[Show abstract][Hide abstract] ABSTRACT: Voice rehabilitation is the main treatment option in cases of behavioral dysphonia, and it has the purpose of enhancing the quality of vocal production and voice-related life aspects. Several efforts have been made to offer a clinical practice that is based on evidence, including the development of specific therapeutic protocols as an option for clinical and scientific improvement. It is necessary to define the focus/objective of the dysphonia treatment, type of approach, and duration in order to establish the intervention criteria. This paper describes the organization of a program of behavioral dysphonia treatment, based on an approach that has been used for over twenty years, named Comprehensive Vocal Rehabilitation Program, and also to present its concepts, theory, and practical fundamentals. The program has an eclectic approach and associates body work, glottal source, resonance, and breathing coordination in addition to knowledge about vocal hygiene and communicative behavior. The initial proposal suggests a minimum time of intervention of six therapeutic sessions that can be adapted according to the patient' s learning curve and development. The goal is to offer a rational and structured therapeutic approach that can be reproduced in other scenarios.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
No signs of denervation were seen in the thyroarytenoid, cricothyroid, and lateral cricoarytenoid muscles of the studied patients.
Brazilian journal of otorhinolaryngology 12/2012; 78(6):7-14. · 0.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The vibration of the vocal fold lamina propria is an important factor involved in vocal production and aging may change the amount of hyaluronic acid in the vocal fold leading to dysphonia.
This study compares the concentration of hyaluronic acid in vocal folds of aged and young female rats. Study design: experimental.
We used the vocal cords of 13 female rats divided into two groups: five aged rats and eight young ones. The tissue concentration of hyaluronic acid was determined using the fluorimetric method with the hyaluronic acid binding-protein coated on plates of enzyme-linked immunosorbent assay (ELISA), conjugated with biotin. Europium-labeled streptavidin was added and, after europium release with the use of enhancement solution, the final fluorescence was measured in a fluorometer.
We found the following concentrations of hyaluronic acid in vocal fold according to the group: 581.7 ng/mg in old female rats and 1275.6 ng/mg in young female rats. Statistical analysis showed differences between groups.
The vocal folds of old female rats have a lower concentration of hyaluronic acid when compared to such concentration on the vocal folds of young female rats.
Brazilian journal of otorhinolaryngology 06/2012; 78(3):14-8. · 0.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate laryngeal sequelae from surgical treatment of recurrent respiratory papillomatosis in children, as well as associated risk factors.
Case-control study. Medical record data analysis of 50 children with recurrent respiratory papillomatosis, divided into two groups: with and without laryngeal sequelae. The group of patients with laryngeal sequelae was compared to those without sequelae in regard to the onset of disease, age at first surgery, number and frequency of surgeries, disease stage, and type of surgery (CO2 laser, cold forceps).
23 patients (46%) sustained laryngeal sequelae. The most frequent sequela was anterior commissure synechia (17 patients [34%]), followed by glottic stenosis (six patients [12%]). There was no statistically significant difference between groups with and without laryngeal sequelae regarding the disease onset (p = 0.93), age at first surgery (p = 0.68), number of surgeries (p = 0.22), annual frequency of surgery (p = 0.93), presence of papilloma in anterior (p = 0.430) or posterior commissure (p = 0.39), and type of surgery (p = 0.27). The Derkay anatomical score (a staging system that assesses the extent of the disease in the aerodigestive tract) was significantly higher in the laryngeal sequelae group (p = 0.04).
Laryngeal sequelae are a frequent complication of recurrent respiratory papillomatosis surgical treatment in children, particularly anterior commissure synechiae and glottic stenosis. Advanced stages are associated with increased risk of laryngeal sequelae after surgery.
Revista da Associação Médica Brasileira 04/2012; 58(2):204-8. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Childhood oral breathing can alter muscular balance and lead to facial deformities. No articles in the literature have reported on the alteration of facial growth patterns in patients who have received tracheotomies. The purpose of this study was to evaluate craniofacial developmental consequences originating from variations in breathing mechanisms in children who are nasal breathers or oral breathers, and those who have been tracheotomized.
