Abstract Introduction Low exposure of the larynx can make laryngeal microsurgery difficult or even impossible. The application of rigid and contact endoscopy enabled oblique and retrograde angled visualization, allowing transoperative staging with greater reach of the anatomical areas. However, there is difficulty or even impossibility of performing the surgical act, due to the incompatibility of the angled path with the straight surgical tools. Objective To demonstrate the efficiency of the variant of the technique for laryngeal microsurgery in cases of difficult laryngoscopy and to analyze the new surgical instruments specific to the endoscopic procedure. Methods This is a cross-sectional retrospective study, based on the analysis of 30 medical records of patients treated surgically at a philanthropic hospital in the state of Sergipe, Brazil, between the years of 2014 and 2015. Results The technical variant used 30- and 70-degree endoscopes that provided complete oblique view of the endolarynx. The association of angled instruments (forceps, suction pumps, retractors and scissors) enabled the execution of the surgical procedures. Conclusion The association of rigid endoscopy with angled instruments promoted full visualization of the surgical lesion and operative resolution.

OBJECTIVES: To characterize the voice quality of individuals with dysphonia and to investigate possible correlations between the degree of voice deviation (D) and scores on the Dysphonia Risk Screening Protocol-General (DRSP), the Voice-Related Quality of Life (V-RQOL) measure and the Voice Handicap Index, short version (VHI-10). METHODS: The sample included 200 individuals with dysphonia. Following laryngoscopy, the participants completed the DRSP, the V-RQOL measure, and the VHI-10; subsequently, voice samples were recorded for auditory-perceptual and acoustic analyses. The correlation between the score for each questionnaire and the overall degree of vocal deviation was analyzed, as was the correlation among the scores for the three questionnaires. RESULTS: Most of the participants (62%) were female, and the mean age of the sample was 49 years. The most common laryngeal diagnosis was organic dysphonia (79.5%). The mean D was 59.54, and the predominance of roughness had a mean of 54.74. All the participants exhibited at least one abnormal acoustic aspect. The mean questionnaire scores were DRSP, 44.7; V-RQOL, 57.1; and VHI-10, 16. An inverse correlation was found between the V-RQOL score and D; however, a positive correlation was found between both the VHI-10 and DRSP scores and D. CONCLUSION: A predominance of adult women, organic dysphonia, moderate voice deviation, high dysphonia risk, and low to moderate quality of life impact characterized our sample. There were correlations between the scores of each of the three questionnaires and the degree of voice deviation. It should be noted that the DRSP monitored the degree of dysphonia severity, which reinforces its applicability for patients with different laryngeal diagnoses.

ABSTRACT PURPOSE: To describe the anatomical course of the intralaryngeal portion of the inferior laryngeal nerve (ILN) and to standardize the surgical access to its thyroarytenoid branch (TAb) through the thyroid cartilage. METHODS: Under surgical microscopy, 33 adult human excised larynges were dissected, to expose the intralaryngeal portion of ILN. The point of entry of TAb, ILN's terminal branch, in the thyroarytenoid (TA) muscle was determined and correlated with thyroid cartilage dimensions. RESULTS: After entering the larynx, the ILN consistently traveled between the thyroid cartilage and the lateral cricoarytenoid muscle in an anterior and slightly cranial course. The distance from the point of entry of the TAb in the TA muscle to the midline (TAb-H) and to the inferior border (TAb-V) of the thyroid cartilage differed according to gender. In females, mean distances of TAb-H and TAb-V were 20.5mm and 5.2mm and in males, 22.3mm and 5.9mm, respectively. CONCLUSION: The intralaryngeal course of the inferior laryngeal nerve presents low variability and measures from landmarks in the thyroid cartilage help to estimate the point of entry of thyroarytenoid branch in thyroarytenoid muscle.

PURPOSE:To compare the inflammatory reaction caused by the injection of a sugarcane biopolymer (SCB) into the vocal fold of rabbits with that caused by calcium hydroxyapatite (CaH).METHODS: CaH (Radiesse(r)) and SCB gel were injected respectively into the right and left vocal cords of thirty rabbits. The rabbits were distributed into two equal groups and sacrificed at three and twelve weeks after injection. We then evaluated the intensity of the inflammatory reaction, plus levels of neovascularization, fibrogenesis and inflammatory changes in the vocal mucosa.RESULTS:The vocal cords injected with CaH had a stronger inflammatory reaction by giant cells in both study periods. The SCB group had a more intense inflammatory involvement of polymorphonuclear cells three weeks after injection. SCB caused a higher level of neovascularization compared with CaH three weeks after the procedure.CONCLUSION:Whereas calcium hydroxyapatite triggers a more intense and lasting inflammatory reaction mediated by giant cells, sugarcane biopolymer causes a greater response from polymorphonuclear leukocytes, as well as higher levels of vneoascularization three weeks after injection.

