Detection of Muscle Tension Dysphonia Using Eulerian Video Magnification: A Pilot Study.

OBJECTIVE: To determine whether Eulerian Video Magnification software is useful in diagnosis of muscle tension dysphonia (MTD). STUDY DESIGN: Prospective. METHODS: Adult patients scheduled in a tertiary care laryngology practice for evaluation of dysphonia were recruited between November 2016 and March 2017. Demographic and clinical data were extracted from patient charts. Diagnosis of MTD was confirmed with videostroboscopic and physical exam and by a speech-language pathologist. Eighteen MTD patients were video recorded while at rest and with phonation. Five patients without MTD also were analyzed as controls. Videos were analyzed using Eulerian Video Magnification software (Massachusetts Institute of Technology) to assess change in blood flow at the forehead, infrahyoid muscles, and sternocleidomastoid muscles, while using the values of the background wall as a control value. RESULTS: Patients with MTD demonstrated little change in perfusion to the infrahyoid muscles of the neck while phonating (+1% ± 55%). Control subjects demonstrated an increase in perfusion to the infrahyoid muscles while phonating (+102% ± 164%), with this change being significant when comparing the two groups (P = 0.04, t = 2.189, df = 21). A change in perfusion of 0% or less to infrahyoid muscles was 75% sensitive and 70% specific for diagnosis of MTD. No differences in perfusion were found between other regions assessed. Patient age and gender did not correlate with any change in perfusion between rest and phonation. CONCLUSION: Our data suggest that Eulerian Video Magnification can be used in the diagnosis of MTD by focusing on the difference in perfusion to the infrahyoid muscles between rest and phonation.

Functional regeneration of recurrent laryngeal nerve injury during thyroid surgery using an asymmetrically porous nerve guide conduit in an animal model.

BACKGROUND: Vocal cord paralysis (VCP) caused by recurrent laryngeal nerve (RLN) damage during thyroidectomy commonly results in serious medico-legal problems. The purpose of this study was to evaluate the usefulness of an asymmetrically porous polycaprolactone (PCL)/Pluronic F127 nerve guide conduit (NGC) for functional regeneration in a RLN injury animal model. METHODS: A biodegradable, asymmetrically porous PCL/F127 NGC with selective permeability was fabricated for use in this study. A 10-mm segment of left RLN was resected in 28 New Zealand white rabbits, and then an asymmetrically porous NGC or a nonporous silicone tube was interposed between both stumps and securely fixed. Vocal cord mobility was endoscopically evaluated at one, four, and eight weeks postoperatively. Nerve growth through NGCs was assessed by toluidine blue staining, and thyroarytenoid (TA) muscle atrophy was evaluated by hematoxylin and eosin staining. Immunohistochemical stainings for acetylcholinesterase (AchE), anti-neurofilament (NF), and anti-S100 protein were also conducted, and transmission electron microscopy (TEM) was used to evaluate functional nerve regeneration. RESULTS: At eight weeks postoperatively, endoscopic evaluations showed significantly better recovery from VCP in the asymmetrically porous PCL/F127 NGC group (6 of 10 rabbits) than in the silicone tube group (1 of 10 rabbits). Continued nerve growth on the damaged nerve endings was observed with time in the asymmetrically porous PCL/F127 NGC-interposed RLNs. TA muscle dimensions and AchE expressions in TA muscle were significantly greater in the asymmetrically porous PCL/F127 NGC group than in the silicone tube group. Furthermore, immunohistochemical staining revealed the expression of NF and S100 protein in the regenerated nerves in the asymmetrically porous PCL/F127 NGC group at eight weeks postoperatively, and at this time, TEM imaging showed myelinated axons in the regenerated RLNs. CONCLUSION: The study shows that asymmetrically porous PCL/F127 NGC provides a favorable environment for RLN regeneration and that it has therapeutic potential for the regeneration of RLN damage.

Age-related blood flow changes in the rat intrinsic laryngeal muscles.

