Littérature scientifique sur le sujet « Vocal folds/abnormalities »

AbstractFew studies have described laryngological evaluation of patients with amyotrophic lateral sclerosis. We assessed the laryngological abnormalities of 35 such patients (24 bulbar onset and 11 limb onset). In nine limb onset patients, we discovered signs of early vagal nerve dysfunction, prior to any clinical presentation of bulbar failure. However, in all bulbar onset patients studied, we noticed changes in the uni/bilateral position of the vocal folds and in the voice quality.

Three-dimensional reconstruction of medical images has emerged as an important visualization tool for studying complex anatomy. These tools have found important applications in neurology and plastic surgery using computed tomography (CT) and magnetic resonance imaging (MRI) data. However, CT and MRI do not sufficiently delineate lesions of the pediatric airway. Inspection through the rod lens telescope remains the standard diagnostic method. A video recording of an endoscopic procedure is essentially a sequence of two-dimensional images captured as the telescope traverses the airway lumen. Using digitized endoscopic video recordings and computer graphics reconstruction techniques, we have developed a preliminary three-dimensional modeling system for the pediatric airway. A series of normal and abnormal telescopic airway examinations were video recorded. Serial sections were obtained by digitizing the video images at uniform intervals as the scope traversed the airway lumen between the vocal folds and the carina. The digitized images were calibrated and used to reconstruct the airway lumen in three dimensions. Classifying airway abnormalities according to the minimal cross-sectional area or with descriptive terms can be subjective and dependent on the endoscopist's observational skills. We hope that this preliminary work will lead to more precise and understandable methods for representing complex airway lesions.

Introduction: Benign vocal fold lesions reduce the efficiency of sound production. Reports of dysphonia cases caused by vocal principles in Indonesia are still very limited. This study aimed to determine incidence and prevalence of benign vocal fold lesions, namely vocal cord nodules, cysts, and polyps.Methods: A descriptive retrospective study was conducted using patient’s medical record of Ear, Nose, and Throat (ENT) Outpatient Unit. Dysphonia patients with benign vocal cord abnormalities were identified. The data analyzed using descriptive analytic.Results: There were 20 patients with benign vocal fold lesions, consisting of 13 patients (65%) with nodules, 3 patients (15%) with polyps, and 4 patients (20%) with cysts. The ratio of male and female patients was 1: 1. Most patients belonged to age group of 20-59 years (12 patients; 60%). In term of occupation, most patients belonged to group III, which is a group of workers who are not professional voice users (12 patients; 60%). Most vocal fold lesions were found in the 1/3 of bilateral anterior (17 patients; 85%). Most therapy was non-operative in 13 patients (65%). Conclusion: Benign vocal fold lesions, including vocal cord nodules, polyps, and cysts, are found in all patients with dysphonic complaints. The prevalence of dysphonia symptoms is quite high every year, but only a small portion are diagnosed with benign vocal cord lesion.

Laryngologists have long recognized that assessment of the mucosal wave is an important part of laryngeal evaluation. This is the first report of a noninvasive measurement of vocal fold displacement velocity in an in vivo canine model. a newly developed calibrating endoscopic instrument capable of measuring distances on the vocal fold surface is described. Displacement velocity was determined in three dogs and compared to physiologic measures in the in vivo phonation model. The results indicate that the calculated displacement velocity is linearly proportional to traveling wave velocity and fundamental frequency. Because traveling wave velocity has been shown to reflect vocal fold stiffness, this method may advance the usefulness of stroboscopy for the study of mucosal wave abnormalities.

Telescopic laryngoscopic examination was performed at the bedside after extubation in 29 consecutive surgical intensive care unit patients who required endotracheal intubation for more than 16 hours. The examinations were documented with a portable video recording system. The majority of patients exhibited evidence of acute endolaryngeal trauma. Vocal fold ulceration and vocal fold motion abnormalities were the most common lesions. Patients with abnormal larynges were followed up after discharge from the intensive care unit. Most of the identified injuries resolved without intervention. However, silent aspiration was identified frequently in patients with vocal fold paresis and was thought to be a significant factor in postoperative pulmonary complications. Early identification of significant laryngeal trauma and/or vocal fold paresis in critically ill patients is important for both postoperative pulmonary care and voice rehabilitation. This pilot study demonstrated that documentation of the laryngeal examination is feasible in critically ill patients in an intensive care unit setting.