OBJETIVO: Propor e verificar a exequibilidade de programa de intervenção fonoaudiológica para indivíduos com sinais de presbilaringe com ou sem queixa vocal. MÉTODO: Dentre 20 idosos integrantes da pesquisa, participaram deste piloto três idosas com média de 67 anos. Antes e após o programa, realizaram exame laringológico, gravação da voz com protocolo CAPE-V, responderam ao Protocolo de Rastreio de Risco de Disfonia (PRRD) e participaram do Programa Vocal Cognitivo para presbifonia elaborado com fundamentação teórica na epistemologia genética de Jean Piaget associado a técnicas vocais baseadas na literatura. É composto por seis sessões, cada uma com ênfase em diferentes aspectos da produção vocal. RESULTADOS: Após o programa, loudness, coordenação pneumofonoarticulatória, clareza articulatória, jitter e proporção harmônico-ruído melhoraram, ficando dentro do esperado para a faixa etária. Nas três participantes observou-se melhora da qualidade vocal, aumento da frequência fundamental e melhora dos tempos máximos de fonação. Em duas observou-se tensão associada à elevação da loudness e melhora no escore PRRD. Observou-se nas participantes redução dos sinais de presbilaringe observados ao exame de laringoscopia, com melhora da coaptação glótica e movimentação da onda mucosa. CONCLUSÃO: Os resultados preliminares apontam perspectivas animadoras em relação à proposta com melhora dos aspectos analisados. O programa proposto mostrou-se exequível e bem delineado, não sendo necessários ajustes para continuidade do projeto.

PURPOSE: To propose and verify the feasibility of a vocal program intervention in patients with presbylarynx signs with or without vocal complaints. METHOD: Among 20 elder participants of the current research, 3 female patients with median age of 67 years were chosen for the pilot study. Laryngological examination, vocal recording with CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice) protocol, and Screening Protocol of Risk of Dysphonia (SPRD) were conducted before and after the program intervention. They joined the Cognitive Vocal Program for presbyphonia based on the genetic epistemology by Jean Piaget associated with vocal techniques based on scientific literature. This program is structured with six sessions and each one of them is focused in different aspects of vocal production. RESULTS: After the program intervention, some aspects such as loudness, coordination between breathing and speaking, accuracy in articulatory movements, jitter, and harmonics-to-noise ratio improved with parameters within the expected range for the age group. Three female participants were observed for better vocal quality, higher fundamental frequency, and better maximum phonation time. In two cases, tension related to loudness elevation and better scores on SPRD was observed. Using by high-speed laryngeal image, we also observed reduction of presbylarynx signs, and remarkable improvement in glottis closure competence and mucosal wave movement of the patients with and without vocal complaints. CONCLUSION: The preliminary results suggest encouraging prospects for the proposal with improvement in the aspects analyzed. This program was well designed and did not require any further adjustments.

Introduction  The study of the dynamic properties of vocal fold vibration is important for understanding the vocal production mechanism and the impact of organic and functional changes. The advent of high-speed videolaryngoscopy (HSV) has provided the possibility of seeing the real cycle of vocal fold vibration in detail through high sampling rate of successive frames and adequate spatial resolution. Objective  To describe the technique, advantages, and limitations of using HSV and digital videokymography in the diagnosis of vocal pathologies. Methods  We used HSV and digital videokymography to evaluate one normophonic individual and four patients with vocal fold pathologies (nodules, unilateral paralysis of the left vocal fold, intracordal cyst, and adductor spasmodic dysphonia). The vocal fold vibration parameters (glottic closure, vibrational symmetry, periodicity, mucosal wave, amplitude, and glottal cycle phases) were assessed. Results  Differences in the vocal vibration parameters were observed and correlated with the pathophysiology. Conclusion  HSV is the latest diagnostic tool in visual examination of vocal behavior and has considerable potential to refine our knowledge regarding the vocal fold vibration and voice production, as well as regarding the impact of pathologic conditions have on the mechanism of phonation.