CONCLUSIONS: These results indicate that a deceased laryngeal blood flow (BF) could be one contributing factor to age-related phonatory and airway dysfunction. OBJECTIVE: Studies of non-laryngeal muscles suggest that decreased BF may contribute to an age-related decline in muscle performance. We hypothesized that there is an age-related BF decrease to the intrinsic laryngeal muscles. MATERIALS AND METHODS: Intrinsic laryngeal muscle BF was measured in young (3-6 months old; n=11) and old (28-30 months old; n=21) male Fischer 344 rats during quiet respiration using the radiolabeled microsphere technique. RESULTS: BF to the posterior cricoarytenoid (PCA) was very high even during this submaximal recruitment, consistent with its specialization for oxidative metabolism and fatigue resistance. The results demonstrated significant (p<0.05) age-related BF decreases in the thyroarytenoid (young, 163; old, 64 ml/min/100 g), cricothyroid (young, 104; old, 52 ml/min/100 g), and PCA (young, 404; old, 235 ml/min/100 g).

Stereological estimates indicate that aging does not alter the capillary length density in the human posterior cricoarytenoid muscle.

Studies of some human skeletal muscles demonstrate an age-related capillarity decrease. An age-related decrease in blood flow to the posterior cricoarytenoid muscle (PCA) in rats has been reported, as well as a decreased ability to abduct the vocal folds. We, therefore, hypothesized that decreased muscle capillarity may contribute to PCA dysfunction in the elderly. Using immunological and stereological techniques, human PCAs (ages 18-98 yr; 28 men, 23 women) were examined for age-related changes in muscle fiber-type-specific and/or total capillary length density. While analysis shows no age-related changes in total muscle or fiber-type-specific capillary length densities (L(V cap)), there are significant age-related increases in L(V cap) within the interstitial tissue (P = 0.001) and in the ratio of the type I L(V cap) to type I surface (P = 0.002), with a strong trend for type II L(V cap) (P = 0.055). There is also an age-related decrease in the muscle fiber surface density for both type I and II fibers (P < 0.001 and 0.04, respectively). Data also show that women have a significantly higher type II L(V cap) (P = 0.039), regardless of age. In addition, with the exception of female type I L(V cap), all measured variables are significantly higher for type I fibers (P < 0.001), independent of age or sex. While data indicate there are age-related changes of capillary-muscle fiber relationships within the PCA, they do not support the hypothesis of an age-related loss of capillarity.

A variant form of nasogastric tube syndrome.

Nasogastric tube syndrome named by Sofferman et al in 1981 is a laryngeal complication presenting with life-threatening vocal cord abductor paralysis derived from peroforation of the NG tube-induced esophageal ulcer. As compared with the previously reported cases of this syndrome, our 4 autopsied patients were so peculiar in the following two points that vocal cord abductor paralysis developed repeatedly and no esophageal ulcer was present in spite of the presence of the laryngeal abductor muscle injury. We hypothesized that the etiology of such a variant form was circulatory injury of the laryngeal abductor muscle which was caused by the compression of the postcricoid blood vessels perfusing this muscle. Nasogastric tube syndrome, which is treatable by decannulation, cannot be ruled out even if no esophageal ulcer is detected by fiberoptic laryngoscopy.

Anatomical study of meandering and functions of human intralaryngeal artery.

In recent years, partial laryngectomy and partial reconstruction are increasingly intended for conservation of functions of phonation and swallowing. In partial reconstruction, it is important to comprehend morphological characteristics of the blood vessels distributed in the larynx, but there have been only few reports discussing detailed information about them. Previous reports on laryngeal blood vessels have shown that branches of some arteries show remarkable "meandering". In the present study, we devised a method for objectively determining the morphological nature, "meandering" and assessed functions of the arteries. Intralaryngeal arteries were excised from the larynx of cadavers prepared for practice in anatomy, and images of the "meandering" artery were analyzed with NIH Image. The extent of "meandering" was expressed mainly as the ratio of the total length of the blood vessel to the distance between the starting point and the end point of meandering. The results showed that there was a significant difference in the extent of meandering between superior posterior and medial posterior branches of superior laryngeal artery. These arteries, which were distributed in the arytenoid region, were found to be of primary importance in partial laryngectomy and partial reconstruction of the larynx.

Vocal fatigue: current knowledge and future directions.

Vocal fatigue is a complex multifaceted clinical phenomenon. Several hypotheses exist concerning its underlying mechanism, and a range of empirical studies have examined its manifestation. This article reviews the literature pertaining to the nature, underlying processes, and salient features of vocal fatigue. First, vocal fatigue is defined, its major symptoms are discussed, and hypotheses concerning its primary physiological and biomechanical mechanisms are considered. Second, studies of experimentally induced vocal fatigue in humans are evaluated. Third, research investigating the clinical and occupational manifestations of vocal fatigue is discussed. Fourth, directions for ongoing research in this area are offered.

