Hyaluronic Acid Concentration in Female Vocal Folds With Reinke's Edema

OBJECTIVE

The aim of the present study was to investigate hyaluronic acid (HA) concentrations in vocal folds among patients with Reinke's edema.

STUDY DESIGN

Prospective and experimental study.

SETTING

Single tertiary center.

METHODS

An HA binding protein isolated from bovine nasal cartilage was used to identify and isolate the HA from samples. Plates coated with biotin-conjugated binding protein and streptavidin-europium conjugate were sequentially incubated with 18 Reinke's edema samples and 11 female vocal fold cover samples from cadavers (the superficial layer of the lamina propria; control group). After the release of europium from streptavidin in enhancement solution, final fluorescence was measured in a fluorometer.

RESULTS

The mean HA concentration in Reinke's edema vocal folds was significantly higher than that in the control vocal folds (9.2 × 10³ vs 0.9 × 10³µg/g).

CONCLUSION

Vocal fold covers affected by Reinke's edema present a higher concentration of HA than do vocal fold covers with no edema.

Pharyngeal Motility Before and After Thyroarytenoid Muscle Botulinum Toxin Injection

Botulinum toxin type A (BTA) injection in intrinsic laryngeal musculature may result in dysphagia and consequent loss of quality of life (QOL) in a percentage of patients. This study aims to evaluate pharyngeal motility as a putative cause for this change in swallow quality in light of high-resolution manometry (HRM). Twenty patients (95% females, median age 66 years) underwent high-resolution manometry before and after BTA injection. Dysphagia was evaluated based on a QOL dedicated questionnaire (SWAL-QOL) before and after BTA injection. Pharyngeal motility at the topography of the vellum, epiglottis, and upper esophageal sphincter (UES) were recorded. Eleven (55%) subjects had worsened QOL after BTA injection. In patients with worsened QOL, UES extension decreased (p = 0.005), UES residual pressure increased (p = 0.02), UES basal pressure decreased (p = 0.04), and velopharynx contraction duration decreased (p = 0.04). UES residual pressure increased (p = 0.01), velopharynx peak pressure (p = 0.04) and upstroke (p = 0.007) decreased in patients with maintained QOL. There was no difference between groups when comparing pre-injection values. UES extension (p = 0.01) and UES maximum relaxation time (p = 0.03) was lower in the group with worsened QOL after BTA as compared to no change in QOL. Pharyngeal motility as measured by HRM was not a predictor for post procedure dysphagia and the changes in motility after BTA injection does not seem to be a strong contributor to dysphagia.

Prevalence of Minor Larynx Structural Alterations: Influence on the Concept of a Normal Vocal Fold

OBJECTIVE

To determine the prevalence of minor structural alterations (MSA) in the vocal fold cover in a population submitted to extralaryngeal site surgery and to characterize them according to morphological and epidemiological parameters.

STUDY DESIGN

This was a cross-sectional and observational study.

SETTING

Tertiary referral medical center.

SUBJECTS AND METHODS

A total of 147 patients underwent general anesthesia for extralaryngeal site surgery indicated for a procedure extraneous to the study and irrespective of the presence of vocal complaint. Next, detection and morphological characterization of MSAs in the vocal fold cover were performed by means of suspension microlaryngoscopy with laryngeal inspection and palpation without surgical intervention related to this procedure. The laryngeal findings were compared with variables from a clinical and demographic characteristics questionnaire given to these individuals.

RESULTS

A 21.1% prevalence of MSAs was identified in the sample, which included a majority of individuals without vocal complaint (95.9%). Of these, 5.4% of individuals had laryngeal microdiaphragms, 16.3% sulcus vocalis, and 4.1% epidermoid cysts. No pouch sulcus or mucosal bridges were found. The identification of these alterations occurred mainly after 10 years of age, without effects of sex, vocal abuse, or upper airway conditions. The most common combination of MSAs was bilateral sulcus vocalis.

CONCLUSIONS

The prevalence of MSAs in laryngeal coverage in this predominantly vocally asymptomatic population was 21.1%, with identification of sulcus vocalis, epidermoid cyst, and laryngeal microdiaphragm. Age was the only clinical or demographic characteristic associated with these alterations.

Comparison of botulinum toxin and propranolol for essential and dystonic vocal tremors

OBJECTIVES

Vocal tremors, which cause social difficulties for patients, may be classified as resting or action tremors. Of the vocal action tremors, essential and dystonic tremors are the most common. Botulinum toxin and oral medications have been used to treat vocal tremors, but no comparative clinical trials have been performed. The aim of this study was to compare the effects of botulinum toxin injection and the oral administration of propranolol in the treatment of essential and dystonic vocal tremors.

METHODS

This clinical trial recruited 15 patients, divided into essential and dystonic vocal tremor groups. Patients in both groups received successive treatment with botulinum toxin and propranolol. The treatments were administered at different times; the order of treatment was randomly selected. Patients were assessed with flexible nasofibrolaryngoscopy and with perceptual and acoustic voice evaluations. A statistical significance level of 0.05 (5%) was used.

