Adam D. Rubin

Changes in glottal contact quotient during resonance tube phonation and phonation with vibrato.

Phonating into narrow hard-walled tubes of varying diameters and length as an extension of the vocal tract is considered a semioccluded vocal tract exercise. Semioccluded vocal tract postures have been postulated to have a therapeutic effect during the treatment of the dysphonic patient. They appear to affect at least two components of the voice source (1) glottal flow pulse and (2) vibrational characteristics of the vocal folds. Vibrato also has been described as a possible therapeutic tool and may decrease phonatory hyperfunction. The aim of this study was to determine the influence of resonance tubes and phonation with vibrato on the closed quotient. Thirty-six adult classical singers were recruited for this study. Subjects were asked to produce four phonatory tasks at comfortable pitch and loudness: sustained vowel [a:] without vibrato, sustained vowel [a:] with vibrato, sustained phonation into a straw without vibrato, and sustained phonation into a straw with vibrato. Computer analysis of the contact quotient (CQ) was performed for each type of phonation in every participant. An increase in CQ variability was observed during tube phonation when compared with vowel phonation. Although there was a decrease in the mean CQ values when comparing vowel phonation without vibrato with the other three phonatory tasks, the difference was not statistically significant. Intrasubject analysis demonstrated a decrease in the CQ during tube and vibrato phonation in most of the participants. Although a causal relationship is not proven, this finding suggests that the use of straws and vibrato during phonation may have potential therapeutic value in the treatment of patients with hyperfunctional voice disorders.

Delivery of an Adenoviral Vector to the Crushed Recurrent Laryngeal Nerve

Objectives Objectives were to create a model of recurrent laryngeal nerve injury for testing the efficacy of potential therapeutic viral gene therapy vectors and to demonstrate that remote injection of a viral vector does not cause significant additional neuronal injury.

Vocal Fold Paresis and Paralysis: What the Thyroid Surgeon Should Know

The thyroid surgeon must have a thorough understanding of laryngeal neuroanatomy and be able to recognize symptoms of vocal fold paresis and paralysis. Neuropraxia may occur even with excellent surgical technique. Patients should be counseled appropriately, particularly if they are professional voice users. Preoperative or early postoperative changes in voice, swallowing, and airway function should prompt immediate referral to an otolaryngologist. Early recognition and treatment may avoid the development of complications and improve patient quality of life.

Remote delivery of rAAV-GFP to the rat brainstem through the recurrent laryngeal nerve

Objective To demonstrate that a recombinant adeno‐associated viral vector (rAAV) carrying the gene for green fluorescent protein (GFP) could be delivered to the rat brainstem by remote injection into the recurrent laryngeal nerve.

Laryngeal paraganglioma in a patient with multiple head and neck paragangliomas

Paragangliomas of the larynx are rare neuroendocrine tumors, with fewer than 70 cases reported in the literature. 1 Typically, laryngeal paragangliomas are not found in patients with multicentric or familial paragangliomas. Only 1 case of laryngeal paraganglioma has been reported in a patient with a synchronous lesion elsewhere (carotid body tumor). 2 We report an additional case of a patient with a laryngeal and multiple other paragangliomas.

Sinus inflammation associated with contralateral inverted papilloma.

Objective To assess with computerized tomography (CT) the association of unilateral inverted papilloma (IP) and contralateral sinus inflammation. Design Retrospective analysis of CT findings in a sample of patients with unilateral IP, a sample with other unilateral sinonasal tumors, and normal controls. Patients and Methods Sixteen patients with unilateral IP comprised the study population. Nine patients with other unilateral sinonasal tumors (five with squamous papilloma, two with squamous cell carcinoma, and one each with adenocarcinoma and large cell carcinoma) were used as a comparison population. Patients undergoing maxillofacial CT for nontraumatic orbital conditions comprised the control sample (n = 12 sides). Each patients preoperative CT scan was evaluated with a modified Lund-Mackay scoring system. The scores for the sides opposite the IPs were compared with the sides contralateral to other sinonasal tumors as well as to normal controls. Results Analysis of all three samples’ contralateral sides simultaneously using analysis of variance revealed a difference (p = 0.010). The contralateral sinus scores in IPs tended to be higher than the sides opposite the other sinonasal tumors (mean, 2.66 ± 1.07 versus 1.18 ± 0.76; p = 0.06). These in turn were higher than the normal controls (mean, 0.75 ± 0.48; p < 0.02). Conclusions Unilateral IPs are associated with contralateral inflammation as detected by CT. This degree of contralateral inflammation is greater than that seen in other sinonasal tumors. The etiology of this association is unclear. A recent histological review suggested IP is an inflammatory polyp and not a true papilloma. Our data further suggest inflammation may be involved in the pathogenesis of IP. Further work is needed to better understand the pathophysiology and behavior of IP and to define its relationship to sinus inflammation.

