Glottic and Neoglottic Insufficiency: Causes, Functional Problems and Evaluation



Fig. 3.1
Left vocal cord paralysis in intermediate position (a) with glottic insufficiency during phonation (b)



Even dysphonia in most cases tends to fade, thanks to the compensation of the mobile hemilarynx, to a favorable position of the paralyzed vocal cord, to a reduction in the atrophic component.

The reason why in a unilateral vocal cord paralysis, laryngeal muscle trophism maintains or restores more or less completely after a period of hypotrophy, depends on a residual neuronal activity and especially on the so-called synkinetic reinnervation. Synkinesis, defined as the synchronous contraction of muscles that do not normally contract together, results from aberrant regeneration of a mixed motor nerve after injury. The recurrent laryngeal nerve contains fibers for the adductor and abductor muscles; after injury may occur a cross axonal reinnervation (abductor to adductor and vice versa) that determines contractile competition. This results in an impaired or chaotic vocal fold mobility but with conservation of the muscular trophism sometimes associated with muscle dyssynergia or asynchrony [40, 41].

Crumley [40] has classified laryngeal synkinesis in IV types:



  • Type I: immobile or poorly mobile vocal folds, no respiratory disorders and good voice quality; vocal cord is in median or paramedian position and trophic


  • Type II: no respiratory disorders and a moderate to severe voice impairment (spasmodic and/or blown and/or erratic); there are sudden spasms of the vocal cords and/or arytenoids and/or false vocal cords


  • Type III: hyperadduction of the vocal cord with emphasis during inspiration; voice is normal but there is a reduction of the airspace with possible mild dyspnea especially during physical activity


  • Type IV: hyperabduction of the vocal fold cord with blown voice up to aphonia and possible aspiration

Type I synkinesis are defined as “favorable” for functional outcome with few or no phonatory or airway symptoms, while the other three types are defined as “unfavorable” because of unsatisfactory voice and airway impairment and/or aspiration.

Type III synkinesis appear to result from a predominant lateral cricoarytenoid muscle reinnervation compared to the posterior cricoarytenoid muscle; in type IV synkinesis the opposite seems to happen.

If a synkinesis is present, some authors recently prefer to define the immobility of the hemilarynx not with the term of paralysis but with the designation of “impairment.”

In case of vocal cord atrophy, voice is mostly breathy and weak in intensity with a decreased MPT; if diseases of the lamina propria are also present or the cause of glottic insufficiency is exclusively in this kind of disease, hoarseness is associated with the acoustic perception of air leak through the glottis [1].

As a result of cordectomy with glottic compensation, voice is more or less breathy with a decreased MPT and increased hoarseness because of the stiffness of the neocord; in case of supraglottic compensation between the false vocal cords or between arytenoids and epiglottis (sphincteric) voice is particularly hoarse.



3.2 Neoglottic Insufficiency: Causes and Functional Correlations


In patients who underwent subtotal laryngectomy, residual anatomical elements to which the sphincter function is entrusted, a prerequisite for airway protection during swallowing and voice production, are arytenoids (one or both) posteriorly and epiglottis or base of the tongue anteriorly. When the ariteno-epiglottic or ariteno-lingual opposition does not allow a complete closure of the neoglottic lumen, there is a neoglottic insufficiency with a variable impact on phonation and swallowing [1].

To better understand the causes that could lead to the neoglottic insufficiency, reconstructive techniques and following compensation mechanisms need to be explained.

In supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP) [42, 43] reconstruction is done by pexy between the cricoid cartilage, hyoid bone, and the suprahyoid epiglottis. In partial laryngectomy with cricohyoidopexy (CHP) [44, 45], even the epiglottis is removed and the reconstruction is done by pexy between the cricoid cartilage and hyoid bone with a transfixed suture that includes a portion of the base of the tongue.

The subtotal laryngectomy with tracheohyoidoepiglottopexy (THEP) or with tracheohyoidopexy (THP) [46] is indicated for glottic carcinomas with subglottic involvement greater than 5 mm and inferior paraglottic space invasion. Compared to supracricoid laryngectomy, with this technique the larynx is removed comprising the entire anterior or anterolateral subglottic space, preserving one or both cricoarytenoid units.

In all these surgical procedures, an arytenoid could be removed or preserved.

The causes of neoglottic insufficiency may be linked to the intervention, to an inadequate rehabilitation process, to postsurgical adjuvant treatments.