Laryngeal web is a rare entity, constituting 5% of all congenital laryngeal lesions, with a reported incidence of 1 in 10,000.1 It usually presents with stridor in childhood, but can be discovered in asymptomatic adults under anesthesia and is associated with failed intubations.2 We present the case of a newborn with stridor and respiratory distress due to laryngeal web. CASE REPORT A 47-day-old boy was referred to our institution for stridor. He was spontaneously born term at 40 3/7 weeks gestational age to a 26-year-old G2P2 (2002). Birth weight was 3104 grams and maturity testing at 39 weeks was appropriate for gestational age. Prenatal and perinatal history was unremarkable. Upon delivery with an initial Apgar score of 5 becoming 6, inspiratory stridor and impending respiratory failure prompted intubation. Post-intubation chest x-ray revealed minimal lung disease and the baby was extubated after 24 hours. Six hours after extubation, stridor was noted again and the baby was reintubated. A chest x-ray showed atelectasis and the baby was managed as a case of pulmonary hypertension. He was weaned from ventilatory support and continuous positive airway pressure (CPAP) was commenced on day 15. Lavage feeding was started on day 18 and 7-day empiric antibiotics were completed. However, stridor and respiratory distress persisted, and the baby was reintubated and recommitted to a mechanical ventilator. Laryngomalacia was suspected, a tracheostomy was recommended and the baby was referred to our institution for further work-up and management. Our admitting impression was a term baby boy with pneumonia, and laryngomalacia versus tracheomalacia. Upon arrival at our institution, chest x-ray showed hazy and reticular opacities at the posterobasal segment of both lower lung lobes, more on the right, and interpreted as bilateral pneumonia. Ampicillin and Cefotaxime were started, and gram stain, culture and sensitivity of endotracheal secretions resulted in moderate growth of S. marscescens and light growth of K. pneumonia, both resistant to Ampicillin. Antibiotics were shifted to Gentamycin and Ceftazidime, given for 10 days. During this time, the baby was also exhibiting myoclonic upper extremity movements but was subsequently cleared for seizures or other structural brain pathology by Neurology. Our plan for airway evaluation was initial flexible endoscopy followed by bronchoscopy if extubation was tolerated. The possibility of a tracheostomy was considered if extubation would not be tolerated. Flexible endoscopy revealed patent nasal airways with no demonstrable nasal obstruction or structural abnormalities. The endotracheal and orogastric tubes were visualized entering the trachea and esophagus respectively. (Figure 1) There was pooling of secretions in the hypopharyngeal area, but no visible masses or lesions. After extubation, a soft tissue band was visualized traversing the right and left true vocal cords posteriorly, consistent with an interarytenoid web. (Figure 2) A space between this band and the interarytenoid area corresponded to the site where the ET tube had passed. The arytenoid mucosa also appeared swollen and edematous. The epiglottis was normal. There was vocal fold motion with incomplete glottic closure, but the full extent of glottic opening and closing could not be assessed due to the band. Because of decreasing oxygenation and episodes of desaturation, the baby was reintubated and a tracheostomy was performed. The baby was weaned off the ventilator a week later, and transferred out of intensive care to a regular room where he tolerated room air. Clotrimazole that had been given for light growth of S. maltophilia obtained intraoperatively was shifted to Levofloxacin and the last dose was given after 7 days. His postoperative course was unremarkable, and he was discharged with a tracheostomy and nasogastric tube, with suck and swallow therapy for eventual oral feeding. Regular monitoring and routine tracheotomy care with periodic tube changes and endoscopic surveillance of the web and signs of reflux are scheduled. DISCUSSION The most likely conditions for stridor presenting at birth are congenital structural anomalies like laryngomalacia (60%), vocal cord paralysis (15-20%), congenital subglottic stenosis (15%), laryngeal web (5%), or subglottic hematoma (1.5%).1,2,3 The larynx develops from the endodermal lining and the adjacent mesenchyme of the foregut between the fourth and sixth branchial arches. The arytenoid swelling is formed at the cranial end of the laryngotracheal tube by the proliferation of the mesenchymal tissue (derived from neural crest cells). It grows towards the tongue and forms the primordial glottis. As it grows further, it changes the primordial glottis into a T-shaped laryngeal inlet.4 Congenital laryngeal webs are uncommon, constituting 5% of all congenital laryngeal