Nobuhiko Isshiki

Phonosurgery
Theory and Practice

With 149 Figures

Springer Japan KK
NOBUHIKO ISSHIKI
Professor and Chief
Department of Plastic Surgery
School of Medicine
Kyoto University
Sakyo-ku , Kyoto, 606 Japan

ISBN 978-4-431-68360-5 ISBN 978-4-431-68358-2 (eBook)

DOI 10.1007/978-4-431-68358-2

Libr ary of Congre ss Cataloging-in-Publication Data

Isshiki, Nobuh iko, 1930-
Phonosurgery : theory and practice . Includes bibliographical references .
1. Larynx-Surgery. 2. Vocal cord s-Surgery. 3. Voice disorders-Surgery. 1. Titl e.
[DNLM : 1. Larynx-surgery. 2. Voice Disorders-surgery. WV 540 186p] RF516 .187
1989 617.5'33059 89-19729

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Foreword

"Phonosurgery: theory and practice" is a book that makes an impor-

tant contribution to the literature in laryngology. Professor Isshiki
has been a driving force in the investigation and correction of certain
conditions of the voice. His leadership in this field over two decades
has proved to be an inspiration to those interested in the diagnosis
and correction of the abnormal voice. His unique background and
training in both otolaryngology and plastic surgery has provided him
with fundamental knowledge and experience in the study of the voice
and larynx and has given him an opportunity to utilize innovative
surgical techniques in the correction of some of these problems.
Professor Isshiki's name is indelibly linked with laryngeal
framework surgery, and those who read this book will not be dis-
appointed. The book provides very adequate information on the phy-
siology and pathology of the voice. Emphasis is given to diagnostic
aspects of abnormalities of the voice which have been made easier
with the development of high technology, such as the use of the com-
puter and improved laryngoscopes, which include brighter lights,
higher resolution lenses, and, when combined with stroboscopy and
high-speed filming videolaryngoscopy, provide a valuable tool in faci-
litating communication between the patient, the physician, and the
voice therapist.
The section on laryngeal framework surgery correctly features Pro-
fessor Isshiki's philosophy and surgical techniques, yet there is a
balanced critique of other available techniques both for surgery to
medialize the vocal cords as well as for tension adjustment surgery to
change the pitch of the voice. The details and illustrations of this
surgery are very appealing indeed.
In the chapters devoted to spastic dysphonia and remobilization of
the vocal cords, there is an equally balanced approach in presenting
and critiquing these techniques. Surely one of the most stimulating
areas of the book is the concluding chapter on potential ideas for
research in the field of laryngology, to which it will provide a better
understanding of the normal as well as the abnormal voice. These
VI Foreword

efforts will hopefully stimulate other workers in this field to make

contributions which will help patients in the future with these vexing
problems.
Surely Professor Isshiki is to be congratulated on his excellent sur-
gical contributions as well as this milestone book, which will be of
great help to surgeons, voice therapists, and scientists in this field and
which will no doubt benefit many future generations of patients.

Eugene N. Myers
Professor and Chairman
Department of Otorhinolaryngology
University of Pittsburgh
President of American Laryngological
Association
Preface

Phonosurgery, which may be defined as surgery primarily intended

to improve the voice, encompasses a wide variety of surgeries, i.e.,
cordal injection, laryngomicrosurgery, laryngeal framework surgery,
neuromuscular surgery, laryngeal reconstruction after laryngectomy,
and even prospective laryngeal transplantation. Among these, how-
ever, that mainly dealt with in this textbook is laryngeal framework
surgery, which is quite different from other types of phonosurgery in
many respects. Laryngeal framework surgery requires basic knowl-
edge about the physiology and pathophysiology of voice production,
because appropriate steps must be taken intraoperatively for any
particular voice to be rectified.
The first four chapters are directed toward the basic and practical
knowledge required for performing laryngeal framework surgery.
Also essential for this surgery is knowledge of the special anatomy of
the larynx. When attempting medialization of the vocal cord for in-
stance, the wrong projection image of the vocal cord on the thyroid
ala would utterly spoil the surgery, producing medialization of the
false vocal cord instead. The fifth chapter focuses on the knowledge
of anatomy required for laryngeal framework surgery.
Laryngeal framework surgery is a delicate surgery where a slight
difference in technique may bring about a big difference in results.
Therefore, all the surgical steps and instruments required are
described in full detail with numerous illustrations.
The first purpose of this book is to assist the surgeon in performing
phonosurgery which will consistently allow the patient the best
obtainable voice in keeping with preoperative expectations. Descrip-
tions of surgical techniques are made on the basis of experience with
over 200 cases of the laryngeal framework surgery.
The second purpose of this text is to bring to light the fact that
much remains to be investigated in the pathophysiology of voice pro-
duction as well as in the treatment for some dysphonias. Although
the physiology of speech production is briefly described in Chap. 2
in a manner to make complicated processes as simple as possible,
VIII Preface