The surgical technique in reconstructive laryngectomies must necessarily be carried out following all the precautions necessary to achieving a satisfactory postoperative organ function.

Preservation of the inferior laryngeal nerves is important for arytenoids motility, but also the preservation of the superior laryngeal nerves for hypopharyngeal visceral sensitivity that is fundamental during the pharyngeal phase of swallowing to trigger the adduction laryngeal reflex. During surgery then is identified the superior neurovascular laryngeal pedicle with preservation of the external portion of the internal branch of the nerve.

Another technical device not to be overlooked is to not place, during pexy performation, the anterior hyoid bone margin in front of the cricoid or tracheal ring (depending on type of reconstruction), in order to obtain an anatomical conformation of the neolarynx which facilitates the opposition of the base of the tongue or the epiglottis to the residual arytenoid (one or both).

In case of CHP and THP, pexy suture must include a portion of base of the tongue, which is thus compacted towards the hyoid bone assuming a convex curvature that allows to better protect the neoglottic aditus during swallowing.

The speech rehabilitation must be carried out properly and completely. Outpatient rehabilitation after discharge is also very important because it aims mainly to arytenoid motility exercises that contribute to refine swallowing and strengthen the quality and intensity of voice.

Patients who undergo adjuvant chemoradiotherapy may show significant regression of functions acquired with postoperative rehabilitation because of postradiation edema, cricoarytenoid ankylosis, decrease of pharyngeal mucosa, and neoglottic sensitivity.

Since the patient with glottic cancer has dysphonia (from mild to severe) as main symptom, which has been gradually established, he tends to accept without much difficulty the postoperative kind of voice that will be breathy, particularly hoarse (with noise as main spectrum component), produced with considerable difficulty for a short duration (few seconds). The critical aspect is constituted by swallowing and persistence, despite rehabilitation treatment, of a neoglottic insufficiency (Fig. 3.2) that determines swallowing alterations that can lead to aspiration pneumonia. The mechanism that assures a neoglottic competence is the movement of one or both arytenoids horizontally toward the midline and anteriorly towards the epiglottis, if present, or, alternatively, towards the base of the tongue with a complete and energic contact. Retropulsion of the base of the tongue is another important protective mechanism especially in CHP and THP.

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Fig. 3.2
Neoglottic insufficiency in a patient who underwent CHP: arytenoids movement towards the midline is preserved while it lacks their anterior contact with the base of the tongue

The vocal production is fundamentally linked to the vibration of arytenoid mucosa, which sometimes is associated with the vibration of other structures such as the mucosal flap that is formed where there was the removed arytenoid, the epiglottis, and the ariepiglottic fold.


3.3 Glottic Insufficiency Evaluation


Glottic insufficiency determines an alteration of the voice as it causes an incomplete closure of the vocal cords during the phonatory vibration, with an air leak more or less significant. The two main consequences are:



  • The phonatory effort for expiration effort required to maintain a sufficient subglottic pressure able to generate a sufficiently audible voice.


  • Dysphonia for expiratory air turbulence that creates noise components mixed with the harmonic components of the glottic sound and to the irregularity of the glottic vibration.

In cases of marked glottic insufficiency, as for example in the outcomes of arytenoidectomy, of enlarged cordectomy or unilateral cordal paralysis in abducted position, dysphagia can also occur with aspiration of foods (especially liquids) during the pharyngeal phase of swallowing.

The evaluation of the patient with glottic insufficiency is performed both at the time of the preoperative clinical-instrumental diagnosis at posttreatment control. For a correct diagnosis and a correct evaluation of the therapeutic (medical, speech therapy, phonosurgery) results, it is essential that the speech pathologist uses a protocol of clinical and instrumental investigations internationally widespread and shared, in order to compare the data obtained from the same patient before and after treatment and the data obtained in other centers with the same therapeutic method or with different methods.

The protocol of essential clinical and instrumental investigations adopted in Italy and in Europe for the evaluation of the patient with dysphonia from glottic insufficiency, as well as for other voice disorders, has been proposed by the European Society of Laryngology (ELS) in 2001 [47], and adopted, with some modifications, by the Italian Phoniatrics and Logopedics Society (SIFEL) and the Italian Society of Otorhinolaryngology (SIO) in 2002 [48, 49] with further modifications [5052].