RESULTS

Botulinum toxin produced statistically significant improvements in perceptual measures of vocal instability in patients with dystonic vocal tremors compared with baseline values and treatment with propranolol. The acoustic measure of variability in the fundamental frequency was significantly lower in patients with dystonic vocal tremors after treatment with botulinum toxin.

CONCLUSION

Essential and dystonic vocal tremors responded differently to treatment. Dystonic vocal tremors responded significantly to treatment with botulinum toxin but not oral propranolol. Essential vocal tremors did not respond significantly to either treatment, perhaps due to the small number of patients, which is a limitation of this research.

Sulfated glycosaminoglycans in human vocal fold lamina propria

Introduction

The distribution, concentration and function of glycosaminoglycans in the various vocal fold tissues are still unclear.

Objective

To evaluate the distribution and concentration of sulfated glycosaminoglycans in different layers of the human vocal fold according to gender and age.

Methods

We used 11 vocal folds obtained from cadavers (7 men and 4 women) with no laryngeal lesion, less than 12 h after death, and aged between 35 and 98 years. The folds underwent glycosaminoglycans extraction from the cover and ligament, and post-electrophoresis analysis. Data were compared according to the layer, age and gender.

Results

The concentration of dermatan sulfate was significantly higher in all layers. No differences were observed in the total concentrations of glycosaminoglycans in layers studied according to gender. It is significantly lower in the cover of individuals aged below 60 years.

Conclusion

Dermatan sulfate, chondroitin sulfate, and heparan sulfate were observed in the human vocal folds cover and ligament of both genders, with the concentration of dermatan sulfate being significantly higher in all layers. Glycosaminoglycans concentration on the cover is significantly lower in individuals below 60 years compared with elderly.

Laryngeal electromyography in dysphonic patients with incomplete glottic closure

The lack of specificity in laryngoscopical examination requires that the diagnosis of superior laryngeal and recurrent laryngeal nerve involvement be carried out with the aid of electromyography.

Objective

This study aims to assess the electrophysiological function of the superior and inferior laryngeal nerves by measuring the electrical activity of the muscles they innervate in dysphonic patients with incomplete closure of the vocal folds during phonation.

Method

Thirty-nine patients with incomplete glottic closure were enrolled in a prospective study and had their cricothyroid, thyroarytenoid, and lateral cricoarytenoid muscles examined bilaterally through electromyography. Insertion activity, electrical activity at rest (fibrillation, positive wave and fasciculation) and during muscle voluntary contraction (recruitment, amplitude, potential length and latency between electrical activity and phonation) were measured.

Results

No altered test results were observed for parameters insertion activity and electrical activity at rest. None of the patients had recruitment dysfunction. The mean electrical potential amplitude values were within normal range for the tested muscles, as were potential durations and latency times between the onset of electrical activity and phonation.

Conclusion

No signs of denervation were seen in the thyroarytenoid, cricothyroid, and lateral cricoarytenoid muscles of the studied patients.

Concentration of hyaluronic acid in human vocal folds in young and old subjects

OBJECTIVE

To compare and evaluate concentrations of hyaluronic acid (HA) in normal vocal folds of both young and elderly people of both sexes.

STUDY DESIGN

Experimental study.

SETTING

The research was carried out at the ENT, Head and Neck Surgery Department and the Pharmacology Institute of São Paulo Federal University.

SUBJECTS AND METHODS

Enzyme-linked immunosorbent assay plates coated with biotin-conjugated binding protein and streptavidin-europium conjugate were sequentially incubated with samples from the middle portion of the cover, vocal ligament, and vocal muscle of 19 young and 20 elderly subjects of both sexes. After the release of europium in an enhancement solution, final fluorescence was measured using a fluorometer.

RESULTS

Statistically significant comparisons: (1) all subject groups combined exhibited a higher HA concentration in the cover and ligament compared with the muscle samples; (2) women subjects had a significantly lower HA concentration in muscle compared with the ligament, and male subjects showed significantly lower HA in muscle compared with the cover; and (3) both genders of young subjects showed a higher HA concentration in ligament samples compared with the muscle.

CONCLUSION

HA concentrations are higher in the cover and ligament compared with the muscle in both genders and age groups, and there is a higher HA concentration in ligament compared with the muscle of young subjects of both genders. HA levels in the cover samples of younger women showed great variability that may relate to ovarian hormone levels, reflecting different phases of the menstrual cycle.

Comparison of clinical characteristics of patients with adductor laryngeal dystonia in the focal and segmental types

Dystonia is a central motor processing neurological disorder characterized by abnormal, often action-induced, involuntary movements or uncontrolled spasms.

AIM

To compare patients with the diagnoses of focal and segmental adductor laryngeal dystonia at the Neurolarynx Outpatient Clinic of the Federal University of São Paulo.

MATERIALS AND METHODS

A clinical retrospective study of data collected from patient registries from 2003 to 2009.

RESULTS

Of 34 patients, 25 presented focal dystonia and 9 presented segmental dystonia. There were 30 females (88. 2%) and 4 males (11. 8%). A relation with a traumatic event was reported in 11 cases (32. 4%). Vocal tremor was observed in 21 patients (61. 8%). The mean age at onset, the age at diagnosis, and time between the onset and the diagnosis were respectively 55, 61. 3 and 6. 3 years. There was no statistical difference between patients with focal laryngeal adductor dystonia and segmental dystonia in the study data.