The sample was divided into 3 groups of 10 each. The nasal group had a mean age of 13.9 years, the oral group had a mean age of 12.7 years, and the tracheotomy group had a mean age of 12.8 years. The masseter and suprahyoid muscles were evaluated with electromyography. The following measurements were made: facial, maxillary, and mandibular widths; nasion-sella-gnathion angle; and facial index.
The tracheotomized group was similar to the nasal group for greater activity of the masseter muscles than of the suprahyoid muscles during mastication, as well as in the measurements of facial, maxillary, and mandibular widths. The oral group showed reductions in each category. The tracheotomized group was similar to the oral group during maximum dental occlusion for significantly higher activity of the suprahyoid muscles compared with the masseter muscles, with reductions in vertical values.
A childhood tracheotomy might affect facial development in a way comparable with that of oral breathers, including abnormal facial growth variations.
American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 10/2011; 140(4):486-92. · 1.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Along the normal aging process, voice tends to become weak, breathy, and loses projection, which may interfere in the communication process. One reliable way to evaluate voice quality is through acoustical analysis using, for instance, the long-term average spectrum (LTAS). The aim of this study was to identify acoustic measures, particularly LTAS's, which characterize vocal aging in women without vocal complaints. For this purpose, 30 elderly and 30 young women were included in this study. All spoke standard Portuguese and none had a history of vocal and laryngeal alterations or respiratory diseases. On the basis of the reading task, in habitual and loud levels, the following parameters were assessed: the equivalent sound level (L(eq)), the speaking fundamental frequency (SFF) and, at the LTAS window, the difference between the levels of the regions of the first formant and fundamental frequency F(0) (L(1) - L(0)), alpha ratio, and the amplitude levels obtained at equal intervals of 160 Hz, ranging from 0 to 8 kHz. There were significant differences between young and old voices for SFF and L(eq) in both levels. In the LTAS window, amplitude levels were higher for young voices, comprising all frequencies except those in the regions between 4.6-6.7 and 4.8-6.5 kHz, in habitual and loud levels, respectively. There were also significant differences regarding L(1) - L(0) and alpha ratio between groups, in both levels.The observed differences in LTAS's slopes, L(1) - L(0) measures, and even L(eq) and SFF measures, may be attributed, to some extent, to lower subglottal pressure or a glottal setting providing a slower glottal closing speed for the elderly group.
Journal of voice: official journal of the Voice Foundation 07/2011; 25(4):411-9. · 0.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Early glottic cancer can be effectively treated with radiation or surgery, but recurrence is a possibility when using any of the treatment modalities.
To assess the outcome of radiotherapy as initial treatment in the control of squamous cell carcinoma of vocal cord (T1) and the effectiveness of salvage surgery (endoscopic or open) after treatment failure.
A retrospective study was based on the analysis of medical records from 43 patients with T1 squamous cell carcinoma of the glottis, radiotherapy as initial treatment and follow-up period of five years.
The rate of recurrence after radiotherapy was 30.2% of the cases, mean diagnosis interval was 29.5 months. As an option for salvage treatment, patients underwent open partial laryngectomy or endoscopic surgery with control rates of 77.7% and 25% respectively.
Our cases showed high rates of recurrence after radiotherapy and open partial laryngectomy was more effective for the salvage surgery.
Brazilian journal of otorhinolaryngology 06/2011; 77(3):299-302. · 0.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To present the accurate surgical indication for the slicing mucosal technique, the case selection, surgical aspects, rehabilitation concerns, and the characteristics of immediate and long-term outcomes.
The literature is still scarce; few cases are submitted to the slicing mucosa technique due to its specific indication; an alternative procedure was designed for cases where mucosal movement is strongly reduced, the inner section of the vocal ligament or submucosal scar tissue, which can eventually be associated with fat inclusion. Some selected cases may require thyroplasty type III to optimize functional results.
Slicing technique is an aggressive powerful resource for the surgical treatment of severe cases of sulcus striae major, in which mucosal wave is absent and glottic chink is moderate to severe; voice is intensely deviated immediately postoperation; vocal rehabilitation is mandatory and an intensive regimen is usually required for the first 2 months; final results can mostly be achieved up to 6 months.
Current opinion in otolaryngology & head and neck surgery 10/2010; 18(6):512-20.