voice production is often beyond our current understanding, and can

even be mysterious. To cite one example, an opera singer can pro-
duce a most beautiful and sonorous sound with her or his resonator,
the vocal tract, which is lined with a slimy mucous membrane. Just
imagine what kind of sound would be produced by a violin if it were
lined with mucosa. As to the phonosurgical procedure itself, much
also remains to be studied, especially in surgery to raise pitch, surgery
for spastic dysphonia, mucosa transplantation, and remobilization of
the paralyzed cord.
For the further promotion of phonosurgery, cooperation among
voice scientists, voice therapists, and phonosurgeons is essential. The
last chapter "Research Potential" was added in the hope of encourag-
ing such cooperation.

Nobuhiko Isshiki
Acknowledgments

Many people were directly or indirectly involved in the production of

this book. First of all, I would like to express my sincere gratitude to
three successive professors of otorhinolaryngology at Kyoto Uni-
versity I worked for, the late Dr. Mitsuharu Goto, Dr. Masanori
Morimoto, and Dr. Manabu Hinoki, for their guidance and en-
couragement in phonosurgery.
When I entered the Ear Nose and Throat (ENT) Department, the
work on voice physiology done by Dr. lanwillen van den Berg had
enlightened and led me to the field of phonosurgery. Dr. Ikuichiro
Hiroto, a former professor of ENT at Kyushu University whom I
worked with for laryngeal research in my early career has always
been a guiding light in my career.
A large portion of the experimental basis for phonosurgery as de-
scribed here in the text was formed while I worked with Dr. Hans von
Leden at UCLA, to whom lowe a great deal for the great opportu-
nity. Dr. Wilbur 1. Gould has paved the way for the continual
exchange of knowledge about voice science between Lenox Hill Hos-
pital and Kyoto University, and the ties are further greatly solidified
by Dr. Stanley M. Blaugrund. I would like to express my sincere
gratitude to both for their cooperation.
It was a great privilege for me to have a foreword written for this
book by Professor Eugene Myers, President of the American Laryn-
gological Association.
Without the cooperation of Professor Iwao Honjo at the ENT De-
partment, my continued work on phonosurgery would not have been
possible after I moved from ENT to plastic surgery. I would like to
acknowledge my appreciation to the following colleagues who so
kindly cooperated with me in developing phonosurgery: Drs. Hiroshi
Okamura, Masahiro Tanabe, Kazutomo Kitajima, Michiaki Hiramo-
to, Tomoko Ishikawa, Hisayoshi Kojima, Masaki Sawada, Yutaka
Harita, Michio Kawano, Masanao Ohkawa, Tomoyuki Haji, Shinzo
Tanaka, Tatsuya Fukazawa, Tatsuzo Taira, Mayuki Goto, Kazuhiko
Shoji, Kazunori Mori, and Koichi Ohmori.
x Acknowledgments

Special thanks are due to Drs. H. Kojima and T. Taira for their
assistance in preparing the figures and Dr. K. Ohmori in collecting
literature. Most of the illustrations were drawn by an excellent artist,
Mr. Toshikazu Asano, and cartoons and some of the surgical figures
in Chap. 6 were created by my daughter, Minako. The efforts of my
secretary Miss Keiko Tanaka, who prepared the manuscript are
greatly appreciated. lowe much to my wife Keiko for her forbear-
ance during the hectic months of this book's preparation.
Lastly but not least, I feel a debt of gratitude to my publisher,
Springer-Verlag, Tokyo for their encouragement and great efforts to
make this book a reality.
Table of Contents

