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ABSTRACT: Objectives: To compare the prevalence of laryngopharyngeal reflux in choristers, teachers and control subjects without vocal load at work, and to determine the risk factors for laryngopharyngeal reflux. Design: A prospective, multicentre, multivariate comparative study Participants: One hundred and nineteen singers from four professional choirs, seventy teachers from four schools, and 111 control subjects with an occupation without vocal load. Main outcome measures: All participants completed a questionnaire about their dietary habits, height and weight, presence of stress, smoking, and allergies, including the nine-item Reflux Symptom Index. The groups of choristers, teachers and the controls were compared to each other with regard to their sex, age, dietary habits, body-mass index, Reflux Symptom Index score and other factors affecting voice quality. The subjects from all three groups with suspected laryngopharyngeal reflux were compared to the subjects without it. The relationship between the Reflux Symptom Index score and the possible risk factors for reflux was estimated. Results: The results showed significantly higher Reflux Symptom Index scores in the choristers than in the teachers and the controls (mean scores 7.86 vs 6.33, p=0.044; 7.86 vs 4.80, p=0.000, respectively) but the number of subjects with suspected laryngopharyngeal reflux (Reflux Symptom Index score > 13) did not differ significantly between the groups. The choristers were significantly more often treated for laryngopharyngeal reflux than the teachers and the controls (41%, 17%, 28%, respectively). The occupation chorister and frequently experiencing stress were the only factors that influenced the total Reflux Symptom Index score. Conclusions: Laryngopharyngeal reflux affects the choristers more often than the teachers or the control subjects without vocal load at work. These results suggest that singing as the main professional activity can notably contribute to the development of the reflux. Vocal load without singing is probably not an important etiological factor for laryngopharyngeal reflux. The extraesophageal symptoms affecting voice require treatment of laryngopharyngeal reflux and proper dietary habits especially in the group with high voice quality demands. © 2012 Blackwell Publishing Ltd.
Clinical otolaryngology: official journal of ENT-UK; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery 09/2012; · 2.39 Impact Factor
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ABSTRACT: The aim of this study is to analyze the impact of various parameters on the course and treatment outcome in patients with laryngotracheal stenosis and recurrent stenosis. Two groups of patients were compared: Group I included 29 patients with primary stenosis, and Group II included 22 patients with recurrent stenosis. The most frequent etiological factor for the development of stenosis was prolonged endotracheal intubation (79.3:77.3%), with subglottic-tracheal (44.8:45.5%) and tracheal (48.3:36.4%) localization being the most affected. Subglottic-tracheal stenosis was more common in men. There were no significant differences between the groups in regard to the grade of lumen obstruction and the length of the resected segment. In male patients, the length of the resected stenotic segment was significantly longer. Subglottic-tracheal stenoses were longer than tracheal ones. Various surgical procedures were performed, with additional management of recurrent laryngeal nerve paralysis, if necessary. Laryngotracheal reconstruction (LTR) with costal cartilage grafting (CCG) was statistically significantly more often performed in Group II, while cricotracheal resection (CTR) was more common in Group I. The incidence of complications in Group I was 24.1%, and in Group II it was 31.8%. Satisfactory airway lumen with undisturbed breathing was achieved in 93.1% of patients in Group I, and in 95.3% in Group II. Since the success rate was similar in both groups of the patients, it could be concluded that treatment outcome depends less on the factors associated with the stenosis, and more on adequate choice of surgical procedure and surgical team know-how.
Archives of Oto-Rhino-Laryngology 02/2012; 269(7):1805-11. · 1.29 Impact Factor
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ABSTRACT: The primary form of tracheal dyskinesia in early childhood is a rare congenital malformation of unknown origin. The degree of the posterior membranous tracheal wall involvement determines the intensity of obstruction and the severity of the clinical picture. The aim of this paper is to present a case of a 14-month-old child with severe tracheal dyskinesia that required surgical treatment. Fascia lata graft fixated with fibrin glue was used in strengthening the posterior tracheal wall. Three years following the surgery, the child is without breathing difficulties. In severe cases of primary dyskinesia, surgical treatment using fascia lata graft, fixated with fibrin glue is recommended in strengthening the posterior tracheal wall.
Auris, nasus, larynx 09/2009; 37(2):263-7. · 0.58 Impact Factor
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ABSTRACT: The aim of this study is to show our experience in using the endo-extralaryngeal laterofixation of vocal cords in treatment of bilateral recurrent laryngeal nerve palsy, and to point out the difficulties and complications of this procedure and the ways of their managing.
