Stroboscopic Examination

Terminology Endoscopy: a technique used by physicians to view internal parts of the body. Laryngoscopy: viewing of the laryngeal area specifically Stroboscopy: “strobos- means whirling” indicates the use of a particular type of light during visualization Videostroboscopy: makes a permanent record of the vocal fold patterns for post hoc analysis

Endoscopy Rigid endoscopes have an oral insertion Flexible endoscopes have a nasal insertion

Nasoendoscopy Flexible scope End of scope Vocal Folds

Rigid Endoscopy Head must be tilted up & back for optimal vision.

Why Videoendoscopy? Primary purposes: 1. To identify the physiologic correlates of perceived resonance & voice quality for speech, 2. To document the status of speech anatomy & physiology during speech production, 3. To assist educational & clinical discussion among clinicians, patients, & other interested individuals.

Secondary Purposes: 1. Confirmation of medical diagnosis, 2. Improving patient counseling & motivation, 3. Providing biofeedback therapy.

Who should do videoendoscopy? Medical personnel- -physicians (identify disease process for surgery) Nonmedical personnel- -SLP (need for specialized knowledge about speech production & application clinically)

Whom is videoendoscopy appropriate? Patients who have: 1) Velopharyngeal and/or laryngeal disorder that affect speech production. i.e. hypernasal patients, cleft palate, vocal fold pathology etc. 2) Have ability to speak & cooperate

Mechanics of Videostroboscopy Use of intermittent illumination to aid in the process of observation, High-speed camera photography motion picture, Constant light to record images in frames on film & sequentially projected, On-line visualization of movement Intervals between flashes can be regulated

Flash 1 Flash 2 Flash 3 Flash 4 image 1 image 2 image 3 image 4 composite image composite image Top: light pulses are regular & produced at the same frequency (still); Bottom: pulses regular but differ 1.5 Hz from the frequency of vibration (motion)

A B (A) Synchronized flash intervals, illumination occurring at same point of each cycle, motionless (B) Flash intervals occur at faster rate, results in motion.

Judgment & Interpretation of Vibratory Pattern Fundamental frequency Periodicity Amplitude of horizontal excursion Glottal closure Symmetry of bilateral movement Mucosal wave

Fundamental frequency Fo is read in Hz on the indicator of the stroboscope, Range should be noted during the evaluation, Interpretation: differentiate between pathological & physiological 1. Stiffer the v.f. tissue, the greater the Fo - increased activity in the CT (physiological example) - scar formation & sulcus vocalis increase Fo (pathologic example)

Periodicity Regularity of successive apparent cycles of vocal fold vibration “periodic”- vibration is considered to be uniform in amplitude and time “aperiodic” vibration can vary in amplitude or frequency Periodicity can be regular, irregular or inconsistent

Periodicity Interpretation: 1. Asymmetry: may be caused by unilateral recurrent laryngeal nerve paralysis, unilateral polyp or unilateral carcinoma 2. Interference with homogeneity: may occur by small cysts or a small carcinoma 3. Flaccidity: abnormally flaccid or pliable tissue caused by severe RLN paralysis or edematous lesion 4. Unsteady Tonus: incapability of maintaining a steady tonus of the laryngeal muscles, seen in spasmodic dysphonia

Horizontal & Vertical Movements Amplitude of Horizontal Excursion Amplitude is the extent of horizontal excursion of the v.f.’s during vibration: each fold rated independently Ratings are made on a 4 point scale small: excursion smaller than normal normal: excursion WNL great: excursion is greater than normal

Amplitude Interpretation: 1. The shorter the vibrating portion, the smaller the amplitude (relative lengths of v.f.’s of men vs. women; or laryngeal webbing) 2. Stiffer the v.f.’s, the smaller the amplitude (normal falsetto voice; carcinoma, papilloma, scar, sulcus vocalis, firm nodule, firm polyp) 3. Greater the mass, smaller the amplitude (carcinoma, granuloma, papilloma, polyp) 4. Greater the Ps, greater the amplitude (loud speech)

Schematic of amplitude changes Center line has no visible movmt. first mark (blue) is normal second (green), great movmt.

