[Recurrent laryngeal papillomatosis]. / Rezidivierende Larynxpapillomatose.

Human papillomaviruses (HPV) 6 and 11 cause 90% of recurrent laryngeal papillomatosis (RLP). It is unclear whether recurrences are caused by new infections or the spread of infected cells. Symptomatic and sometimes curative treatment is laser surgery or conventional microsurgical removal. RLP surgery aims to relieve shortness of breath and improve the voice. Patients (especially children) are affected by voice problems, repetitive surgeries, pulmonary manifestations, and psychological trauma. Vaccination with Gardasil 9 (Merck & Co., Rahway, NJ, USA) prevents new infections with HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58 and induces vaccine antigen-specific antibodies and CD4+ T helper cells. According to current studies, RLP can be avoided with prophylactic vaccination. The treatment is associated with a general vaccination risk (European Medicines Agency approval: girls and boys from 9 years). Studies also show that the vaccine after removal of HPV-associated neoplasia/papilloma prevents recurrences. Extension of the vaccination recommendation to prevent recurrences of HPV-associated diseases in men may promote applicability and herd immunity. For rare and treatment-refractory cases with laryngotracheal involvement, systemic therapy with bevacizumab (e.g. Avastin; Genentech, San Francisco, CA, USA), a VEGF antibody, is a promising adjuvant treatment option.

[Injection Glottoplasty]. / Injektionsglottoplastik.

Glottal insufficiency often causes voice problems, but also dysphagia, dyspnoe while speaking as well as a limited global strength and endurance. Injection glottoplasty represents a valid therapeutic option. This article describes indication, materials, technique, and outcome expectations. For selection of the appropriate material and technique morphological changes and parameters of vocal function should be considered.

Female Classical Singers Apply Different Resonatory Strategies Than Male: Insights from an MRI-Based Analysis.

INTRODUCTION: The morphology of the vocal tract plays a crucial role in singing. Adjustments of the lower part of the vocal tract are essential for voice quality and timbre. Structured investigations of this region are challenging due to the small extent of the morphological modifications. MATERIAL AND METHODS: This study analyzed the morphology of the endolaryngeal tube and parts of the surrounding hypopharynx for the sustained vowels /a/, /e/, /i/, //, and // by 11 female singer subjects who were at the beginning of their academic singing studies. As in a previous study with male subjects, analysis was based on two phonatory conditions: a natural, speech-like phonation and a singing phonation, like in classical singing. By means of 3D image processing from magnetic resonance imaging, multiple measures were derived. The data were statistically analyzed using linear mixed effects models and ANOVA. RESULTS: The female singers enlarged the ratio of the endolaryngeal tube to the adjacent hypopharynx for singing. DISCUSSION: In contrast to the findings of the male singers in a previous study, the ratios of the laryngeal volumes to the neighboring hypopharynx increased while singing. The female singer subjects of the present study increased those ratios, mediated by an over-proportional enlargement of the endolaryngeal tube. Existing acoustic differences to male singers are thus given a morphological basis. CONCLUSION: The study gives insight into the characteristic adjustments of the vocal tract of female classical singers. The resonatory strategies for females in classical singing differ from those found in males.

Relationship between epilarynx tube shape and the radiated sound pressure level during phonation is gender specific.

OBJECTIVE/HYPOTHESIS: The aim of the study was to measure the morphology of the epilaryngeal tube during sustained phonation as a function of loudness variation and to compare subjects of different genders. STUDY DESIGN: This is a prospective study. METHODS: Five female and five male classically trained singers were recorded by magnetic resonance imaging with simultaneous audio recordings while sustaining phonation at three different loudness conditions. Three-dimensional subsections of the vocal tract were segmented on multi-image-based cross-sections. Different volume and area measures were determined and their relation to sound pressure level and loudness condition was analyzed. RESULTS: Male singers tended to narrow the epilaryngeal tube when increasing sound pressure level whereas female singers did not. CONCLUSION: Strategies of vocal tract adjustments during loudness variation in classical singing appear to be gender specific.

How to precisely measure the volume velocity transfer function of physical vocal tract models by external excitation.