The surveys provided by the “SIFEL protocol” to which we refer are “subjective” and “objective.” The ideal condition would be to be able to assess the dysphonia through a unique “objective” – investigation – but phonation is a “multidimensional” phenomenon [53] and cannot be properly assessed through a single examination.

The clinical and instrumental investigations contained in the ELS protocol and in the SIFEL protocol are:



  • Laryngeal stroboscopy


  • Perceptive evaluation of dysphonia


  • Voice spectral analysis


  • Patient self-assessment of dysphonia

The Italian protocol also includes the phoniatric medical history and logopedic assessment (agreement pneumo-phono-articulatory, posture, muscular tensions).

Cards for collection of data obtained from clinical and instrumental investigations are different for the “common” adult dysphonic patient and for dysphonic children or singers [5456].


3.3.1 Laringostroboscopy


The laryngostroboscopy is a semiobjective examination because it depends on the experience of the examiner; it is essential that the exam be recorded and reviewed carefully in slow motion.

In the case of glottic insufficiency by unilateral vocal fold paralysis, the most important parameter is the position of the fixed vocal cord (Fig. 3.3): if it is fixed in median or paramedian position the speech therapy would be sufficient for gaining a good voice, but if it is in an intermediate or lateral position a laryngoplasty (injective or external) is often necessary for cordal medialization.

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Fig. 3.3
Laryngostroboscopy in a patient with right vocal cord paralysis in paramedian position

In case of glottic insufficiency after cordectomy it is essential to assess the site of voice production: it may be glottic (vocal fold or neocord) or supraglottic (between ventricular folds or between arytenoids and epiglottis). The stroboscopical collection card [1] includes evaluation of laryngeal morphology, supraglottic structures contraction, the site of phonatory vibration, vocal cords/arytenoids motility, the level of the vocal cords, vocal cord profile, glottic closure, cordal vibration and mucosal wave amplitude and symmetry, vibration cycle periodicity, and vibration interruptions.


3.3.2 Perceptive Evaluation of Dysphonia


For the perceptive evaluation of dysphonia the “GIRBAS” scale (ELS guidelines) [47] is used. It assesses six vocal parameters, on a scale with 3° of severity. These parameters are:



  • The overall Grade of dysphonia (G)


  • The degree of Instability of the voice (I)


  • The degree of Roughness of the voice (R)


  • The degree of Breathiness of the voice (B)


  • The degree of Asthenia of the voice (A)


  • The degree of Strain of the voice (S)

In our card, some other parameters are added, such as the intensity of the voice and the tonal pitch.

The perceptive evaluation of dysphonia is a subjective examination: to make it more possible to correct and compare, it is necessary to be done in a collegial manner by two or more experienced examiners (usually a phoniatric and a speech therapist).


3.3.3 Spectral Analysis of Voice


The spectral analysis of voice is composed both by objective and semiobjective investigations [57].

The objective investigations are the multiparametric acoustic analysis, the aerodynamic indices (maximum phonation time), and the phonetogram.

(a)

The multiparametric acoustic analysis can be realized by several computer softwares, the most internationally widespread is the multidimensional voice program (MDVP) [58, 59].

The software analyzes the three central seconds of a vowel / a / kept at constant pitch and intensity. In a star-like graphic are inserted 11 basic acoustic parameters [60] (Fig. 3.4):

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Fig. 3.4
MDVP star-like graphic of a patient with left vocal cord paralysis (the same of Fig. 3.1). Acoustic parameters obtained for the vowel /a/ are included in the red area. The green area included normal values


1.

Jitt – Percent jitter (normal value, nv 1.04 %)

It is the average relative variability in the short term, from period to period, of the fundamental period; it is an index of irregularity of glottic vibration and is related to hoarseness.

 

2.

vFo – Variation of the fundamental frequency (nv >1.10)

It is the relative variability in the medium to long term, from period to period, of the fundamental period. It is an index of the ability to maintain the voice intoned to the same note during the 3 s of vocalization.

 

3.

Shim – Percent shimmer (nv >1.04 %)

It is the average relative variability in the short term, from period to period, of peak-to-peak amplitude. It is an index of irregularity of glottic vibration and is related to breathy and hoarse voice.

 

4.

vAm – Amplitude variation in the medium to long term (nv >8.28)

It is the average relative variability in the medium to long term period by period, of peak-to-peak amplitude. It is an index of the capacity to maintain a constant subglottic pressure during the 3 s of vocalization.