1. Introduction .................................... 1

2. Physiology of Speech Production ................... 5

2.1 General View ................................... 5
2.2 Exhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.3 Vibration of the Vocal Cords ...................... 7
2.4 Glottal Sound ................................... 11
2.5 Resonance and Articulation of the Vocal Tract. . . . . .. 14
2.6 QualityofVoice ................................. 18
2.7 Intensity of Voice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 18
2.8 Fundamental Frequency of Voice .................. 18
2.9 Conditions for Normal Phonation .................. 20
2.10 Summary ....................................... 20

3. Pathophysiology of Voice Production . . . . . . . . . . . . . . .. 23

3.1 Imperfect Closure of the Glottis. . . . . . . . . . . . . . . . . . .. 23
3.2 Stiffness and Mobility of the Vocal Cord Mucosa ..... 28
3.3 Imbalance Between the Two Vocal Cords ........... 29
3.4 Three-Dimensional Representation of Normal and
Hoarse Voice Ranges. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 32
3.5 Summary ....................................... 32

4. Assessment of Vocal Function ........ . . . . . . . . . . . . .. 35

4.1 Perceptual Assessment of the Hoarse Voice ......... 35
4.2 Acoustic Analysis of the Hoarse Voice. . . . . . . . . . . . .. 36
4.3 Aerodynamic Test for Vocal Function .............. 42
4.3.1 Air Flow Measurement. . .. . . . . .. . . . . . . . . . . . . . . . .. 42
4.3.2 Vocal Efficiency ................................. 44
4.4 Recording of Vocal Intensity and Pitch. . . . . . . . . . . . .. 48
4.4.1 Vocal Intensity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 48
4.4.2 Vocal Pitch ..................................... 50
XII Table of Contents

4.5 Manual Test 52

4.6 Stroboscopic Examination ....................... . 52
4.7 Video laryngoscopy .............................. . 52
4.8 Electromyography .............................. . 54
4.9 X-ray and MRI ................................. . 54
4.10 Ultrasonic Measurement ......................... . 58

5. Anatomy for Laryngeal Framework Surgery ........ . 61

5.1 Projection ofthe Anterior Commissure ............. 61
5.2 Projection of the Upper Surface ofthe Vocal Cord. . .. 64
5.3 Thyroid Cartilage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 65
5.4 Projection of the Cricoid Cartilage on the Thyroid
Lamina......................................... 69
5.5 Cricoid Cartilage ................................ 70
5.6 Cricoarytenoid Joint ............................. 71
5.7 Muscle Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 72
5.8 Asymmetry ofthe Thyroid Cartilage. . . . . . . . . . . . . . .. 72
5.9 Soft Tissue Behind the Thyroid Cartilage. . . . . . . . . . .. 73
5.10 Summary ....................................... 73

6. Medial Displacement of the Vocal Cord . . . . . . . . . . . . .. 77

6.1 Teflon Injection Versus Laryngeal Framework Surgery 81
6.2 Motivation for and Classification of Laryngeal
Framework Surgery .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 82
6.3 Thyroplasty Type I (Medialization) . . . . . . . . . . . . . . . .. 82
6.3.1 Principle and Indications . . . . . . . . . . . . . . . . . . . . . . . . .. 82
6.3.2 Premedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 84
6.3.3 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 84
6.3.4 Skin Incision and Exposure of the Thyroid Ala . . . . . .. 84
6.3.5 Design of the Window ............................ 85
6.3.6 Cutting the Cartilage Window ..................... 87
6.3.7 Adjustment of Medial Displacement of the Window .. 88
6.3.8 Fixation of the Window . . . . . . . . . . . . . . . . . . . . . . . . . .. 92
6.3.9 Closure of the Wound ............................ 99
6.3.10 Postoperative Care and Course .................... 101
6.3.11 Reversion of Voice ............................... 102
6.3.12 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 102
6.3.13 Second Operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 103
6.3.14 Results of Thyroplasty Type I . . . . . . . . . . . . . . . . . . . . .. 103
6.3.15 Summary ....................................... 103
6.4 Vocal Cord Atrophy ............................. 105
6.5 Surgical Correction of Dysphonia Associated with
Aging .......................................... 108
6.6 Arytenoid Adduction. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109
6.6.1 Indication-Advantages and Disadvantages ......... 109
Table of Contents XIII