The distribution of ganglion cells in the posterior cricoarytenoid muscle of the normal adult rat. A light and electron microscopic study.

We employed by light and electron microscopy to examine the innervation of the posterior cricoarytenoid muscle of the adult rat. The laryngeal nerve was found to often bifurcate into two different bundles. One contained large myelinated (motor) nerve fibers, which were located along the frontal (ventral) muscle surface and entered the muscle at its middle portion to form neuromuscular contacts with individual muscle fibers. The other nerve bundle consisting of clustered ganglion cells (20-30 microm in diameter) and their associated nonmyelinated and small-sized myelinated nerve fibers were mainly found on the dorsal side of the muscle and often ran along the peripheral clefts or depressions of the muscle surface. The nerve bundle often extended side branches, which entered the muscle to be distributed among muscle fibers and near arterioles. Some ganglion cells are considered to enter the muscle, accompanied by branched nerves. Intramuscular ganglion cells and their associated nerve fibers examined by electron microscopy were similar in fine structure to perimuscular ganglion cells and their associated nerve fibers. Nerve fibers contained abundant clear synaptic vesicles which were cholinergic in nature, and often formed synapses with both neighboring axons and the cell body of the ganglion cells. These findings suggest that, in the rat posterior cricoarytenoid muscle, perimuscular and intramuscular ganglion cells exist and may be involved in innervating and contracting smooth muscle cells of the arterioles, thus regulating the blood flow or intravascular pressure.

Occurrence of capillaries with fenestrae in the intrinsic laryngeal muscles of the guinea pig after unilateral denervation.

Capillaries in the posterior cricoarytenoid and the arytenoid muscles of the guinea pig were examined by electron microscopy 3 days after transection of unilateral recurrent laryngeal nerve. The denervated posterior cricoarytenoid muscle had neuromuscular junctions (NMJs) lacking terminal axons, while in the unpaired arytenoid muscle, normal and denervated NMJs coexisted among muscle fibres being seemingly normal. Capillaries in both muscles were almost of the continuous type. However, approximately 10% of capillaries around the denervated NMJs and among some muscle fibres in both muscles, often had a small number (< 10) of fenestrae bridged by a single-layered diaphragm. The untreated normal muscles contained only continuous capillaries. These findings suggest that denervation may induce the fenestrated changes of intramuscular capillaries.

Laryngotracheal anatomy and physiology.

Thorough knowledge of the laryngotracheal anatomy and physiology is a prerequisite for understanding the pathophysiology and for an adequate treatment of patients with anomalies, stenoses and other pathology in this area. The larynx is part of the upper respiratory tract, our voice organ and it prevents the passage of secretion and food to the lower airways. Anatomical differences between adults and children, males and females are important to consider, as the size of the structures underlies the decision for the size of tubes and cannulas to be used. Knowledge of the muscles and mucosa is important in augmentation, e.g. in phono-surgery and for procedures in patients with laryngeal palsy. The trachea with its location causes specific problems in the treatment of stenoses and tumours. The mucociliary system is nowadays being more focused upon.

Blood flow distribution to upper airway muscles.

Radiolabeled (15-microns) microspheres were used to measure blood flow to upper airway muscles [alae nasi (AN), intrinsic laryngeal, tongue, cervical strap, and hyoid musculature], diaphragm (DI), and parasternals (PS) during spontaneous breathing in 24 anesthetized tracheotomized supine dogs. Six dogs were also studied while -28 +/- 3 (SE) cmH2O tracheal airway pressure was generated against an inspiratory resistance (IR) (upper airway bypassed). Blood flow to posterior cricoarytenoid muscle (PCA) [24.0 +/- 2.1 (SE) ml.min-1.100 g-1] was greater than that to DI (18.0 +/- 2.3 ml.min-1.100 g-1) and comparable to that to PS (21.4 +/- 2.9 ml.min-1.100 g-1). Blood flow per unit weight did not differ between AN, tongue muscles, laryngeal adductors, cervical strap muscles, and cricothyroid (CT). Average blood flow to these muscles was only 8.0 +/- 0.8 ml.min-1.100 g-1. With the exception of CT, blood flow to these upper airway muscles was less than that to DI and PCA. Relative to blood flow during spontaneous breathing, IR loading increased blood flow to AN by a factor of 7.5, to PCA by 3.4, to DI by 3.2 and to PS by 1.9. There was no change in blood flow in the other muscles during loading. Our results show that at rest blood flow to main glottic dilator (PCA) is similar to that to main inspiratory muscles. Furthermore, in response to an IR load, blood flow to PCA and AN increased by an equivalent or greater amount than that to DI.(ABSTRACT TRUNCATED AT 250 WORDS)

[An ultrastructural study of the neuromuscular junctions of the cat intrinsic laryngeal muscles. II. Synapse formation by autonomic nerves].