[Show abstract][Hide abstract] ABSTRACT: The diversity of vestibular fold (VeF) behavior during phonation, as well as the lack of insight regarding both the anatomy and muscle fiber composition hinder our understanding of their role during phonation. The concave shape of the free margin of VeF appears to be standard, but little is known regarding the variability of this shape. We, therefore, sought to determine the laryngoscopic features related to changes in the free margin of the VeFs during phonation in patients with unilateral vocal fold paralysis. Laryngeal images from 39 patients with unilateral paralysis associated with recurrent laryngeal nerve damage were evaluated with regard to variations in length and shape of the VeFs (concave, straight, or convex) during both respiration and phonation. The VeFs on both the paralyzed and unaffected sides were analyzed during both phonation and respiration resulting in 156 total images. During phonation, all VeFs on the nonparalyzed side were straight or convex, whereas on the paralyzed side, only 20 of the 39 were straight or convex during phonation. During respiration, significant differences in the shape of the nonparalyzed side were observed. During phonation, a nonconcave appearance on the paralyzed side usually correlated with a similar appearance during respiration. VeF length decreased during phonation in 30 nonparalyzed VeFs in contrast to only 13 paralyzed folds. When subjects switched from respiration to phonation, the VeFs were typically nonconcave on the nonparalyzed side. In contrast, on the paralyzed side, nonconcave VeFs were consistent across both tasks. In patients with unilateral vocal fold paralysis, VeF conformation is likely determined from extralaryngeal than intrinsic muscle. These findings have important theoretical considerations for laryngeal treatment.
Journal of voice: official journal of the Voice Foundation 03/2010; 25(1):111-3. · 0.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evaluate the efficacy of local application of cidofovir in association with surgical treatment of recurrent laryngeal papillomatosis in children. Study design: Prospective.
Fourteen patients, with an average age of 4.7 years and with two or more relapses after surgical treatment, were submitted to resection of the papillomas and injection of 22.5 mg of cidofovir (7.5 mg/ml) in the tissue where the lesions had been removed. After 2 to 3 week intervals, the same dose of cidofovir was repeated two or three times. In the case of relapse, a new cycle of surgery followed by local applications of cidofovir was repeated. Five children presented HPV-6 and five HPV-11, while in four, the type was not determined.
Before beginning of the study, patients were submitted, on the average, to 2 operations a year for control of relapses. After treatment with cidofovir, the annual rate for surgery dropped to 1.1 (p = 0.013). The average interval between relapses before beginning of the study was 1.4 months; at the end of the study, the interval reached 4.4 months (p = 0.014). Patients with HPV-6 did not show a significant change in the intervals between relapses after treatment with cidofovir, while 60% of the children with HPV-11 were disease free at the study end.
Cidofovir was found to be an effective adjuvant in the treatment of recurrent laryngeal papillomatosis in children, when used in the form of local applications in association with surgical resection of the lesions. HPV-11 may be more susceptible to the beneficial effects of cidofovir.
Revista da Associação Médica Brasileira 01/2009; 55(5):581-6. · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Current surgical techniques for laryngeal exposure pose distinct limitations. To address these issues, this article describes a novel surgical technique. Our technique, termed Transventricular Chondroplastic Laryngotomy, allows for extensive and direct external access to the endolarynx. This procedure is described in both a cadaver and animal models. Three pigs were submitted to thyroid cartilage window opening without touching the laryngeal ventricle, and seven animals were submitted to the full procedure, opening a thyroid cartilage window with wide ventricular opening. The animals were sacrificed 20 days following the procedure. Prior to sacrifice, all animals underwent laryngoscopic examination and following euthanasia, the larynx and cervical regions were examined grossly, in addition to histologically. This surgery allowed for extensive exposure of the ipsilateral vocal fold and the contralateral hemilarynx, through the laryngeal ventricle, and thus enabled bi-instrumental handling of the vestibular fold, laryngeal ventricle, and from the anterior commissure to the arytenoids, bilaterally. No postoperative complications were observed. Access to the ventricle was easily and directly achieved through the thyroarytenoid muscle. We hypothesize that transventricular chondroplastic laryngotomy will emerge as the surgical technique of choice in patients presenting with difficult exposure and/or traditional surgical instruments are not feasible. Future transventricular chondroplastic laryngotomy clinical applications of the procedure are discussed including the resection of lesions and more complex reconstruction of vocal folds.