6.6.2 Exposure of the Thyroid Ala ...................... 110

6.6.3 Dislocation of the Cricothyroid Joint ............... 110
6.6.4 Approach to the Muscle Process ................... 112
6.6.5 Opening the Cricoarytenoid Joint .................. 116
6.6.6 Suture Traction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 120
6.6.7 Adjustment of Vocal Cord Adduction .............. 122
6.6.8 Slight Medial Displacement of the Vocal Cord ....... 125
6.6.9 Excessively Tight Closure of the Glottis .......... . .. 126
6.6.10 Other Pathological Conditions . . . . . . . . . . . . . . . . . . . .. 127
6.6.11 Closure of the Wound ............................ 127
6.6.12 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 127
6.6.13 Postoperative Course . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 127
6.6.14 Modified Operation-Deprivation of the Posterior
Cricoarytenoid Muscle ........................... 128
6.6.15 Summary ....................................... 129

7. Surgery to Lower Vocal Pitch: A-P Relaxation ........ 131

7.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 131
7.1.1 Mutational Voice Disorder-Functional or Organic? 131
7.1.2 Dysphonia Due to Excessively Stiff Vocal Cords. . . . .. 134
7.2 Surgical Procedure ............................... 134
7.2.1 Vertical Incision in the Thyroid Ala ................ 134
7.2.2 Width of Vertical Strip Excision .................... 135
7.2.3 Fixation ....................................... , 137
7.2.4 Complications and Postoperative Care . . . . . . . . . . . . .. 139

8. Surgery to Elevate Vocal Pitch ..................... 141

8.1 Indication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 141
8.2 Principle of Surgery .............................. 143
8.3 Cricothyroid Approximation ...................... 143
8.3.1 Surgical Technique ............................... 143
8.3.2 Results and Complications ........................ 144
8.3.3 Lee's Modification ............................... 146
8.4 A-P Lengthening ofthe Thyroid Ala ................ 147
8.4.1 A-P Expansion of the Thyroid Ala by Vertical
Insertion of a Strip Implant. . . . . . . . . . . . . . . . . . . . . . .. 147
8.4.2 Inferiorly Based Midline Cartilage Flap: Anterior
Commissure Advancement of Le J eune ............. 148
8.4.3 Superiorly Based Cartilage Flap: Anterior Commissure
Laryngoplasty of Tucker ... . . . . . . . . . . . . . . . . . . . . . .. 149
8.4.4 Comparison of the Three Techniques ............... 150
8.5 Comparison of Cricothyroid Approximation with
Anterior Commissure Advancement Techniques ..... 152
8.6 Longitudinal Incisions in the Vocal Cords ........... 153
8.7 Stripping of the Vocal Cord Mucosa ................ 153
XIV Table of Contents

8.8 Intracordal Injection of Corticosteroid .............. 154

8.9 Partial Evaporation ofthe Vocal Cord by Laser ...... 154
8.10 Conservative Approach to Direct Surgical Intervention
in the Vocal Cord ................................ 155

9. Combined Technique: Medialization and Tension

Adjustment ..................................... 157
9.1 Medialization Combined with Slackening of the Vocal
Cords .......................................... 157
9.2 Medialization Combined with Tightening of the Vocal
Cords .......................................... 160
9.2.1 Thyroplasty Type I and Cricothyroid Approximation 160
9.2.2 Koufman's Technique ............................ 162

10. Spastic Dysphonia ................................ 163

10.1 Definition and Diagnosis . . . .. . . . . . . . . . . . . . . . . . . . .. 163
10.2 Surgical Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 164
10.2.1 Sectioning the Recurrent Laryngeal Nerve (Dedo) . . .. 164
10.2.2 Selective Section of Nerve Branch to Adductor Muscles
(Iwamura, Carpenter) ............................ 166
10.2.3 Selective Section of the Thyroarytenoid Muscle ...... 166
10.2.4 Thyroplasty Type II or III (Isshiki) ................. 167
10.2.5 Injection of Botulinum Toxin . . . . . . . . . . . . . . . . . . . . .. 170
10.2.6 Electrical Stimulation of the Recurrent Laryngeal
Nerve .......................................... 170
10.2.7 Tissue Evaporation .............................. 171
10.2.8 Other Possibilities ............................... 171

11. Surgical Management of Scar of the Vocal Cord ...... 175

1l.1 Mucosa Transplantation .......................... 175
1l.2 Collagen Injection ............................... 178

12. Remobilization of the Paralyzed Vocal Cord .......... 181

12.1 Nerve Anastomosis (Nerve to Nerve or Nerve to
Muscle) ........................................ 181
12.2 Nerve-Muscle Pedicle ............................ 182
12.3 Switching ofIntact Muscle ........................ 184
12.4 Artificial Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 184
12.5 Conclusion ...................................... 184

