Evaluation of the Voice
John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford in Head & Neck Surgery Plastic Surgery, 2018
Speech is the expression of or the ability to express thoughts and feelings by articulate sounds. The term voice is often used to refer to speech as a whole. However, when used in the context of voice evaluation, it is generally restricted to the acoustic output resulting from the interaction of vocal fold vibration with the vocal tract in vowel production. Phonation is a term used to describe the physical and physiological processes of vocal fold vibration in the production of speech sounds. Impaired voice production due to abnormal vocal fold vibration is known as dysphonia, while no voice or whispery voice associated with no vocal fold vibration is termed aphonia. Hoarseness is a non-specific, general term used to describe any change in voice quality.
Larynx
Neeraj Sethi, R. James A. England, Neil de Zoysa in Head, Neck and Thyroid Surgery, 2020
At birth the larynx occupies an elevated position within the neck; there is direct communication from the nasopharynx to the laryngeal inlet which channels air inspired through the nose directly into the trachea and lower respiratory tract. This arrangement permits simultaneous breathing and feeding and is evident until 18–24 months of age. After that time the larynx descends and in adults sits low in the neck. This laryngeal descent causes potential compromise of the lower airway from ingested matter, from vomitus or refluxate since the laryngeal inlet (comprising epiglottis, aryepiglottic folds and arytenoid cartilages) can be regarded as a defect in the anterior pharyngeal wall. The mechanisms in place to prevent aspiration include:
Cessation of breathing during swallowing
Temporary elevation of the larynx to approximate the epiglottis to the arytenoid, corniculate and cuneiform cartilages
Opposition of the vocal cords to close off the laryngeal sphincter
Once a swallow has successfully been achieved, descent of the larynx to its resting position occurs along with lateralisation of the vocal cords and return to normal respiration. Phonatory sounds are generated by passage of inhaled air across adducted vocal cords. Various physiological events at the level of the glottis cause the airflow to develop a wave form, the frequency of which varies among males (100–120 Hz), females (180–220 Hz) and children (250–300 Hz). The sound wave generated at the glottis is then modulated through the structures of the supraglottis, oropharynx and oral cavity, which results in resonate, articulated and amplified speech.
Complications of Thyroid Surgery
Madan Laxman Kapre in Thyroid Surgery, 2020
The techniques of RLN repair include primary end-to-end anastomosis, ansa cervicalis to RLN anastomosis, and a primary interposition graft [38]. End-to-end nerve approximation is preferred and can be achieved with three or four perineural stitches of 6.0 or 7.0 suture placed using microsurgical instruments. However, when there is a gap of >5 mm, or the anastomosis is under significant tension, a graft can be taken from the ansa cervicalis, transverse cervical nerve, or supraclavicular nerve [48]. These techniques also apply when sacrifice of the nerve is necessary for oncologic reasons and there is pre-operative vocal cord paralysis, as patients will experience a normal or improved voice post-operatively, secondary to the return of thyroarytenoid muscle tone and bulk, regardless of the length of time of vocal cord palsy [48]. IONM may also be helpful in these scenarios allowing the surgeon to identify the distal stump of the RLN. Non-surgical management for RLN injury includes voice therapy, vocal cord injection augmentation, medialization laryngoplasty (type 1 thyroplasty), arytenoid adduction, and cricothyroid subluxation [38]. Bilateral vocal cord palsy is a life threatening complication associated with thyroidectomy. Previous reports place its incidence at 0.6%, but the advent of IONM and staging procedures have likely decreased this incidence. A recent review by Sarkis et al. of 7,406 patients found the incidence to be much lower at 0.09% [49]. Their work and work by the International Neural Monitoring Study Group corroborate the importance of IONM to avoid this most dreaded complication [44,49]. The typical symptoms include inspiratory stridor, but phonation may be normal due to medial position of the vocal cords. Acutely, the majority of patients will require intubation and subsequent tracheostomy to stabilize the airway prior to definitive treatment [49].
