTH, total calcium (Ca), ionized calcium (Ca2+), phosphate (P), magnesium (Mg), and albumin were measured preoperatively and at 0 hour, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours postoperatively. RESULTS: 108 patients were recruited to the study. A total of 50 patients (46%) experienced hypocalcemia. The serum i-PTH concentration was linearly related to the time of measurement, while concentrations of P, Mg, albumin, Ca, and Ca2+ were not. We compared odds ratios, and found that the concentration of i-PTH at 6 hours post operation was the most closely related to the occurrence of hypocalcemic symptom. On ROC analysis using i-PTH level at 6 hours, an i-PTH level of 10.6 mg/dL was found to maximize both sensitivity and specificity at the same time point. CONCLUSION: We found that i-PTH was a predictor of hypocalcemia, and that the earliest predictor of hypocalcemic symptoms was an i-PTH concentration lower than 10.6 mg/dL obtained 6 hours after total thyroidectomy.

Comparison of Natural Drainage Group and Negative Drainage Groups after Total Thyroidectomy: Prospective Randomized Controlled Study

PURPOSE: The aim of this study was to compare a negative pressure drain with a natural drain in order to determine whether a negative pressure drainage tube causes an increase in the drainage volume. MATERIALS AND METHODS: Sixty-two patients who underwent total thyroidectomy for papillary thyroid carcinoma (PTC) were enrolled in the study between March 2010 and August 2010 at Gyeongsang National University Hospital. The patients were prospectively and randomly assigned to two groups, a negative pressure drainage group (n=32) and natural drainage group (n=30). Every 3 hours, the volume of drainage was checked in the two groups until the tube was removed. RESULTS: The amount of drainage during the first 24 hours postoperatively was 41.68+/-3.93 mL in the negative drain group and 25.3+/-2.68 mL in the natural drain group (p<0.001). After 24 additional hours, the negative drain group was 35.19+/-4.26 mL and natural drain groups 21.53+/-2.90 mL (p<0.001). However, the drainage at postoperative day 3 was not statistically different between the two groups. In addition, the vocal cord palsy and temporary and permanent hypocalcemia were not different between the two groups. CONCLUSION: These results indicate that a negative pressure drain may increase the amount of drainage during the first 24-48 hours postoperatively. Therefore, it is not necessary to place a closed suction drain when only a total thyroidectomy is done.

Lingual Squamous Cell Carcinoma Surrounded by Granular Cell Tumor / 전남의대학술지

The granular cell tumor (GCT) is an uncommon, benign lesion with a preference for subcutaneous sites. In the head and neck, the tongue is the most common site, followed by the larynx. We experienced a case of a 27-year-old woman with lingual squamous cell carcinoma (SCC) surrounded by GCT. The pathological findings established that the lesion was SCC covered by GCT in the midline of the tongue. The size of the mass was very small, however, so we excised it in a diamond shape. There is an interesting association between GCTs and other malignant neoplasms. However, no causal relationship between GCT and these other carcinomas has been established. Here we report on an SCC coexisting with GCT at the same site as a median tongue lesion and review the literature.

Analysis of Clinical Feature and Management of Laryngeal Fracture: Recent 22 Case Review

PURPOSE: Laryngeal fracture is rare, but complications are frequent and severe. Controversy still exists in regards to its proper management. The aim of this study was to present the clinical findings and management of laryngeal fracture in Korea. MATERIALS AND METHODS: We analyzed the medical records of 22 patients with laryngeal fracture at a tertiary care trauma center from 2000 to 2010 retrospectively. RESULTS: In total, 22 patients (19 men and 3 woman) presented with laryngeal fractures caused by blunt (n=13) or penetrating (n=9) injury. Pain (68.1%), odynophagia (68.1%), hoarseness (18.1%), hemoptysis (13.6%), and subcutaneous emphysema (9%) were the common presenting symptoms and noncomminuted fracture was common. High velocity blunt trauma (mostly traffic accidents) patients had more extensive injury and poor voice outcomes. Penetrating trauma patients due to physical assault or suicide attempt demonstrated more frequently injuries on the left side. CONCLUSION: In driver-caused traffic accidents, where injuries in a wide area within the larynx occurred, poor voice results were seen, and these injuries required aggressive treatment. When endotracheal intubation was performed at experienced emergency centers with fiberoptic laryngoscopes, airway management was safely achieved. In addition, if the fractured laryngeal framework was corrected at appropriate times, voice results were good.

Lingual Squamous Cell Carcinoma Surrounded by Granular Cell Tumor / 전남의대학술지

The granular cell tumor (GCT) is an uncommon, benign lesion with a preference for subcutaneous sites. In the head and neck, the tongue is the most common site, followed by the larynx. We experienced a case of a 27-year-old woman with lingual squamous cell carcinoma (SCC) surrounded by GCT. The pathological findings established that the lesion was SCC covered by GCT in the midline of the tongue. The size of the mass was very small, however, so we excised it in a diamond shape. There is an interesting association between GCTs and other malignant neoplasms. However, no causal relationship between GCT and these other carcinomas has been established. Here we report on an SCC coexisting with GCT at the same site as a median tongue lesion and review the literature.

Pseudocyst of the Vocal Fold: Distinct Disease Entity or Not? / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Koufman described a pseudocyst of the vocal folds for the first time in 2001. A pseudocyst in all parts of the body and that is related to secretory glands is already well known, but such a lesion of the vocal folds has only been mentioned a few times. It is unclear whether or not to define a pseudocyst of the vocal folds as a benign lesion of the vocal folds. The objective of this study was to introduce the demographic and clinical findings of pseudocyst and to discuss our diagnostic and therapeutic strategies. SUBJECTS AND METHOD: We carried out a retrospective review of all the medical records, the preoperative voice lab results and the operation records from 2006 to 2009. All the patients underwent laryngomicrosurgery due to benign vocal folds lesions. We select 11 cases that showed subepithelial lesion without a definite capsule. RESULTS: Seven patients had had the history of voice abuse. One patient has been a smoker, another was an ex-smoker and the others were non-smokers. According to aerodynamic assessment, the maximum phonation time was 14.6 seconds and the mean airflow was typically increased. On laryngoscopy, all were translucent and spherical or fusiform subepithelial lesions. The preoperative stroboscopic findings showed a uniform feature of damping on the vocal fold lesion. Both the unroofing technique and the microflap technique were used. CONCLUSION: A pseudocyst would be a subepithelial lesion without a definite epithelial lining that contains serous discharge. We suggest that a pseudocyst of the vocal fold is a new benign lesion.

A Case of Acute Suppurative Labyrinthitis Complicated by Chronic Otitis Media / 대한이비인후과학회지

With the development of antibiotics, tympanogenic labyrinthitis complicated by otitis media rarely occurs nowadays. Only few cases of acute serous or suppurative labyrinthitis in otitis media patients have been reported previously in the literature. Acute suppurative labyrinthitis caused by direct bacterial invasion into the inner ear leads to potentially severe, irreversible hearing loss, vertigo and spontaneous nystagmus toward the healthy side. Magnetic resonance image might be helpful to recognize the inflammatory lesions of the labyrinth. Treatment for tympanogenic labyrinthitis includes an appropriate use of antibiotics and establishment a draining route. Recently, we experienced an unusual case of acute suppurative labyrinthitis complicated by chronic otitis media without cholesteatoma. We also review and discuss the clinical manifestations, radiologic findings and treatment strategy of this disease.