Recently, 3D printing has been increasingly used to create physical models of the vocal tract with geometries obtained from magnetic resonance imaging. These printed models allow measuring the vocal tract transfer function, which is not reliably possible in vivo for the vocal tract of living humans. The transfer functions enable the detailed examination of the acoustic effects of specific articulatory strategies in speaking and singing, and the validation of acoustic plane-wave models for realistic vocal tract geometries in articulatory speech synthesis. To measure the acoustic transfer function of 3D-printed models, two techniques have been described: (1) excitation of the models with a broadband sound source at the glottis and measurement of the sound pressure radiated from the lips, and (2) excitation of the models with an external source in front of the lips and measurement of the sound pressure inside the models at the glottal end. The former method is more frequently used and more intuitive due to its similarity to speech production. However, the latter method avoids the intricate problem of constructing a suitable broadband glottal source and is therefore more effective. It has been shown to yield a transfer function similar, but not exactly equal to the volume velocity transfer function between the glottis and the lips, which is usually used to characterize vocal tract acoustics. Here, we revisit this method and show both, theoretically and experimentally, how it can be extended to yield the precise volume velocity transfer function of the vocal tract.

Three-dimensional Vocal Tract Morphology Based on Multiple Magnetic Resonance Images Is Highly Reproducible During Sustained Phonation.

OBJECTIVES: The extraction of a three-dimensional (3D) morphology of the human vocal tract (VT) from magnetic resonance imaging (MRI) during sustained phonation can be used for various analyses like numerical simulations or creating physical models. The precision of visualizing techniques nowadays allows for very targeted acoustical simulation evaluating the influence of subsections of the VT for the transfer function. The aim of the study was to assess the accuracy of the 3D geometry based on MRI data in repetitive trials. STUDY DESIGN: This is a prospective study. METHODS: Four experienced singers underwent an MRI while repeating a specific vocal task 20 times consecutively. Audio recordings were made by means of an optical microphone. Images were restacked and subsections of the VT were segmented on multi-image-based cross sections using a semiautomatic algorithm. Different volume and area measures were evaluated. RESULTS: A high reproducibility of the morphologic data based on multiple images by means of the applied segmentation method could be shown with an overall variation of around 8%. CONCLUSIONS: 3D modeling of the VT during sustained phonation involves a complex experimental setting and elaborate image processing techniques. Functional comparative analysis or acoustical simulations based on such data should take the found variability into account.

Adult Cochlear Implant Users Are Able to Discriminate Basic Tonal Features in Musical Patterns: Evidence From Event-related Potentials.

OBJECTIVE: Measurement of electrophysiological correlates of discrimination abilities of basic musical features in pre- and postlingually deafened adult cochlear implant (CI) users. STUDY DESIGN: Electroencephalographic study. Comparison between CI users and matched normal hearing controls. PATIENTS: Thirty-six hearing impaired adults using a cochlear implant for 4 to 15 months. Profound hearing impairment was acquired either before (N = 12) or after language acquisition (N = 17). Seven patients suffered from a single-sided deafness. METHODS: Presentation of auditory stimuli consisting of musical four tone standard patterns and deviant patterns varying with regard to tone pitch, timbre, intensity, and rhythm of two different degrees. Analysis of electrophysiological, event-related mismatch responses. RESULTS: Cochlear implant users elicited significant mismatch responses on most deviant features. Comparison to controls revealed significantly smaller mismatch negativity amplitudes. Except for one parameter (pitch) there were no reliable differences between pre- and postlingually deafened CI users. CONCLUSION: Despite a highly reduced complexity of neural auditory stimulation by the cochlear implant device in comparison to the physiological cochlear input, CI users exhibit cortical discriminatory responses to relatively subtle basic tonal alterations.

A Fast Semiautomatic Algorithm for Centerline-Based Vocal Tract Segmentation.

Vocal tract morphology is an important factor in voice production. Its analysis has potential implications for educational matters as well as medical issues like voice therapy. The knowledge of the complex adjustments in the spatial geometry of the vocal tract during phonation is still limited. For a major part, this is due to difficulties in acquiring geometry data of the vocal tract in the process of voice production. In this study, a centerline-based segmentation method using active contours was introduced to extract the geometry data of the vocal tract obtained with MRI during sustained vowel phonation. The applied semiautomatic algorithm was found to be time- and interaction-efficient and allowed performing various three-dimensional measurements on the resulting model. The method is suitable for an improved detailed analysis of the vocal tract morphology during speech or singing which might give some insights into the underlying mechanical processes.