During the period from 2003 to 2006, 14 patients with bilateral palsy of the recurrent laryngeal nerve were treated with method of Lichtenberger's endo-extra laryngeal laterofixation of the vocal cord The patients were 12 female and 2 male from 26 to 78 (average 57.4) years old. The earliest intervention was performed 8 day after the onset of paresis and not later than 40 days.
In 11/14 (78.6%) of the patients bilateral palsy of the recurrent laryngeal nerve occured as a result of thyroid gland surgery. At the admission 2 (14.3%) patients had tracheostomy while 12 (85.7%) had no tracheostomy. Edema was the most often complication of the endo extra laryngeal laterofixation and it appeared in 8/14 (57.1%) patients. The earliest swelling of the laryngeal tissue was recorded on the first postoperative day and the latest one started 7 days after the intervention. Edema developed in 7/11 (63.6%) after total thyreoidectomy, in 1/3 (33.3%) with traumatic injuries in the neck Because of progression of the edema which provoked narrowing of the airway at the laryngeal level tracheostoma was peformed in 2 patients. Inflammation of laryngeal tissue with sudden obstruction of the airway resulted in death in one patient. Malposition of the thread toward the midle part of the vocal cord happened very often if intervention was not performed in JET ventilation anesthesia. The vocal card function was repaired bilaterally in 2 patients and unilaterally in 1 patient (the total being 3 out of 14 patients, i.e. 21.4%) four months after the laterofixation, and the threads were removed. Lung functional test showed the increase in average value PEF% from 26.53 before to 39.43 after laterofixation, and PIF from 0.83 before to 1.19 after intervention. Resistance R% in the upper airway decreased from the average 257.95 as before to 215.83 after the intervention, while the index FEV1.0/PEF (ml/L/min) remained almost the same before 13.25 and after the intervention 13.50 and that showed that the upper airway obstruction, in spite of good clinical tolerance by the patients, still persisted in all patients after the laterofixation.
Lichtenberger's endo-extra laryngeal laterofixation of the vocal cord is a good alternative method for bilateral palsy of the recurrent laryngeal nerve which provide sufficient upper airway without tracheostomy.
Medicinski pregled 02/2008; 61 Suppl 2:51-6.
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Slobodan Mitrović
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ABSTRACT: The goal of psycho acoustic or subjective voice analysis, in a phoniater's everyday work, is to describe a subjective experience based on the physical parameters created in the process of phonation. The work was a clinical prospective study and the sample consisted of 80 people of both sexes, 40 people with benign and pseudo tumors of vocal cords and 40 people with malign tumors of vocal cords. All the patients were otorinolaringologically and phoniatrically examined. The subjective acoustic analysis was done with the patients pronouncing numbers from 1 to 10 in the comfortable zone. Afterwards, the quality of the voices was estimated in RBH scale. The subjective acoustic analysis found roughness in the voices of 87,50% patients in the first group and the most frequent value was Mod=3 ( intense roughness), 62,50% patients. Hoarseness was present in 90,00 % cases , with largest value Mod=2 (moderate hoarseness), 55,00% patients. In the second group, roughness existed in the voices of 70,00% patients, most often intense one (Mod=3), 30,00% patients. Hoarseness existed in 95,00% cases, 45,00% with moderate (Mod=2) and 35,00% with intense one. T test showed that there is a statistically significant difference between the strength of the roughness determined by the subjective acoustic analysis in the first and the second group, with p<0,01. The difference between the strength of the hoarseness in the first and the second group is also statistically significant, with p<0,01. All the growths on vocal cords irrespective of their nature change the characteristics of the voice, most of all its clearness. In cases of vocal cords tumors, by the subjective acoustic analysis, i.e. the perception of the psycho physiological characteristics of voice, a human ear can register pathological phenomena of the voice but cannot determine the character of the growth on the vocal cords.