 

5.

NHR – Noise to harmonic ratio (nv <0.19)

It is the average ratio between the disharmonious components of spectral energy (noise) in the band 1500–4500 Hz and the harmonious components of spectral energy in the band 70–4500 Hz. It is an overall assessment of the presence of noise in the range of mid-low frequencies.

 

6.

VTI – Voice Turbulence Index (nv >0.061)

It is the average ratio between the noise components in the band 2800–5800 Hz and the harmonic components in the band 70–4500 Hz. The high frequency noise is related to the turbulence due to incomplete glottic closure and is an acoustic correlated to the “breathy voice.”

 

7.

SPI – Soft Phonation Index (nv <14.12)

It is the average ratio between the components of the harmonic spectral energy of low frequency (70–1600 Hz) and high frequency (1600–4500 Hz). The more stronger the vocal cord adduction, the more lower the SPI value, since harmonics of high frequency are abundant.

 

8.

FTRI – Fo Tremor Intensity Index (nv >0.95 %)

It is the percentage ratio between the rate of periodic modulation of the Fo and the average Fo.

 

9.

ATRI – Amplitude Tremor Intensity Index (nv 4.37 %)

It is the percentage ratio between the rate of the peak amplitude and the average peak amplitude.

 

10.

DVB – Degree of voice breaks (nv 0 %)

It is the percentage ratio between the total duration of the intervals of sound interruption and that of the entire sample.

 

11.

DSH – Degree of subharmonics or degree of diplophonia (nv 0 %)

It is an index of the recurrence of sub-harmonic components over the whole voice sample.

 

The 11 acoustic parameters in the MDVP were grouped in five regions [60]:



  • I Fundamental frequency perturbation: Jitt, vFo


  • II Amplitude perturbation: Shim, vAm


  • III Spectral energy balance: NHR, VTI, SPI


  • IV Tremor frequency and amplitude: FTRI, ATRI


  • V Diplophonia – voice break: DSH, DVB

Other two fundamental acoustic parameters are:



  • The harmonic to noise ratio (H/NR) (nv ≥7.4) or Yumoto Index [59, 61] is the ratio between the intensity of the harmonic component (sound) and that of the disharmonious component (noise) present in the whole spectrum of the examined signal.


  • The average fundamental frequency of the conversation voice (FoM) is calculated on a whole standard sentence or, more easily, on the word /aiuole / (nv man 80–150 Hz, woman 180–250 Hz) [50].

 

(b)

The maximum phonation time MPT (nv >10 s) is a quantitative aerodynamic index that is calculated from producing a vowel / a / kept at constant pitch and intensity as long as possible [62]. The best result from three tests is chosen. They can be identified under three classes of severity for values less than the threshold value [50]:



  • Normal >10 s


  • Slight alteration 8–10 s


  • Moderate alteration 5–7 s


  • Severe alteration <5 s

In case of severe glottic insufficiency the MPT is always severely altered.

 

(c)

The phonetogram is a graph in which the values of the fundamental frequency of the voice (in Hz) are on the X-axis divided into semitones of a piano keyboard while the values of the intensity (in dB SPL) for the various Fo produced are on the Y-axis (Fig. 3.5). The subject is required to produce an ascending and descending siren (glissato) with the vowel / a /, from the lowest to the highest note that he is able to produce, prior at the minimum and then at the maximum intensity [57]. The test is repeated three times and each time the software acquires new information to complete the phonetogram.

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Fig. 3.5
Spectrogram 0–4000 Hz in long window of the vowel /a/ (a) and of the word /aiuole/ (b) of a patient with left vocal cord paralysis (the same of Figs. 3.1 and 3.4) with noise components and sub-harmonics

 

The parameters of evaluation that are taken into consideration are mainly the pitch range (in semitones) [53, 63], the dynamic intensity (Range dB max), and the maximum intensity at the level of the average Fo of the voice of conversation (dB max at average Fo) [50, 57]. The execution of phonetogram is useful as control in the same subject after medical treatment, speech therapy, or phonosurgery, as the threshold values for phonetogram parameters in dysphonia were not defined with certainty.

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Jul 8, 2017 | Posted by in OTOLARYNGOLOGY | Comments Off on Glottic and Neoglottic Insufficiency: Causes, Functional Problems and Evaluation

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