OBJETIVO: Identificar efeitos imediatos das vibrações sonorizadas e do som basal em indivíduos saudáveis por meio de parâmetros acústicos e quimografia de alta velocidade. MÉTODOS: Participaram 30 sujeitos, 12 homens e 18 mulheres (19 a 45 anos) sem alterações laríngeas. As vozes foram gravadas à taxa de 44.100 amostras/segundo e as videolaringoscopias de 4.000 quadros/segundo, antes e depois dos exercícios vocais. Foi desenvolvida uma rotina computacional para extrair Jitter e Shimmer. Foram geradas quimografias de alta velocidade a partir das imagens laríngeas para a análise dos tempos de fase: fechada (FF); aberta (FA); de fechamento (Ff) e de abertura (Fa), e usados o Teste t de Student pareado e o teste Mann-Whitney, com nível de significância de 0,05. RESULTADOS: Após as vibrações sonorizadas, houve diminuição de Jitter (0,018 para homens e p<0,01para mulheres) para ambos os gêneros e diminuição de Shimmer (p<0,01) ao gênero feminino. Houve diminuição de FF (p=0,046) e de Ff (p=0,026) e aumento de FA (p=0,05) em pregas vocais femininas. Após o som basal, foram identificados diminuição de Jitter (p<0,01) em vozes femininas e da Ff (p=0,026) em pregas vocais masculinas. CONCLUSÃO: Foi possível verificar mais efeitos imediatos positivos após as vibrações sonorizadas principalmente em qualidade vocal e pregas vocais de mulheres. No entanto, são necessárias pesquisas com maior número de amostras masculinas e investigação sobre o tempo adequado do som basal para corroboração dos resultados desta pesquisa.

Purpose: To identify the immediate effects of voiced vibration and vocal fry exercises on healthy subjects by means of acoustic parameters and high-speed kymography. Methods: Thirty healthy subjects (18 women and 12 men, aged from 19 to 45 years old) participated in this study. The voices were recorded at the range of 44.100 samples/second, before and after of the vocal exercises. We developed a computational routine to extract jitter and shimmer. High-speed kymography was generated from laryngeal images for the analysis of the phase times: closed (CPh), open (OPh), of closing (cPh) and of opening (oPh) and used the paired t-Student test and the Mann-Whitney test, with a significance level of 0.05. Results: After voiced vibrations, acoustic parameters showed reduced jitter for both genders (p=0.018 for men and p<0.01 for women) and reduced shimmer for female voices (p<0.01). There was a decrease in CPh (p=0.046) and cPh (p=0.026) and an increase in OPh (p=0.05) in female vocal folds. After vocal fry, we identified decreased jitter (p<0.01) in female voices and cPh (p=0.026) in male vocal folds. Conclusion: We observed more positive immediate effects of the voiced vibrations, mainly in voice quality and vocal folds among females. Nevertheless, studies with larger male sample and investigation of the appropriate time of vocal fry are necessary to confirm the results of this search.

INTRODUCTION: Endolaryngeal injection of botulinum toxin into the thyroarytenoid (TA) muscle is one of the methods for treatment of focal laryngeal dystonia. However, after treatment, there is variation in laryngeal configuration as well as the side effects reported by patients. As a consequence of the functional variability of results, it was hypothesized that botulinum toxin diffuses beyond the limits of the muscle into which it is injected. OBJECTIVES: After injection of botulinum toxin into the TA muscle for the treatment of focal laryngeal dystonia, patients differ in terms of laryngeal configuration and side effects. We hypothesized that this toxin diffuses from the target muscle to adjacent muscles. METHOD: The TA muscles of 18 cadaver larynges were injected with aniline blue (0.2 mL). After fixation in formaldehyde and nitric acid decalcification, the larynges were sectioned in the coronal plane and the intrinsic muscles were analyzed. RESULTS: We found diffusion of aniline blue to the lateral cricoarytenoid muscle, cricothyroid muscle, and posterior cricoarytenoid muscle in 94.3%, 42.9%, and 8.6% of the cases, respectively. In terms of the degree of diffusion to adjacent muscles, we found no differences related to the size (height and width) of the TA muscle or to gender. CONCLUSIONS: Our findings suggest that diffusion of botulinum toxin from its injection site in the TA muscle to the lateral cricoarytenoid muscle is likely in most cases. On the other hand, diffusion to the cricothyroid muscle occurs in approximately half of cases and diffusion to the posterior cricoarytenoid muscle occurs in very few cases.