Srpski Arhiv za Celokupno Lekarstvo. 01/2003;
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ABSTRACT: Introduction As yet there is no single reliable and accurate method for detection of neck lymph node metastases. Therapeutic approaches differ from one author to other. The aim of this paper was to establish the extent to which, with good control of primary process, we can control spreading of malignant disease by means of selective neck dissection. Material and method This retrospective study included 595 surgically treated patients in the period 1990 - 1998. There were 525 patients with malignant laryngeal tumors, and 70 patients with malignant hypopharyngeal tumors. Preoperative diagnostics of enlarged lymph nodes was based on palpation of the neck without CT, US, NMR diagnostics. With all risky N0 patients, selective neck dissection was performed for presence of occult metastases. Intraoperative frozen section analysis was not performed. Adjuvant radiotherapy was performed in all patients in whom presence of neck lymph node metastases was histologically proved. Results Selective lateral neck dissection was performed in 389 (65.4%) patients. In 78 (20%) patients, lymph node metastases were patohistologically detected. In 5 (6.4%) transitional cellular cancer was histologically diagnosed, and the remaining 73 (93.6%) presented with squamous cell cancer. Postoperative radiation therapy was applied in 54 patients (69.2%) while 24 (30.8%) were not irradiated. 5-year survival was achieved in 18 (23.1%), and 3-year survival was achieved in 15 (19.2%) patients. Out of 45 patients who lived less than tree year, 18 (40%) presented with metastatic relapse and fatal outcome. Relapse of neck metastases appeared in 12 (11.9%) on the side and in the zones of lymph nodes which were included in neck dissection. Recurrence of neck metastases appeared in 8.3% of patients who were not irradiated postoperatively and in 32.1% of cases irradiated postoperatively. Discussion This study includes comparison of our results with results of literature data. Conclusion Neck lymph node metastases point to advanced malignant process of the third or forth stage of the disease when results are the worst and 5-year survival decreases with or without adjuvant radiotherapy.
Medicinski Pregled. 01/2003;
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Slobodan Mitrović
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ABSTRACT: Introduction Subjective voice analysis represents a diagnostic tool in phoniatry and is a part of everyday practice if a phoniatrist has a 'trained ear'. Material and methods This clinical prospective study included a sample of 20 male patients with malignant tumors involving one vocal cord - right or left. All patients underwent otorhinolaryngological and phoniatric examinations. Subjective acoustic analysis was done when patients pronounced numbers from 1 to 10. Afterwards, voice quality was evaluated separately by two professionals using a 4-levels scale: RBH scale (roughness-breathiness-hoarseness) and GIRBAS scale (grade-instability-roughness-breathiness-asthenia-strain). Results 60% of patients presented with vocal cord immobility. Subjective acoustic analysis revealed hoarseness in 100% of patients (the most frequent value was Mod=3 intense hoarseness in 45% patients). Instability existed in 100% of patient (40% moderate, 40% intense). Strained voice existed in 100%, most frequently intense (45%). Conclusions All patients with glottic carcinoma presented with hoarseness, strain and instability of phonation. Non vibration of vocal cord significantly affects the degree of dysphonia, roughness, strain and instability. Aerodynamic changes affect voice hoarseness. RBH scale is simple, but GIRBAS scale described more psyhoacoustic phenomena most important in patients with glottic carcinoma.
Medicinski Pregled. 01/2003;
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ABSTRACT: Introduction A phoniatrist analyzes the professional's voice at the beginning of his vocal studies or career but also later, in cases of voice disorder. Phoniatric examination of professional singers must be done according to "all inclusive" protocols of examination. Such protocols must establish the status of basic elements of phonatory system: activator generator and resonator of voice and articulatory space. Anamnesis All patients requiring phoniatric examination no matter if they are candidates for professional singers, need to provide anamnestic data about their previous problems regarding voice or singing. Clinical examination This examination is necessary and it must include: examination of nose, cavum oris, pharynx, ears and larynx. Subjective acoustic analysis This analysis is based on evaluation of physiological and pathophysiological manifestations of voice. Musical voice range Determination of musical voice range during phoniatric examination does not intend to make any classification of voice, nor to suggest to vocal teacher what he should count upon from future singers. Musical range can be determined only by a phoniatrist skilled in music or with musical training, but first of all vocal teacher. Objective acoustic analysis These methods are used for examination of phonatory function, or laryngeal pathology. They are not invasive and give objective and quantitative information. They include laryngostroboscopy, spectral analysis of voice (sonography) and fundamental parameters of voice signal (computer program). Speech examination Articulation is very important for solo singers, because good articulation contributes to qualitative emission of sound and expression of emotions. Hearing tests Tonal-threshold audiometry is performed as a hearing test. Additional tests They include rhinomanometry, vital capacity measurements maximal phonation time and phonation quotient. Conclusion Phoniatric examination is a necessary proceeding which must be performed before admission to the academy of solo singing, and then during singers' education and career. The phoniatric protocol must include a minimal number of parameters, which can be increased if required. All parameters of phoniatric examination must be adequatly evaluated by experts.