The purpose of this study is to identify the origin of the nerve terminals of unknown origin observed at the previously denervated neuromuscular junctions in the cat intrinsic laryngeal muscles. The results were as follows: 1. Until 3 weeks after the transection of the recurrent laryngeal nerve, no nerve terminals were found at the neuromuscular junctions of the intrinsic laryngeal muscles except for the cricothyroid muscle, and no nerve fibres were detected in the Schwann tubes formed by Schwann cells and perineural cells. In addition, autonomic nerves around the vessels in the muscles were markedly decreased. 2. At 6 weeks, accompanied by an increase of autonomic nerves around the vessels, nerve fibres and nerve varicosities containing a number of large granular vesicles were observed in the Schwann tubes. 3. From 9 to 30 weeks, nerve terminals containing large granular vesicles were found at the neuromuscular junctions in all cases, even though the superior laryngeal nerve or the vagal nerve was transected on the ipsilateral side. 4. A spontaneous discharge was recognized in 6/8 cases after 6 weeks, but an evoked electromyogram could not be recognized. 5. The synaptic vesicles of the nerve terminals were labelled by 5-hydroxydopamine (5-OHDA), which was used as a marker for the sympathetic nerve. From these results, it was indicated that if the transected recurrent laryngeal nerve was prevented from regenerating, the autonomic nerves around the vessels entered into the Schwann tubes and reached the denervated neuromuscular junctions, instead of the motor nerve. The effect of autonomic nerves on muscle fibres was discussed.

Fundamental frequency modulation of the human voice by the heartbeat: preliminary results and possible mechanisms.

Signal-averaging techniques reveal that the vocal fundamental frequency (F0) of a sustained vowel is modulated over a period equal to that of the speaker's heart cycle. Average F0 deviation varies in an orderly way from about 0.5% to about 1.0% as F0 changes. Location of the peak deviation in the time frame of the heart cycle also changes systematically with vocal F0. Modulation of the vocal F0 is likely to be caused by pressure-related changes in the stiffness of the vascular bed of the vocal folds and by alterations of the geometry of the thyroarytenoid muscle produced by periodic vascular engorgement.

[Vascularization of the larynx. Update of classical anatomic data from an anatomical study of 100 subjects]. / La vascularisation du larynx. Révision des données anatomiques classiques à partir d'une étude anatomique de 100 sujets.

The study was conducted after arterial and venous neoprene latex injection to 100 fresh subjects. Three laryngeal arteries are constant: superior, inferior and posterior. The superior laryngeal artery is of variable origin: in 84% of cases it arises from superior thyroid artery. Anastomoses between the three laryngeal pedicles and the muscle territories supplied by the arteries are described. Vascularization of cartilages is according to a precise plan and cricothyroid and cricoarytenoid joints are the site of constant arterial anatomoses. Origin of superior laryngeal artery fluctuates due to sliding phenomena. The notion of a neurovascular pedicle is fundamental: it is formed by the neural crest derivation and the corresponding artery, that is to say the artery and nerve of a branchial arch. This is to be compared with the notion of pure musculocutaneous and glandular pedicles. The larynx is a junctional zone between 4th and 6th branchial arches and is integrated with the cervicocephalic system of aortic arches.

Tracheal reconstruction with pedicled thyroid cartilage.

Limited areas of tracheal stenosis have been repaired with a variety of techniques. More extensive upper tracheal defects present a greater challenge with less predictable success. The following is the description of yet another technique for reconstruction of extensive upper tracheal defects. We report on the use of a muscle-pedicled thyroid alar graft which carries its own blood supply and perichondrial covering, supplies a large, conveniently shaped graft, requires one operative site and one operative sitting, and has proven advantageous even in the comprised patient.