INTRODUCTION: The effects of voiced vibration technique can be assessed by laryngeal imaging. Kymographic images derived from high-speed videoendoscopy allow actual visualization of vocal folds vibration. PURPOSE: The aim of this study is to identify the immediate effects of the voiced vibration technique in healthy vocal folds using high-speed digital laryngeal imaging. METHODS: Samples were obtained from 15 healthy subjects with no history of voice disorders (6 men and 9 women aged 21 to 43 years). High-speed videoendoscopy recordings were performed before and after the voiced vibration technique. Kymographic images were obtained using high-speed videoendoscopy. The vocal folds were examined in their open and closed positions and the characteristics of the opening and closing phases were determined. A customize computational routine was used quantify these parameters. The closing, opening, and speed quotients were also calculated. RESULTS: In this study, women displayed statistically significant differences in opened phase (P= 0.05*), closed phase (P= 0.046*), and closing phase (P= 0.026*) phase characteristics. Men displayed the highest difference rate in opening time characteristics (P= 0.06). The closing and opening quotients for the female group showed significant differences (P= 0.029* and P= 0.049*, respectively). The speed quotient exhibited statistically significant differences in the male group (P= 0.048*). CONCLUSION: The kymographic images indicated that the immediate effect of the voiced vibration technique was smooth contact in healthy vocal fold vibration.

Nenhum tecido ou substância ideal foi encontrado para a injeção em pregas vocais. O objetivo deste estudo prospectivo foi avaliar o uso do Durasphere como substância de injeção na prega vocal canina. MATERIAIS E MÉTODOS: Em seis cães adultos foram injetados 0,3mL de Durasphere no terço médio da prega vocal direita no músculo tireoaritenoideo e 0,3mL de soro fisiológico na prega contralateral. Os animais foram sacrificados após 7 dias (três cães) e 90 dias (três cães). Analisamos os processos inflamatórios no músculo vocal e na lâmina própria das pregas vocais. RESULTADOS: No músculo vocal com Durasphere havia uma inflamação significativamente maior que no músculo controle, formouse um infiltrado linfomononuclear moderado após 7 dias e leve após 90 dias. Não observamos formação de corpos estranhos ou granulomas. Já na lâmina própria houve um processo inflamatório leve nos dois grupos, sem diferença entre eles. CONCLUSÃO: Trata-se de uma substância com biocompatibilidade comprovada em humanos, com resultados preliminares e inéditos de sua injeção em pregas vocais caninas que causou um processo inflamatório moderado no músculo vocal após 7 dias e leve após 90 dias, sem formação de corpos estranhos ou granulomas.

There is no ideal tissue or substance to be injected in the vocal folds. The objective of the present study was to assess the use of Durasphere in canine vocal fold injection. MATERIALS AND METHODS: in six adult dogs we injected 0.3 mL of Durasphere in the middle third of the thyroarytenoid muscle and 0.3 mL of saline solution in the contralateral vocal fold. The animals were slaughtered after seven days (three dogs) and after 90 days (three dogs). We analyzed the inflammatory process in the vocal fold and in the lamina propria of the vocal folds. RESULTS: in the vocal muscle which received Durasphere there was a significantly more intense inflammation when compared to the control muscle - there was a moderate lymphomodular infiltrate after seven days and mild after 90 days. We did not observe foreign bodies nor granulomas. On the lamina propria there was a mild inflammatory process in the two groups, without difference between them. CONCLUSION: this is a substance of proven biocompatibility in humans, with preliminary and unprecedented results and its injection in canine vocal folds caused a moderate inflammatory process after seven days and mild after 90 days, without foreign bodies or granuloma formation.

Os corticosteróides são potentes inibidores da inflamação e da cicatrização. Administração local de esteróides diretamente na laringe tem sido relatada em diversas patologias laríngeas. OBJETIVO: O objetivo desse estudo é realizar uma revisão da literatura sobre o uso de infiltração de corticosteróide em pregas vocais, em pacientes com patologias vocais benignas, inflamatórias e crônicas de laringe. METODOLOGIA: Realizou-se uma busca eletrônica na base de dados Medline, selecionando-se estudos clínicos que utilizavam corticosteróides em patologias benignas da laringe. RESULTADOS: Os corticosteróides são indicados nas seguintes situações: 1) doenças inflamatórias agudas, principalmente naquelas relacionadas a edema que comprometa a via aérea; 2) doenças auto-imunes com alterações laríngeas; 3) estenose laríngea; 4) em lesões benignas inflamatórias das pregas vocais, como nódulos, pólipos e edema de Reinke, para diminuir o processo inflamatório pré-cirúrgico ou na tentativa de se evitar uma intervenção cirúrgica; 5) em fonocirurgia, com o objetivo de reduzir a formação de cicatriz. Seu uso pode ser profilático, visando à prevenção da formação de cicatriz ou terapêutico em uma cicatriz já formada. CONCLUSÃO: Os corticosteróides podem ser considerados uma opção terapêutica importante no manejo de várias patologias, principalmente aquelas de origem inflamatória que causam alterações vocais.