Medicinski pregled. 01/2002;
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Slobodan Mitrović
[show abstract]
[hide abstract]
ABSTRACT: Subjective voice analysis represents a diagnostic tool in phoniatry and is a part of everyday practice if a phoniatrist has a "trained ear".
This clinical prospective study included a sample of 20 male patients with malignant tumors involving one vocal cord-right or left. All patients underwent otorhinolaryngological and phoniatric examinations. Subjective acoustic analysis was done when patients pronounced numbers from 1 to 10. Afterwards, voice quality was evaluated separately by two professionals using a 4-levels scale: RBH scale (roughness-breathiness-hoarseness) and GIRBAS scale (grade-instability-roughness-breathiness-asthenia-strain).
60% of patients presented with vocal cord immobility. Subjective acoustic analysis revealed hoarseness in 100% of patients (the most frequent value was Mod = 3 intense hoarseness in 45% patients). Instability existed in 100% of patient (40% moderate, 40% intense). Strained voice existed in 100%, most frequently intense (45%).
All patients with glottic carcinoma presented with hoarseness, strain and instability of phonation. Non vibration of vocal cord significantly affects the degree of dysphonia, roughness, strain and instability. Aerodycnamic changes affect voice hoarseness. RBH scale is simple, but GIRBAS scale described more psyhoacoustic phenomena most important in patients with glottic carcinoma.
Medicinski pregled 56(7-8):337-40.
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ABSTRACT: Phoniatric rehabilitation is mainly aimed at restoring satisfactory phonation. Voice quality depends on the capacity of intact vocal cords to compensate the deficiency involved, as well as on automatism of phonation.
The study included 50 patients. All subjects underwent history taking, reported symptoms that urged them to visit a phoniatrician; they were submitted to a clinical otorhinolaryngologic and phoniatric examinations, voice assessment by subjective acoustic analysis, spectral analysis by digital sonography and laryngostroboscopy. All patients underwent Seeman's method of laryngeal compression.
The examined group of 50 subjects included 17 males (34%) and 33 females (66%). Vocal cord palsy was most often due to neck surgery (strumectomy) in 19 patients (38%), followed by an idiopathic palsy involved in 12 patients (24%). Disocclusion of 1-2 mm and 3-3 mm was registered in 54% and 24% patients, respectively. After treatment total occlusion was established in 20% of patients, while disocclusion of up to 1 mm, 1-2 mm or 2-3 mm persisted in 36%, 20% and 2% of patients, respectively. T-test revealed a statistically significant difference in glottic incompetence prior to and after treatment (p < 0.01). After treatment, using Seeman's method of digital compression of the larynx, 48% of patients regained satisfactory speech and voice clarity and 50% of them still presented mild dysphonia. Moderate dysphonia was registered in 2%, but none of the patients had severe dysphonia.
Central laryngeal palsies made 4% of our examined group, while according to the literature they make 1.2-8.7% of all laryngeal palsies. In majority of cases, paralysis of the recurrent laryngeal nerve was due to neck surgery (38%), but literature reports indicate that iatrogenic palsies are mostly due to operation of the thyroid. The well known fact that the left recurrent nerve is more frequently paralysed, has been confirmed in our study as well.
Accurate and efficient treatment of unilateral laryngeal palsies requires team work. Phoniatric rehabilitation of the disorder using Seeman's method has proved efficient in diminishing the glottic incompetence and dysphonia. Patients who fail to respond to phoniatric rehabilitation should be treated using other therapeutic modalities.
Medicinski pregled 56(1-2):59-62.
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ABSTRACT: INTRODUCTION: A phoniatrist analyzes the professional's voice at the beginning of his vocal studies or career but also later, in cases of voice disorder. Phoniatric examination of professional singers must be done according to "all inclusive" protocols of examination. Such protocols must establish the status of basic elements of phonatory system: activator, generator and resonator of voice and articulatory space. ANAMNESIS: All patients requiring phoniatric examination no matter if they are candidates for professional singers, need to provide anamnestic data about their previous problems regarding voice or singing. CLINICAL EXAMINATION: This examination is necessary and it must include: examination of nose, cavum oris, pharynx, ears and larynx. SUBJECTIVE ACOUSTIC ANALYSIS: This analysis is based on evaluation of physiological and pathophysiological manifestations of voice. MUSICAL VOICE RANGE: Determination of musical voice range during phoniatric examination does not intend to make any classification of voice, nor to suggest to vocal teacher what he should count upon from future singers. Musical range can be determined only by a phoniatrist skilled in music or with musical training, but first of all vocal teacher. OBJECTIVE ACOUSTIC ANALYSIS: These methods are used for examination of phonatory function, or laryngeal pathology. They are not invasive and give objective and quantitative information. They include: laryngostroboscopy, spectral analysis of voice (sonography) and fundamental parameters of voice signal (computer program). SPEECH EXAMINATION: Articulation is very important for solo singers, because good articulation contributes to qualitative emission of sound and expression of emotions. HEARING TESTS: Tonal-threshold audiometry is performed as a hearing test. ADDITIONAL TESTS: They include rhinomanometry, vital capacity measurements, maximal phonation time and phonation quotient. CONCLUSION: Phoniatric examination is a necessary proceeding which must be performed before admission to the academy of solo singing, and then during singers' education and career. The phoniatric protocol must include a minimal number of parameters, which can be increased if required. All parameters of phoniatric examination must be adequately evaluated by experts.