Journal of voice: official journal of the Voice Foundation 08/2008; 23(5):619-24. · 0.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: It is well known that phonotraumatic events may produce laryngeal inflammation, vocal fold hemorrhage and different types of mass lesions. This study describes a vocal fold self-disruption that occurred on stage to a lead actor in the role of Richard III. The study design is as case presentation. A 43-year-old actor presented with a sudden voice loss that first occurred on stage after a series of presentations. He also had a cold-like condition that had not been treated. His past medical history included an average of ten cigarettes per day for ten years and a 10-year history of gastritis and stomach ulcer. Perceptual, acoustic, and laryngeal analyses were performed following pharmacological and voice therapy. Perceptual and acoustic analyses showed mild deviations whereas laryngeal visual examination revealed a complete right vocal fold detachment from the anterior commissure to the vocal process, with generalized hyperemia. A mild diffuse Reinke's edema was observed on the left vocal fold. Mild discomfort was present only during the first day of the acute period. Modified vocal rest was recommended and a series of vocal exercises were administered. The patient performed again 4 days later, after following a series of behavioral modification techniques that included casting guidelines during the subsequent 15 days. Healing was exceptional and his voice returned to normal. This unique case with an exceptional recovery emphasizes the etiological aspects of scar formation after phonotrauma. Positive contributing factors may include a good vocal technique and adequate training as well as the protective upregulated genes present in Reinke's edema.
Journal of voice: official journal of the Voice Foundation 07/2008; 23(6):726-32. · 0.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We sought to perform a morphometric analysis of myelinated fibers from laryngeal nerves with the aim of verifying quantitative changes due to the aging process.
A 1-cm fragment was collected from the superior laryngeal nerves and recurrent laryngeal nerves from 12 cadavers during autopsy. The sample was divided in two groups: an adult group (aged <60 years) and an elderly group (aged > or =60 years).
The total number of myelinated fibers from the superior laryngeal nerves was similar in both groups (adult group = 9017 +/- 1692, elderly group = 7918 +/- 1624; P = 0.79). The adult group had a higher total number of myelinated fibers in the recurrent laryngeal nerves than that of the elderly group (adult group = 3276 +/- 383, elderly group = 2381 +/- 669; P = 0.005), as well as a higher total number of fibers in the laryngeal nerves (both superior and recurrent) than the elderly group (P = 0.02).
The adult group has a higher total number of myelinated fibers in the laryngeal nerves than the elderly group.
Otolaryngology Head and Neck Surgery 06/2007; 136(5):747-51. · 1.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To study the effect of local application of cidofovir in patients with recurrent laryngeal papillomatosis (RLP) by measuring the interval between recurrences and the extent of disease at each recurrence.
The study group included 10 patients with RLP. Videolaryngoscopic analysis of previous RLP operations for each patient before starting cidofovir and the number and timing of pre-cidofovir recurrences of the disease provided data for a self-control group. The cidofovir was injected with a laryngeal needle during papilloma resection operations. To evaluate the changes and the extent of the disease, the authors developed a staging system based on anatomic topography. The extent of the disease and the intervals between recurrences were analyzed and statistically compared.
The median interval between recurrences significantly increased from 102 days before cidofovir to 239 days after treatment. No local or systemic side effects were observed.
The study supports the hypothesis that cidofovir is an effective adjunct in treating recurrences of RLP. EBM rating: C-4.
Otolaryngology Head and Neck Surgery 08/2006; 135(1):22-7. · 1.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laryngopharyngeal reflux has shown high prevalence and it is an interesting issue for otorhinolaryngologists, head and neck surgeons, and gastroenterologists. The present paper presents the most recent findings in diagnosis and management of laryngopharyngeal reflux.