lesions; their incidence has been estimated at approximately 1 in 10,000 births.4 They are due to incomplete recanalization of the laryngotracheal tube during the third month of gestation, leading to different degrees of laryngeal webs. The most common site of development is at the level of the vocal folds anteriorly, although they may occur in the posterior interarytenoid or in the subglottic or supraglottic area.5 Diagnosis may be made via flexible or rigid laryngoscopy, or airway films if subglottic or cricoid pathology is present.4 Most congenital webs present at birth or in the first few months of life. Symptoms range from mild dysphonia to significant airway obstruction, depending on the size of the web. Hoarseness, croup, and dysphagia are some other symptoms. A third of children with laryngeal webs have anomalies of the respiratory tract, most commonly subglottic stenosis. When congenital in origin, this may be associated with various syndromes like Di-George syndrome, velocardiofacial (Shprintzen) syndrome, conotruncal anomaly face syndrome.6,7 Laryngeal webs may be classified according to airway obstruction. A T1 web is uniform in thickness with no subglottic extension, has true vocal cords clearly visible in the web, usually has no airway obstruction, and hoarseness as the only usual presenting sign. A T2 web is slightly thicker, with a significantly thicker anterior component, and may have minimal subglottic involvement, and a usually husky voice. A T3 web is thick with a solid anterior portion that extends into the subglottis, the true vocal cords are not well delineated, and there is marked vocal dysfunction, with a weak and whispery voice. A T4 web is uniformly thick and extends into the subglottic area with resulting subglottic stenosis. Respiratory obstruction is severe, and the patient is almost always aphonic.4,7 Webs may also be classified according to location, whether anterior, posterior (interarytenoid), subglottic, or supraglottc.4 Our patient had a type 1, interarytenoid laryngeal web. About 75-90% of laryngeal webs are located anteriorly and extend toward the arytenoids. Occasionally, a minor web will not be diagnosed until the child is older and undergoes evaluation for chronic hoarseness.1 It may vary in thickness, and the boundary is the vocal process.5 Posterior webs may present with apparent bilateral vocal cord paralysis, especially if an interarytenoid web in the posterior larynx limits vocal fold abduction. This type of congenital web is rare and often necessitates a tracheotomy in the early years of life. Stridor is the major presenting clinical feature (as in our case), but patients can also present with obstructive cyanosis at birth or episodes of apnea.2 Asymptomatic patients do not require treatment. Treatment depends on the severity of airway obstruction, and may be single or multi-staged. If a patient presents with difficulty breathing, the airway must first be secured. This can be done through endotracheal intubation, which can be converted into a tracheostomy if prolonged intubation is expected.6 Long-term tracheotomy with observation for eventual decannulation after 3 to 5 years may be practiced. Surgical division can be achieved using laryngeal knives, microscissors, galvanocautery or radiofrequency. However, these are frequently unsuccessful as vocal cords re-adhere in the area where the web was separated.4,8 Surgical correction results in two opposing surfaces with denuded epithelium that tend to heal together and reform a web. To prevent re-adhesion, a keel, stent or probe may be positioned between the two raw edges. Steroid injections or mitomycin may also diminish re-adhesion.2 Extensive webs often require arytenoidectomy or even open laryngeal reconstruction to correct subglottic stenosis. This can be done with a costal graft, a posterior cricoid split, or a T-tube.9 Given that our patient has a type 1 laryngeal web with a thin band, some may suggest that we observe the patient for 3-5 years in the hope that it might be outgrown.3 Others would divide or excise the web.3,4 However, the course of healing in our pediatric patient may be different compared to adults. If we perform outright division, there could be a higher risk of re-adhesion. Moreover, the presence of reflux (swollen arytenoids) may hasten the recurrence of the web or contribute to development of another laryngeal pathology like laryngomalacia.3 We are not aware of any definite treatment protocol that applies to our patient. As such, our current plan is serial monitoring to determine when he will be a good candidate for surgery. At the very least, we want to see a resolution of signs of reflux that may increase the risk of recurrence post surgery. We have yet to determine our final plan for surgical intervention and the optimal timing for it, and are open to receiving your comments.