13. Potentials for Research ........................... 187

13.1 Problems ....................................... 187
13.2 Diagnosis ....................................... 187
13.2.1 Manual Test .................................... 187
Table of Contents xv
13.2.2 Assessment of Vocal Cord Stiffness. . . . . . . . . . . . . . . .. 188
13.2.3 Mechanical Conditions for Vocal Cord Vibration ..... 189
13.3 Planned Surgery ...... . . . . . . . . . . . . . . . . . . . . . . . . . .. 189
13.4 Voice Therapy and Phonosurgery .................. 190
13.4.1 Functional or Organic? ........................... 190
13.4.2 Performing Voice Therapy First .................... 191
13.4.3 Performing Surgery First. . . . . . . . . . . . . . . . . . . . . . . . .. 191
13.4.4 Driver and Navigator (Pilot) . . . . . . . . . . . . . . . . . . . . . .. 192
13.5 Relaxation as Postoperative Voice Training ......... 192
13.6 False Vocal Cord Phonation ....................... 193
13.7 Outcome of Surgery to Elevate Vocal Pitch .......... 194
13.8 Lubrication of the Vocal Cord ..................... 194
13.9 Laryngeal Pacing ................................ 195

14. Conclusion . ..................................... 197

Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 199

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 229

 1. Introduction

Fig.!.!. The mechanics search for a fault in the machine (larynx) by audition of the
engine sound (voice) and inspection (fiberscopy)
2 Introduction

Some dysphonias, functional or organic, are extremely intractable; just to cite a

few examples, they include spastic dysphonia, vocal cord atrophy, and sulcus
vocalis. The one most difficult to treat appears to be, from personal experience,
scarred vocal cords after laryngeal trauma. Once the vocal cord mucosa becomes
scarred, there is no means now available to restore normal mobility and pliabil-
ity of the mucosa, which are essential to the vibration of the vocal cords. Experi-
enced laryngologists are well aware of the fact that a major surgical intervention
in the vocal cord involves some risk of further deterioration of the voice.
The vocal cord, in other words, has been resistant to surgical invasion, except
for simple excision of a polyp or a nodule or injection of alloplastic material. It is
only possible to exert an influence on the vocal cords from outside without
directly touching them. This is the basis of laryngeal framework surgery, with
which this book is mainly concerned. Laryngomicrosurgery, though a part of
phonosurgery, will not be examined because the techniques have already been
fairly well established.
Modern surgery in general has shifted its main goal from extirpation to func-
tional reconstruction with the use of still developing techniques such as micro-
surgery, artificial organs, and transplantation. Against this trend, it has to be
admitted that phonosurgery lags far behind the other fields. In addition to the
greatest obstacle of scarring, lack of knowledge of the mechanism involved is
responsible for that lag. Vocal function, which is quite new phylogenetically, is
rather vulnerable and sensitive to what appears to be insignificant pathology.
Slight swelling or almost unidentifiable rheological changes of the vocal cord
may cause hoarse voice or even aphonia. When confronted with the discrepancy
between the voice and the laryngeal finding in such cases, laryngologists tend to
use the terms functional or psychogenic, and the problem then becomes that of
the voice therapist. In reality, the term functional, often used without positive
reasons, does not provide any information as to what is wrong with the mecha-
nical properties of the vocal cord. Vocal cord vibration will be discussed here
mainly from a mechanical viewpoint.
It should be stressed that the final stage of voice production is a purely
mechanical phenomenon. Even though certain types of dysphonia are really
psychogenic in nature, one or more mechanical factors must be involved to
account for the dysphonia: imperfect closure of the glottis or an excessively tense
vocal cord, for instance. Voice therapy aims at restoring a normal voice by train-
ing, psychotherapy, or other means, but what is actually altered by the therapy is
entirely mechanical and includes air flow and pressure, position, stiffness, and
thickness of the vocal cord. Change in the voice occurs through a variation in
these mechanical factors. Voice therapy or psychotherapy can be or occasionally
is better done without knowing exactly which mechanical factor is to be cor-
rected. If the patient is overconscious of these factors or of the larynx, the
smooth operation of the therapy tends to be disturbed.
If the mechanical factors responsible for a dysphonia are structual, organic,
irreversible, or resistant to functional training, there may be an indication for
surgical correction. Before deciding whether surgery is necessary, we should
have a definite idea about what mechanical factor is to be corrected. This is the
reason why the surgeon is compared to the mechanic.
A mechanic's task starts with assessing the problem from the sound produced.
Introduction 3