Early acquisition of esophageal phonation following tracheoesophageal Phonation
Published in Acta Oto-Laryngologica, 2006
Hiroshi Iwai, Takashi Shimano, Mariko Omae, Toshihiko Kaneko, Toshio Yamashita
Conclusions. Tracheoesophageal phonation appears to participate in early acquisition of esophageal phonation, which remains the preferred method of voice restoration among patients. Further studies into factors predicting and mechanisms underlying acquisition of esophageal phonation among alaryngeal patients may provide information facilitating superior quality of life. Objective. The aim of this study was to examine early acquisition of esophageal phonation following tracheoesophageal phonation, and underlying mechanisms and preferred phonatory methods for alaryngeal patients who master both tracheoesophageal and esophageal phonation. Patients and methods. Subjects comprised 44 alaryngeal patients and were divided into three groups: group A (n = 13), esophageal phonation alone; group B (n= 21), tracheoesophageal phonation alone; and group C (n = 10), patients who acquired esophageal phonation after learning tracheoesophageal phonation. Results. The results indicated that acquisition of tracheoesophageal phonation significantly accelerated acquisition of esophageal phonation to 59.3 days from 184.6 days. Patients in group C stopped tracheoesophageal phonation and predominantly used esophageal phonation. No factors predicting acquisition of esophageal phonation were identified among patients who had mastered tracheoesophageal phonation, including age at time of surgery, irradiation, neck dissection, acquisition time of tracheoesophageal phonation, and maximum phonation time of tracheoesophageal phonation. No evidence of air leakage through the shunt during esophageal phonation was noted in group C.
Relationship Between 3D Behavior of the Unilaterally Paralyzed Larynx and Aerodynamic Vocal Function
Published in Acta Oto-Laryngologica, 2003
Eiji Yumoto, Koji Nakano, Yukio Oyamada
Objective—We used multi-slice helical computerized tomography (MSHCT) to evaluate the 3D characteristics of the laryngeal structures in patients with unilateral vocal fold paralysis (UVFP) during phonation, and compared the results with those obtained using an aerodynamic vocal function test. Material and methods—The subjects were 37 patients with UVFP. The region over the larynx was scanned during quiet phonation and again during inspiration using MSHCT, and 3D endoscopic and coronal reconstruction images were produced. Maximum phonation time (MPT) and mean airflow rate (MFR) during phonation were measured. Results—During phonation, the affected fold was thinner than the healthy fold in 30 subjects and located at a higher position than the healthy fold in 21 subjects. Abduction or thinning of the affected fold during phonation (paradoxical movement) was seen in seven subjects. MFR was significantly greater when the affected fold was thinner than the healthy fold during phonation, and MPT was significantly shorter when the affected fold showed paradoxical movement. Over-adduction of the healthy fold during phonation was present in 15 subjects. There were no significant differences in MPT or MFR between subjects with and without over-adduction. Conclusion—The combination of MSHCT endoscopic and coronal reconstruction images enables the 3D characteristics of the unilaterally paralyzed larynx to be visualized during phonation, and some of these characteristics are significantly correlated with vocal function in patients with UVFP.
Brain activity during phonation in healthy female singers with supraglottic compression: an fMRI pilot study
Published in Logopedics Phoniatrics Vocology, 2019
Maryna Kryshtopava, Kristiane Van Lierde, Charlotte Defrancq, Michiel De Moor, Zoë Thijs, Evelien D'Haeseleer, Iris Meerschman, Pieter Vandemaele, Guy Vingerhoets, Sofie Claeys
This pilot study evaluated the usability of functional magnetic resonance imaging (fMRI) to detect brain activation during phonation in healthy female singers with supraglottic compression. Four healthy female classical singers (mean age: 26 years) participated in the study. All subjects had normal vocal folds and vocal characteristics and showed supraglottic compression. The fMRI experiment was carried out using a block design paradigm. Brain activation during phonation and exhalation was analyzed using Brain Voyager software (Brain Innovation B.V., Maastricht, The Netherlands). An fMRI data analysis showed a significant effect of phonation control in the bilateral pre/postcentral gyrus, and in the frontal, cingulate, superior and middle temporal gyrus, as well as in the parietal lobe, insula, lingual gyrus, cerebellum, thalamus and brainstem. These activation areas are consistent with previous reports using other fMRI protocols. In addition, a significant effect of phonation compared to exhalation control was found in the bilateral superior temporal gyrus, and the pre/postcentral gyrus. This fMRI pilot study allowed to detect a normal pattern of brain activity during phonation in healthy female singers with supraglottic compression using the proposed protocol. However, the pilot study detected problems with the experimental material/procedures that would necessitate refining the fMRI protocol. The phonation tasks were not capable to show brain activation difference between high-pitched and comfortable phonation. Further fMRI studies manipulating vocal parameters during phonation of the vowels /a/ and /i/ may elicit more distinctive hemodynamic response (HDR) activity patterns relative to voice modulation.
Related Knowledge Centers
- Vocal Folds
- Larynx
- Glottis