Glottal Closure Rated as ‘complete” or “incomplete” Determined by the extent of v.f. approximation dung the maximum closing of the vibratory cycle Complete: glottis completely closed for each cycle Incomplete: glottis never closed during cycle Inconsistent: glottis completely closed during some cycles and incompletely closed during others

Glottal Closure Interpretation: 1. Impaired adduction of the v.f.’s (RLN paralysis, ankylosis) 2. Nonlinear edge (nodule, polyp, papilloma, carcinoma) 3. Stiff edge (no mucosal wave) (scars, sulcus vocalis)

A B C D E F G H (A) complete closure, (B) spindle-shaped gap along entire edge, (C) spindle-shaped gap at middle, (D) hourglass-shaped gap, (E) gap by unilateral oval mass, (F) gap with irregular shape, (G) gap at post. glottis, (H) gap along entire length

Symmetry of bilateral movement Degree to which the 2 vocal folds provide mirror images of one another during vibration, Timing and extent of excursion during vibration, if same then symmetrical, if not asymmetrical, Describe asymmetry (i.e. excursion of right fold has a greater amplitude etc.)

Mucosal Wave Mucosal waves can be described as: 1. Absent: no observable traveling wave 2. Small: wave is present, but less marked than normal 3. Normal: clearly observable traveling mucosal wave 4. Great: extraordinarily marked wave

Mucosal Wave Interpretation: 1. Stiffer the mucosa, less marked the wave (falsetto, scars, papillomas, cysts, fiberoptic nodules) 2. Partially stiff mucosa (wave stops traveling at stiff portion, sulcus vocalis, localized scar, small cyst) 3. Tight or loose glottal closure (decrease in wave, hyper- or hypokinetic phonation)

Readings If you would like extra readings on stroboscopy you may want to refer to: Hirano & Bless, Videostroboscopic Examination of the larynx, Singular Publishing, 1993.

Benign Laryngeal Pathologies Category 2: Voice difficulties due to abnormal growths & lesions, tissue degeneration, joint immobility, or fractures caused by: intubation, gastro-esophageal reflux, chronic cigarette smoking inhalation, presbylaryngis, thyroid gland disease, upper respiratory infection, cervical rheumatoid arthritis, & external laryngeal trauma Granulomas Webs Pacydermia laryngis Hyperplastic-leukoplakic lesions Cricoarytenoid joint fixation Bowing Infectious laryngitis

Granuloma Primary voice symptom: hoarsness Description: mass lesions on the vocal process of the arytenoid cartilage in post. larynx, unless large does not effect the vibrating portion of the vocal folds, vascular lesion from tissue irritation in post. larynx Etiology: persistent misuse (contact), intubation during surgery, gastroesophageal reflux

Granuloma Acoustic Signs: Measurable Physiological Signs: Greater than normal perturbation (jitter & shimmer) Measurable Physiological Signs: Normal airflow rates Observable Physiological Signs: Irregularly shaped masses of tissue either at the site of the vocal processes of the arytenoids or elsewhere on the vocal folds

Treatment Antireflux regime (raising head off bed, not eating before retiring, drugs such as propulsin) Surgery Support by SLP during management process for lesions

Case 33 (CD 1, Track 33) History: 65 year old male Significant smoking history 4 months of mild hoarseness & sore throat Frequent heartburn symptoms, acid regurgitation & chronic throat clearing Enjoys spicy foods, teas, colas, late night snacks

Case 33 Examination Findings: Mildly hoarse-harsh Videostroboscopy- 2 large, smooth, rounded, pearl-colored masses near vocal process or arytenoids Interlock during phonation Inhibit complete posterior glottic closure Diagnosis: bilateral vocal process granulomas secondary to chronic reflux laryngitis

Granuloma (Case 33): Pretreatment

Case 33 Treatment: Treatment Results: Dietary & lifestyle changes to decrease GER Prescribed Prilosec (Omeprazole), 20 mg orally every 12 hours to inhibit gastric acid secretion Treatment Results: Repeat video 4 weeks after antireflux therapy Subjective voice improvement Reflux symptoms disappeared Near complete resolution of right granuloma Left not changed, but more sessile & rounded

Granuloma (Case 33): Post-treatment

Discussion Chronic gastroesophageal reflux may manifest as laryngeal disease May describe heartburn symptoms 34% will present with isolated laryngeal symptoms excess “phlegm” chronic throat clearing acid regurgitation dysphagia

Papilloma Primary voice symptom: hoarseness, low pitch Description: multiple wart-like lesions, develop in epithelium & deeper in LP, vocalis muscle, Etiology: caused by viruses, may spread to larynx, trachea & bronchi, children (juvenile papilloma) & adults