Glottic Closure Patterns: Type I Thyroplasty Versus Type I Thyroplasty With Arytenoid Adduction

OBJECTIVES/HYPOTHESIS The goal of laryngeal framework surgery in patients with unilateral vocal fold paralysis is to improve glottic closure by medializing the paralyzed vocal fold. Type I thyroplasty (Th) and arytenoid adduction (AA) are two of the most commonly performed procedures. Two of the main rationales for performing an AA are to improve closure of the posterior glottis and correct vertical height discrepancy. The purpose of this study was to evaluate if AA with Th yields better posterior glottic closure and vertical height equality than Th alone. STUDY DESIGN Retrospective. METHODS Using visual analog scales, three blinded reviewers evaluated glottic closure patterns in patients who underwent Th or Th with AA. Pre- and postoperative videostroboscopic examinations of 45 patients with unilateral vocal fold paralysis, who underwent laryngeal framework surgery, were evaluated. RESULTS No significant difference was identified in postoperative scores for midmembranous glottis closure (P=0.282), closure just anterior to the vocal processes (P=0.426), respiratory glottis closure (P=0.158), or vertical height discrepancy (P=0.113). CONCLUSIONS Although larger glottic gaps and vertical height discrepancies may lead some surgeons to predict that an AA is warranted, the usefulness of AA may not always be related to these parameters. Ultimately, voice improvement and not geometry should guide the surgeons decision making.

Neuromuscular electrical stimulation of the cricothyroid muscle in patients with suspected superior laryngeal nerve weakness.

In this retrospective case study, we report the apparent clinical effectiveness of neuromuscular electrical stimulation (NMES) in combination with voice therapy (VT) for rehabilitating dysphonia secondary to suspected superior laryngeal nerve (SLN) weakness in two female patients. Both patients failed or plateaued with traditional VT but had significant improvement with the addition of NMES of the cricothyroid muscle and SLN using a VitalStim unit. Stimulation was provided simultaneously with voice exercises based on musical phonatory tasks. Both acoustic analysis and endoscopic evaluation demonstrated important improvements after treatment. In the first patient, the major change was obtained within the primo passaggio region; specifically, a decrease in voice breaks was demonstrated. In the second patient, an improvement in voice quality (less breathiness) and vocal range were the most important findings. Additionally, each patient reported a significant improvement in their voice complaints. Neuromuscular laryngeal electrical stimulation in combination with vocal exercises might be a useful tool to improve voice quality in patients with SLN injury.

Dysphagia Due to Inclusion Body Myositis: Case Presentation and Review of the Literature

Objective: This report aimed to present a case of inclusion body myositis presenting with dysphagia and to review the literature. Methods: Case report and literature review. Results: Inclusion body myositis is a chronic progressive acquired myopathy, uniquely distinguished by its selective muscle involvement, normal or moderately elevated muscle enzyme concentrations, and a progressive corticosteroid-resistant course. Compared to other inflammatory myopathies, the esophagus is the most commonly involved organ. Specifically, upper esophageal sphincter dysfunction often occurs. Dysphagia may be the only symptom at the time of presentation. Conclusion: Unlike other inflammatory myopathies, dysphagia in inclusion body myositis is steroid resistant. Management can be difficult. The otolaryngologist must consider underlying neuromuscular processes when evaluating the patient presenting with oropharyngeal dysphagia.

Dysfunction of the recurrent laryngeal nerve and the potential of gene therapy.

Injury to the recurrent laryngeal nerve causes vocal fold paresis or paralysis resulting in poor voice quality, and possibly swallowing dysfunction and/or airway compromise. Injury can occur as part of a neurodegenerative disease process or can be due to direct nerve trauma or tumor invasion. Management depends upon symptoms, the cause and severity of injury, and the prognosis for recovery of nerve function. Surgical treatment techniques can improve symptoms, but do not restore physiologic motion. Gene therapy may be a useful adjunct to enhance nerve regeneration in the setting of neurodegenerative disease or trauma. Remote injection of viral vectors into the recurrent laryngeal nerve is the least invasive way to deliver neurotrophic factors to the nerves cell bodies within the nucleus ambiguus, and in turn to promote nerve regeneration and enhance both nuclear and nerve survival. The purpose of this review is to discuss the potential role for gene therapy in treatment of the unsolved problem of vocal fold paralysis.