1. Stroboscopic Examination

2. 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

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

4. Nasoendoscopy
Flexible
scope
End of
scope
Vocal
Folds

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

6. 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.

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

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

9. 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

10. 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

11. 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)

12. 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.

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

14. 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)

15. 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

16. 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

17. 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

18. 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)

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

20. 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

21. 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)

22. 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

23. 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.)

24. 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

25. 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)

26. 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.

27. 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

28. 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

29. 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

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

33. 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

34. 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

35. Granuloma (Case 33): Pretreatment

36. 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

37. Granuloma (Case 33): Post-treatment

38. 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

39. 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

40. 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

43. 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

44. 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

45. 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

46. Papilloma (Case 35): Pretreatment

47. 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

48. Papilloma (Case 35): Post-treatment

49. 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

50. 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.

51. Inhalation Trauma: Anterior Web Formation

52. 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)

53. 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

54. 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

55. 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

56. 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

57. Vocal Fold Bowing (Case 27): Pretreatment

58. 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

59. Vocal Fold Bowing (Case 27): Post-treatment

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

61. 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