Papilloma Measurable Physiological Signs: Increases stiffness may cause increased pressure Observable Physiological Signs: Present as whitish cluster of tissue (raspberry) Interfere with glottic closure Increased stiffness impedes horizontal excursion & mucosal wave will be absent in the area of lesion

Case 35 (CD 2; Track 2) History: 28 year old female Presented with long history of recurrent laryngeal papillomas dating 7 years back Six previous procedures for removal of lesions Experiencing dysphonia at time of testing

Case 35 Examination Findings: Perceptually- severely breathy hoarse quality with high pitch breaks occasionally Maximum phonation time = 5 seconds Acoustic Analysis- Fundamental frequency = 180 Hz Jitter %= 3.4 Shimmer= 0.56 dB Harmonic to noise ratio= 1.0 dB

Case 35 Examination findings: Treatment: Videostroboscopy: Papillomatous tissue distributed over the left true vocal fold, obscuring fold from direct view Right fold not involved Glottic chink exists during phonation False folds adduct during phonation Diagnosis: Recurrent laryngeal papillomas Treatment: CO2 laser ablation Post operative speech therapy

Papilloma (Case 35): Pretreatment

Case 35 Treatment Results: Discussion: CO2laser excision of papillomas Returned for speech therapy 2 weeks post surgery Perceptual improvement of voice Episodic hoarse voice with shrill-like outbursts Discussion: Cauliflower-like lesions caused by infection with the human papilloma virus (HPV) Benign neoplasm Multiple recurrences

Papilloma (Case 35): Post-treatment

Blunt or Penetrating Trauma Etiology: Strangulation, penetrating neck wound, blunt trauma resulting from blow to the neck, fracture of larynx Require medical/surgical treatment Voice restoration after surgery

Inhalation & Thermal Trauma Etiology: Inhalation of gases, smoke or steam Chemical traceobronchitis Hot fumes cause reflex closure of the glottis (protects trachea & respiratory tracts Symptoms: Inflammation, burns, soot around nose or mouth, respiratory distress, stridor, wheezing, hoarseness.

Inhalation Trauma: Anterior Web Formation

Vocal Fold Bowing: Presbylaryngis Occurs when myoelastic tension is diminished, causing concavity from the midline of glottis Etiology: Aging degenerative changes, weakness or hyponicity of laryngeal muscles (RLN damage)

Vocal Fold Bowing: Presbylaryngis Perceptual: Higher than normal pitch (Thinning) Hoarse-breathy quality Pitch breaks Tremor Acoustic Findings: Increased jitter % shimmer Reduced S/N ratio (increased noise) Elevated subglottal pressure Increased airflow

Case 27 (CD 1; Track 27) History: 80 year old female 6 month history of deteriorating voice 16 months later- Thyroidectomy Chronic hoarseness as chief symptom Aspiration of thin liquid Vocal fatigue Shortness of breath Left vocal fold paralysis was suspected

Case 27 Examination Findings: Acoustic Findings: Extrinsic laryngeal region WNL Perceptually severely hoarse-breathy with shrill overlay MPT= 7 seconds Acoustic Findings: Fundamental frequency= 369 Hz Jitter %= 1.2 Shimmer= 0.62 dB Harmonic to noise ratio= 1.5 dB

Case 27 Aerodynamic Findings: Videostroboscopy: Mean airflow= .496 l/sec Subglottal pressure= 10.6 cm H20 Glottal Resistance= 200 cm/ H20 /lps Videostroboscopy: Chink across entire length Bowed vocal folds (more on left side) Both folds were symmetrical & motile

Vocal Fold Bowing (Case 27): Pretreatment

Case 27 Treatment Recommendations: Treatment Results: Unilateral medialization of the left cord Voice therapy to follow Isshiki thyroplasty rather than folds injection of collagen or fat was considered Treatment Results: Left medialization thyroplasty Marked improvement in glottal competency across midline Mild compromise of airway secondary to surgery Left fold is edematous Right fold remains bowed

Vocal Fold Bowing (Case 27): Post-treatment

Vocal Fold Bowing (Case 27): Post-treatment-Phonation

Discussion Bowed vocal folds caused by normal aging & progressive muscle atrophy Exhibited by those with long standing weakness, paresis, & atrophy of vocal folds secondary to nerve damage Results in spindle shaped glottal chink