A disfunção das pregas vocais (DPV) é caracterizada por movimento paradoxal de fechamento das pregas vocais, ocorrendo de forma episódica e involuntária durante a inspiração, levando à obstrução das vias aéreas. Os pacientes que apresentam DPV costumam não responder ao tratamento indicado para asma, levando ao uso inapropriado de corticóides sistêmicos com efeitos colaterais, freqüentes passagens em setores de emergência, hospitalizações por vezes desnecessárias e, com menos freqüência, intubação e traqueostomia. O objetivo principal deste estudo foi o de investigar a relação desta problemática com a economia psíquica destes pacientes, no que diz respeito à psicogênese e as possibilidades de tratamento por meio do método clínico de investigação e tratamento psicanalíticos. Para isto, foram incluídos 5 pacientes do sexo feminino, com idades entre 30 e 55 anos, que foram acompanhadas em tratamento psicanalítico no ambulatório do Serviço de Imunologia Clínica e Alergia do Instituto Central do HCFMUSP. Constatamos que a DPV aparece de maneira singular na vida de cada paciente investigada, porém com características peculiares que indicam uma localização psíquica capaz de operar como uma satisfação inconsciente frente a um conflito anterior. A princípio, abordar a paciente como se esta não possuísse asma pode levar a uma reação negativa, interpretada por elas como um fingimento ou uma estratégia consciente de obter ganhos primários. A interlocução entre o psicanalista e os demais profissionais da equipe mostra-se de significativa importância
Vocal fold dysfunction (VFD) is characterized by paradoxical movement of closing of the vocal folds, occurring of irregularly and involuntary form during the inspiration, leading to the blockage of the aerial ways. The patients who present VFD do not answer to the treatment indicated for asthma, leading to the unnecessary use of systemic steroids with collateral effect, frequent visits in emergency sectors, hospitalizations and, sometimes, intubations and tracheotomies. The main objective of this study was to investigate the relation of this problematic and the psychic economy of these patients, in whom it says respect to psychogenic explanation and the possibilities of psychoanalytical treatment. For this, 5 patients of the feminine sex had been enclosed, with ages between 30 and 55 years, that had been followed in psychoanalytical treatment in the clinic of the Service of Clinical Imunologia and Allergy of the Central Institute of the HCFMUSP. We evidence that the VFD appears in singular way in the life of each investigated patient, however with peculiar characteristics that indicate a psychic localization capable to operate as an unconscious satisfaction to a previous conflict. To approach the patient as if this did not possess asthma can lead to a negative reaction, interpreted for them as a deceit or a conscientious strategy to get primary profits. The interlocution between the psychoanalyst and the members of the team reveals of significant importance

Despite the large incidence of speech problems in the modern life, our knowledge about the effect of supraglottic laryngeal structures on human phonation is lacking. These structures are mainly consisting of aryepiglottic folds, epiglottis, arytenoids, and false folds (ventricular folds). Shape and size of these structures depends on several factors including race, gender, age, and laryngeal abnormalities.