CONCLUSIONS

There were no statistical differences among patients with focal adductor laryngeal dystonia and segmental dystonia relating to age of onset, age of diagnosis, gender, time between onset and diagnosis, presence of associated tremor, and relation to trauma.

The difficult management of patients with respiratory segmental Dystonia

Respiratory dystonia is a rare and difficult to diagnose disorder, that causes breathing restriction of various degrees. The objective of the study is to report the case of a patient with respiratory dystonia involving the larynx and the pharynx and its evolution concerning spasms intensity and control.

CASE REPORT

A 24 year-old-man has been followed for 5 years. The diagnosis was made by means of nasofibroscopy and electromyography. Treatment was carried out with laryngeal and pharyngeal Botulin toxin injections, as it became necessary for symptoms control.

CONCLUSION

The difficult management can be secondary to the lack of knowledge on the etiology and physiopathology of the impairment, and because of the limitations in the treatment of associated respiratory symptoms.

Adduction laryngeal dystonia: proposal and evaluation of nasofibroscopy

Dystonias are organic central motor processing disorders characterized by involuntary muscular contractions or incontrollable spasms induced by task-specific movements. Adduction laryngeal dystonias present with important speech impairments, with inappropriate spasms and abrupt voice breaks. The diagnosis is based on clinical features, evaluation by a speech therapist and transnasal fiber optic laryngoscopy.

AIM

Our objective is to propose and evaluate a task-oriented transnasal fiber optic laryngoscopy protocol, which shows the spasms, and propose maneuvers that reduce or make them disappear, in order to facilitate the diagnosis.

METHODS

transversal study. Analysis of the transnasal fiber optic laryngoscopy records of 15 patients with adductor laryngeal dystonia using the proposed protocol.

RESULTS

most of the speech and non-vocal tasks allowed us to identify the spasms and reduce or make them disappear. We propose the exclusion of two of the maneuvers that dont bring new data to the evaluation.

CONCLUSION

the protocol was useful for the evaluation of the patients, showing changes in muscle behavior in the structure under investigation.

Immunohistochemistry as a method to study elastic fibers of human vocal fold

Aim: Verify the use of immunohistochemistry as a method to measure all forms of elastic fibers at human vocal folds. Study design: transversal cohort. Material and method: We collected vocal folds following these criterion: age between 25 and 40, Caucasian men, dead by gun shot, within 12 hours of death, without instrumentation of the larynx or suspicion of neck injury and without mucosal lesions noted by microscopy. Ten vocal folds were collected and one, of a man aged 28 years, was selected to study. The vocal fold was transversely cut in 9 regions and in each segment three slides were made. These slides were stained by Verhoeff and Weighert´s resorcin-fuchsin and used for immunohistochemistry. The elastic compound was measured by colorimetric software analysis. Results: In Verhoeff and Weighert´s resorcin-fuchsin, the intermediate and deep layer showed values higher than those of the superficial layer. The amount of tropoelastin identified by the antibody at the superficial layer was close to those of intermediate and deep layer. Conclusions: Immunohistochemistry is a method that can identify and measure all forms of elastic fibers at human vocal fold.

Changes in eating habits following total and frontolateral laryngectomy

CONTEXT

Swallowing is a continuous dynamic process, characterized by complex stages, that involves structures of the oral cavity, pharynx, larynx and esophagus. It can be divided into three phases: oral, pharyngeal and esophageal. Dysphagia is characterized by difficulty with, or the inability to swallow food of normal consistencies.

OBJECTIVE

To investigate the presence of swallowing difficulties and modifications made to the consistency of the food consumed in cases of total and partial laryngectomy, with or without subsequent radiotherapy, among patients who had not been diagnosed as having dysphagia.

TYPE OF STUDY

Descriptive study.

SETTING

Voice Clinic of São Paulo Hospital, Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, Brazil.

METHOD

36 laryngectomy patients: 25 total and 11 frontolateral cases, were studied. A survey consisting of a 23-item questionnaire was applied by a single professional.

RESULTS

Among those interviewed, 44% reported having modified the consistency of the food consumed (56% of the total and 20% of the partial frontolateral laryngectomy cases). It was not possible to investigate the influence of radiotherapy on the groups in this study, because the partial frontolateral laryngectomy cases were not exposed to radiotherapy. There was a higher incidence of complaints of swallowing difficulties in total laryngectomy cases (p < 0.027) than in partial frontolateral cases. However, there was no relationship between the surgery and weight loss. We also noted the patients' other problems regarding the eating process, as well as the compensation that they made for such problems.

DISCUSSION

Research has shown an association between laryngectomy and swallowing difficulties, although there have been no reports of associated changes in eating habits among laryngectomized patients.

CONCLUSIONS

This study showed that difficulty in swallowing is not rare in total and frontolateral laryngectomy cases. Such patients, even those who did not complain of dysphagia, also had minor difficulties while eating, and had to make some adaptations to their meals.