Medicinski pregled 55(7-8):309-13.
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Slobodan Mitrović
[show abstract]
[hide abstract]
ABSTRACT: The goal of psycho acoustic or subjective voice analysis, in a phoniater's everyday work, is to describe a subjective experience based on the physical parameters created in the process of phonation. The work was a clinical prospective study and the sample consisted of 80 people of both sexes, 40 people with benign and pseudo tumors of vocal cords and 40 people with malign tumors of vocal cords. All the patients were otorinolaringologically and phoniatrically examined. The subjective acoustic analysis was done with the patients pronouncing numbers from 1 to 10 in the comfortable zone. Afterwards, the quality of the voices was estimated in RBH scale. The subjective acoustic analysis found roughness in the voices of 87.50% patients in the first group and the most frequent value was Mod = 3 (intense roughness), 62.50% patients. Hoarseness was present in 90.00% cases, with largest value Mod = 2 (moderate hoarseness), 55.00% patients. In the second group, roughness existed in the voices of 70.00% patients, most often intense one (Mod = 3), 30.00% patients. Hoarseness existed in 95.00% cases, 45.00% with moderate (Mod = 2) and 35.00% with intense one. T test showed that there is a statistically significant difference between the strength of the roughness determined by the subjective acoustic analysis in the first and the second group, with p < 0.01. The difference between the strength of the hoarseness in the first and the second group is also statistically significant, with p < 0.01. All the growths on vocal cords irrespective of their nature change the characteristics of the voice, most of all its clearness. In cases of vocal cords tumors, by the subjective acoustic analysis, i.e. the perception of the psycho physiological characteristics of voice, a human ear can register pathological phenomena of the voice but cannot determine the character of the growth on the vocal cords.
Srpski arhiv za celokupno lekarstvo 131(1-2):40-2. · 0.19 Impact Factor
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ABSTRACT: As yet there is no single reliable and accurate method for detection of neck lymph node metastases. Therapeutic approaches differ from one author to other. The aim of this paper was to establish the extent to which, with good control of primary process, we can control spreading of malignant disease by means of selective neck dissection.
This retrospective study included 595 surgically treated patients in the period 1990-1998. There were 525 patients with malignant laryngeal tumors, and 70 patients with malignant hypopharyngeal tumors. Preoperative diagnostics of enlarged lymph nodes was based on palpation of the neck, without CT, US, NMR diagnostics. With all risky N0 patients, selective neck dissection was performed for presence of occult metastases. Intraoperative frozen section analysis was not performed. Adjuvant radiatitherapy was performed in all patients in whom presence of neck lymph node metastases was histologically proved.
Selective lateral neck dissection was performed in 389 (65.4%) patients. In 78 (20%) patients, lymph node metastases were pathohistologically detected. In 5 (6.4%) transitional cellular cancer was histologically diagnosed, and the remaining 73 (93.6%) presented with squamous cell cancer. Postoperative radiation therapy was applied in 54 patients (69.2%) while 24 (30.8%) were not irradiated. 5-year survival was achieved in 18 (23.1%), and 3-year survival was achieved in 15 (19.2%) patients. Out of 45 patients who lived less than tree year, 18 (40%) presented with metastatic relapse and fatal outcome. Relapse of neck metastases appeared in 12 (11.9%) on the side and in the zones of lymph nodes which were included in neck dissection. Recurrence of neck metastases appeared in 8.3% of patients who were not irradiated postoperatively and in 32.1% of cases irradiated postoperatively.
This study includes comparison of our results with results of literature data.
Neck lymph node metastases point to advanced malignant process of the third or forth stage of the disease when results are the worst and 5-year survival decreases with or without adjuvant radiotherapy.
Medicinski pregled 56(5-6):221-6.