He or she must be able to take appropriate steps for a particular abnormal sound
to be rectified (Fig. 1.1).
Besides the sound (voice) analysis, fiberscopy during operation also provides
useful information which helps in deciding the steps that should be taken.
However, knowledge concerning the rheological features of the vocal cord is
very limited. Little is known about the mechanism of pathological voice produc-
tion. There still remains a great potential for improving our surgical procedures.
It is imperative to develop some special means of softening the scar. It will be
interesting to see to what extent lasers can contribute to surgery with less scar-
ring. Computer analysis of voice may in the near future provide an automatic
rheological diagnosis of what is wrong with the vocal cord or glottal closure
instead of the auditory assessment we largely rely upon at present. These forth-
coming developments, as related to surgery, are also taken up in this book.
For further development of phonosurgery, a team approach by the surgeon,
voice scientist, and voice therapist is becoming more and more important. I, for
example, have often received very valuable assistance from Dr. K. Ishizaka, an
engineer specializing in computer simulation of voice production. The reader
who is not concerned with details of the theoretical aspects of phonosurgery may
read just the summary at the end of each chapter before proceeding to the sur-
gical techniques. In this type of delicate surgery, a minute variation in the proce-
dure makes a large difference in the results, possibly leading to disappointment.
Therefore, the surgical technique is described in full detail.
2. Physiology of Speech Production

2.1 General View

Speech production at the peripheral level consists of three stages: exhalation,
phonation, and articulation (Table 2.1). Exhalatory movement of the respira-
tory organ provides the subglottal air flow (direct current). The air flow is cut
into puffs (alternating current) at the closed glottis as the vocal cords vibrate.
The sound thereby produced at the glottis is referred to as the primary laryngeal
tone or glottal sound (source). Through the resonance of the vocal tract, the
glottal sound is modified so that some frequency components are amplified and
others are attenuated.
In addition to resonance, the dynamic movement of the vocal tract together
with the air flow supply produces sound by the process of air plosion or turbu-
lence. The sounds thus produced are termed plosive or fricative sound, respec-
tively. Articulation in a broad sense means the whole process by which the glot-
tal sound is changed into speech sound through the dynamic movement of the
vocal tract. In a narrower sense, it may refer to the dynamic movement of the
vocal tract, chiefly the lingual movement, and the consequent sound production,
while excluding the resonance effect. In the latter case, it may be said that glottal
sound is modulated into speech by the effects of resonance and articulation.

Table 2.1. Voice and speech production at peripheral level

Level Subglottic Larynx Vocal tract
respiratory system
Process Exhalation Phonation Articulation (resonance
and articulation)
-> Primary laryngeal ->
Consequence Air outflow (DC) tone (AC) Speech sound
6 Physiology of Speech Production

2.2 Exhalation
The exhalatory air stream from the lung is the energy source for the voice. It is
rarely problematic in dysphonia. Discoordination between the respiratory and
phonatory systems may occur in a functional dysphonia or aphonia, or in some
dysphonias due to disorders of the central nervous system. Extremely reduced
vital capacity will result in weakening of the voice and a shorter period of sus-
tained vowel production. The respiratory pattern greatly affects the voice quality
indirectly as well. Deep breathing tends to relax the muscle contraction, thereby
lowering the vocal pitch and facilitating smooth and coordinated action of the
muscles related to voice production. It is critically important in singing pedagogy
and in treating various functional dysphonias.
Acoustical coupling between the subglottal cavity and the vocal cord vibration
is theoretically important and interesting, but in practice it rarely presents as a
clinical problem mainly because of good damping and dull resonance of the sub-
glottal cavity. It is involved when simulating voice production using an excised
larynx or in voice production with an artificial larynx after laryngectomy.