Clinical presentation of laryngopharyngeal reflux is widely varied and it may be manifested by a wide range of signs and symptoms. Other diseases that affect the larynx may also show the same signs and symptoms, such as, for example, vocal abuse, allergy, asthma, sinusitis, and smoking. Overvaluation of signs and symptoms related to reflux may be responsible for overdiagnosis of laryngopharyngeal reflux disease. The 24-hour dual-probe pH monitoring is considered the gold standard for the diagnosis of laryngopharyngeal reflux disease, and is essential in cases of pharyngolaryngeal complaints. The management of laryngopharyngeal reflux cases should be based on severity of symptoms, laryngoscopic findings, and frequency of reflux episodes. Proton-pump inhibitors are the preferred drugs for managing patients with laryngopharyngeal reflux and the best control can be achieved by prescribing high doses, twice a day. Patients that do not respond satisfactorily to clinical management are candidates for surgical fundoplication.
Laryngopharyngeal reflux is characterized by a set of signs and symptoms resulting from extraesophageal manifestations of gastroesophageal reflux disease; however, this set of signs and symptoms may be related to other causes and the results of management, based on clinical presentation, vary widely and have low cure index.
Current opinion in otolaryngology & head and neck surgery 07/2006; 14(3):138-42.
[Show abstract][Hide abstract] ABSTRACT: The etiology and pathogenesis of laryngeal microwebs are heterogeneous, and in most cases they are an incidental finding. It has also been suggested that microwebs could be a familial trait, representing a postblastogenic embryonic vestigial structure that might alter the biomechanical and vibratory properties of the vocal fold. Vocal nodules are small benign swellings along the margins of the vocal cords, with preferential location at the junction of the anterior and middle thirds, and usually resulting from mechanical trauma. The authors studied a sample of 107 patients with vocal nodules, looking for a possible correlation with microwebs due to the predicted involvement in the vibration of vocal cord margins. Glottic proportion, type of glottic closure, nodule location and the main complaints in patients with microwebs were compared with those in a sample of patients without microwebs. In the present study, microwebs were found in 9.4% of the patients, who showed much smaller glottic proportion than patients with micronodules only. Furthermore, vocal nodule location was not related to the presence and/or absence of laryngeal microwebs.
Folia Phoniatrica et Logopaedica 02/2006; 58(6):392-9. · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To analyze the senile larynx, considering morphological aspects during respiration and functional aspects during phonation, comparing it to the young adult larynx.
A retrospective study was conducted of 100 laryngeal images of adults without vocal complaints, 50 laryngeal images of young adults aged 20-45 years and 50 laryngeal images of elderly individuals aged 65-85 years, of both genders. Images were produced by means of a rigid endoscope and stroboscopy. The morphological aspects analyzed were: laryngeal symmetry, vocal fold bowing, prominence of the vocal process and glottic proportion. The functional aspects analyzed were glottic closure, laryngeal vestibule behavior, phase (timing of closure) and amplitude symmetry of mucosal wave and tremor of laryngeal structures.
Significant differences between the young adult larynx and the geriatric larynx were found for the following parameters: vocal fold bowing, prominence of the vocal process, glottic proportion, phase and amplitude symmetry of mucosal wave and tremor of laryngeal structures.
The data suggests that the geriatric larynx differs from the young adult larynx in many characteristic aspects.
Folia Phoniatrica et Logopaedica 02/2006; 58(3):151-8. · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study evaluated the relationship between voice complaint and deviant vocal fold status with special regard to presbylarynx, in patients aged more than 60 years, with pharyngeal-laryngeal complaint. The material consisted of clinical histories and images obtained by laryngoscopies from protocols from the Larynx Institute-INLAR, Sao Paulo, Brazil, of 210 patients, 88 men and 122 women, aged more than 60 years, who had sought otorhinolaryngologic treatment. Indicative glottic characteristics of the presbylarynx, such as vocal fold bowing, prominence of vocal processes, and spindle-shaped glottic chink, were analyzed. The increase in mass, leukoplakia, and other vocal fold alterations, distinct from these two, grouped as miscellaneous, as well as the presence or absence of voice complaint were also analyzed. Vocal fold bowing, prominence of vocal processes, and spindle-shaped glottic chink showed a strong correlation among each other. The presence of presbylarynx was accompanied by less voice complaint than the presence of vocal fold mucosa alterations, which in turn are more common where an absence of presbylarynx exists.
Journal of Voice 04/2005; 19(1):84-94. · 1.55 Impact Factor