Steroids are potent inhibitors of inflammation and wound repair. Local administration of steroids directly into the larynx has been reported in many laryngeal diseases. AIM: The purpose of this study is to review related literature about the use of steroid injection in patients with benign, inflammatory and chronic vocal disease. METHODOLOGY: We performed an electronic survey in Medline database and selected clinical trials regarding steroid use in benign laryngeal diseases. RESULTS: Steroids are indicated in these situations: 1) acute inflammatory diseases, mainly when edema compromises the airways; 2) auto- immune disease with laryngeal involvement; 3) laryngeal stenosis; 4) benign lesions of the vocal folds, e.g., nodules, polyps and Reinke's edema, to reduce the inflammatory reactions before phonosurgery or in an attempt to avoid surgery; 5) In phonosurgery, aiming to reduce scarring. In this case, it could be used as a preventive measure in vocal fold scarring, or for scar treatment. CONCLUSION: Steroids may be considered an important therapeutic option in the management of many diseases, specially the inflammatory ones, associated with vocal changes.

Há na literatura inúmeras descrições de amiloidose limitada à laringe, sendo que esta afecção corresponde a cerca de 1% dos tumores benignos da laringe. Entretanto, há somente três relatos de amiloidose acometendo a região do anel de Waldeyer. Descreveremos um raro caso de amiloidose em que há acometimento de sítios distintos do trato aéreo-digestivo superior: pilar amigdaliano, rinofaringe, supraglote e glote, sem continuidade aparente do tecido amilóide. Abordaremos, também, o seguimento pós-operatório com uma disfagia grave.

There are some reports of localized amyloidosis in the larynx, an entity that corresponds to one percent of all benign tumors of this region. However, there are only two cases of amyloidosis in the Waldeyer's ring 6, 13, 14. We hereby describe a rare case of amyloidosis in areas not associated with the upper aero-digestive tract: tonsil pillar, rhinopharynx, supraglottis and glottis, without visible continuity of amyloid tissue. We will also discuss post-operative follow up with severe dysphagia.

As laringopatias relacionadas ao trabalho acarretam conseqüências para os profissionais da voz. OBJETIVO: Analisar o perfil destes profissionais atendidos em um hospital terciário. FORMA DE ESTUDO: Estudo de coorte histórica longitudinal. MATERIAL E MÉTODOS: Análise retrospectiva de prontuários. Os diagnósticos foram fornecidos através de videoestrobolaringoscopia. RESULTADOS: Foram atendidos 163 pacientes (119 do sexo feminino, 44 do sexo masculino), idade média de 36,5 anos. Em relação aos grupos profissionais, encontramos profissionais da voz falada (vendedores, professores, telemarketing, recepcionistas, atores e profissionais de saúde) e da voz cantada. Os diagnósticos foram: alteração estrutural mínima (33%), nódulos (22%), edema de Reinke (10%) e pólipos (6%). Foi observada correlação com tabagismo (p=0,002), sexo (p=0,004) e idade (p<0,001), com tendência para associação do tabagismo com edema de Reinke e leucoplasia; sexo feminino com AEM, nódulos e edema de Reinke; pacientes acima de 40 anos com edema de Reinke, e dos mais jovens com nódulos, cordite e AEM. O tempo de queixa foi superior a 6 meses em 74% dos casos. CONCLUSÃO: Este perfil inclui profissionais da voz falada e cantada. Houve predomínio das AEMs, seguida por nódulos, edema de Reinke e pólipos.

Work-related laryngopathy may have negative consequences for voice professionals. AIM: To analyze the profile of voice professionals seen in a tertiary level hospital. STUDY DESIGN: a longitudinal historical cohort. METHODS: A retrospective analysis of patient files. Diagnosis was reached using videostroboscopy. RESULTS: 163 patients (119 females and 44 males) were seen. The mean age was 36.5 years. Professionals included spoken voice users (salesman, teachers, telemarketers, receptionists, health professionals) and singers. The most frequent diagnoses were: minor structural changes (33%), nodules (22%), Reinke’s edema (10%), and polyps (6%). A correlation was observed between smoking, age and gender; there was an association between smoking and Reinke’s edema, leucoplasia and tabagism, females and Reinke’s edema, nodules and minor structural changes, and also between patients aged over 40 years and Reinke’s edema, and patients under 40 with nodules, laryngitis, and minor structural changes. Symptoms lasted more than 6 months in 74% of patients. CONCLUSION: The profile of voice professionals seen in a tertiary hospital included spoken voice patients and singers. In our study minor structural changes predominated, followed by nodules, Reinke edema and polyps.