Formant frequencies and bandwidths of the vocal tract transfer function are affected by the mechanical impedance of the vocal tract wall.

The acoustical properties of the vocal tract, the air-filled cavity between the vocal folds and the mouth opening, are determined by its individual geometry, the physical properties of the air and of its boundaries. In this article, we address the necessity of complex impedance boundary conditions at the mouth opening and at the border of the acoustical domain inside the human vocal tract. Using finite element models based on MRI data for spoken and sung vowels /a/, /i/ and /Ω(-1)/ and comparison of the transfer characteristics by analysis of acoustical data using an inverse filtering method, the global wall impedance showed a frequency-dependent behaviour and depends on the produced vowel and therefore on the individual vocal tract geometry. The values of the normalised inertial component (represented by the imaginary part of the impedance) ranged from 250 g/m(2) at frequencies higher than about 3 kHz up to about 2.5 × 10(5) g/m(2)in the mid-frequency range around 1.5-3 kHz. In contrast, the normalised dissipation (represented by the real part of the impedance) ranged from 65 to 4.5 × 10(5) Ns/m(3). These results indicate that structures enclosing the vocal tract (e.g. oral and pharyngeal mucosa and muscle tissues), especially their mechanical properties, influence the transfer of the acoustical energy and the position and bandwidth of the formant frequencies. It implies that the timbre characteristics of vowel sounds are likely to be tuned by specific control of relaxation and strain of the surrounding structures of the vocal tract.

Lower Vocal Tract Morphologic Adjustments Are Relevant for Voice Timbre in Singing.

The vocal tract shape is crucial to voice production. Its lower part seems particularly relevant for voice timbre. This study analyzes the detailed morphology of parts of the epilaryngeal tube and the hypopharynx for the sustained German vowels /a/, /e/, /i/, /o/, and /u/ by thirteen male singer subjects who were at the beginning of their academic singing studies. Analysis was based on two different phonatory conditions: a natural, speech-like phonation and a singing phonation, like in classical singing. 3D models of the vocal tract were derived from magnetic resonance imaging and compared with long-term average spectrum analysis of audio recordings from the same subjects. Comparison of singing to the speech-like phonation, which served as reference, showed significant adjustments of the lower vocal tract: an average lowering of the larynx by 8 mm and an increase of the hypopharyngeal cross-sectional area (+ 21:9%) and volume (+ 16:8%). Changes in the analyzed epilaryngeal portion of the vocal tract were not significant. Consequently, lower larynx-to-hypopharynx area and volume ratios were found in singing compared to the speech-like phonation. All evaluated measures of the lower vocal tract varied significantly with vowel quality. Acoustically, an increase of high frequency energy in singing correlated with a wider hypopharyngeal area. The findings offer an explanation how classical male singers might succeed in producing a voice timbre with increased high frequency energy, creating a singer`s formant cluster.

The Young's procedure for severe epistaxis from hereditary hemorrhagic telangiectasia.

BACKGROUND: Surgical treatment of epistaxis in hereditary hemorrhagic telangiectasia (HHT) has historically been managed with the laser procedure or the septodermoplasty procedure. For transfusion-dependent patients with severe epistaxis we have been performing the Young's procedure or surgical closure of the nostrils. The objective of this study was to report treatment of severe epistaxis related to HHT with the Young's procedure and assess patient outcome. METHODS: Patients with severe iron or blood transfusion-dependent epistaxis who underwent a Young's procedure in three otolaryngology HHT centers were reviewed. Patients were evaluated for postoperative epistaxis and subjective outcome. RESULTS: Forty-three patients underwent a Young's procedure for severe epistaxis and were observed for a mean of 34 months. The procedure was well tolerated by all patients and 30 of 36 patients (83%) experienced complete cessation of bleeding after the Young's procedure. Patients had a mean increase in hemoglobin of 4.68 g/dL after the procedure. The average Glasgow Benefit Inventory score after surgery was 43.56. No patients requested a reversal of the procedure. CONCLUSION: The Young's procedure is a safe and efficacious procedure with complete cessation of epistaxis in most patients with severe epistaxis and HHT.