,;

Fig. 2.1 Bernoulli effect. A negative

pressure develops perpendicular to the
high speed flow sucking the surrounding
substance toward it
Vibration of the Vocal Cords 7

2.3 Vibration of the Vocal Cords

To maintain a body in vibration, two antagonistic forces (working in opposite
directions) must act alternately. For vibration of the vocal cords, these are the
opening force arising from subglottal pressure and the closing force from elasticity
of the vocal cord and the Bernoulli effect. According to the Bernoulli theory, the
velocity of flow is high at the stricture, creating a pressure drop perpendicular to
the wall of the stricture. A common example of this is a thin shower curtain
being drawn toward the jet of water (Fig. 2.1). The lighter or more mobile the
curtain, the greater the movement. Similarly, as the air is jetted out through the
narrow glottis, negative pressure develops there to suck in the vocal cords. How
much this contributes to closing the glottis depends upon the mobility of the
vocal cord mucosa. The more mobile the mucosa, the greater the role of the
Bernoulli effect in closing the glottis in the vibratory cycle. Great mobility of the
vocal cord mucosa is, therefore, one of the essential conditions for easy voice
production. Mobility of the skin in man varies with the anatomical site, posture,
and other conditions. The skin of the back of the hand is more mobile than that
of the palm because it is more loosely connected to the underlying tissue. The
normal mobility of the skin of the back of the hand is greatly reduced when the
skin is scarred or stretched, or when the hand is clenched or expanded by sub-
cutaneous injection of a saline solution (Fig. 2.2). Similarly, the vocal cord mu-
cosa loses its mobility when it is scarred, stretched, or swollen. In other words,
the factors that affect the mobility of the mucosa are: (a) submucosal tissue con-
nection, (b) rheology of the mucosa, and (c) redundancy in area of the mucosa.
Using excised human larynges, one research group (Haji et aI., in press) has
assessed the mobility of the vocal cord and false vocal cord by measuring the
displacement of the mucosa at several points as it was suctioned at a certain
negative pressure (Fig. 2.3). The mobility is greater at the midpoint of the vocal
cord than at the anterior commissure or arytenoid region. It is reduced when the
vocal cords are tensed or swollen by submucous injection of saline solution.
These results indicate that a greater role is played by the Bernoulli effect in chest
register than at falsetto and, further, may partly account for the mechanism of
dysphonia in acute laryngitis.
The thin superficial layer of the mucosa is of critical importance for vocal cord
vibration. Its rheological aspects, especially stiffness, are greatly affected by
whether the surface is wet or dry.
The significance of the Bernoulli effect in closing the glottis has also been
corroborated by a number of stroboscopic and high-speed film observations of
vocal cord vibrations.
It was found by Musehold (1898 2 ) and Kirikae (1943 2 ) that the trajectory of
the vibrating vocal cord edge is elliptical rather than horizontal. It was further
confirmed that the glottis starts opening at the lower margin of the cord and,
prior to full opening at the uppermost margin, has already begun closing again at
the lower margin. This phase lag between the upper and the lower margins,
particularly notable in chest register, was termed Randkantenverschiebung
(mobility of the vocal cord edge) by Schonharl (1960 1 ) (Fig. 2.4). It is often
lacking in dysphonia. Schonhiirl laid a great deal of emphasis on the clinical
importance of this phase lag, a view which has been shared by many: van den
8 Physiology of Speech Production

a b

c d
Fig. 2.2a-d. Mobility of the mucosa. The mucosa of the vocal cords must be very mobile
to be effectively sucked by the negative pressure due to Bernoulli effect. Similar to the
skin of the back of the hand, the mobility is reduced when the skin is stretched (b),
swollen (c), or scarred (d)
 Vibration of the Vocal Cords 9

-30cmHg

t
Vocal cord
mucosa mmmm /IZJJmm 'lIlVI/IIII1I/
Fig. 2.3. Experimental set-up for assessing the mobility of the vocal cord (Haji et al., in
press). The mobility of the mucosa is assessed by the amount of displacement when the
mucosa is sucked at a constant negative pressure: a suction tube which contacts the mu-
cosa is withdrawn until it detaches from the mucosa. The distance between the point of
contact and that of detachment represents the mobility of the mucosa

Fig. 2.4. Normal vibratory cycle of the vocal 8

cords (Sch6nharI1960). Left, cross section.
The vibration proceeds in numerical sequence
downward. The lower portions of the vocal
cords start closing earlier than the upper por- 9
tions (5-7). Right, laryngostroboscopic
finding corresponding to each vibratory phase
10 Physiology of Speech Production

Berg (myoelastic-aerodynamic theory; 19582 ), Smith (1954 2 ), von Leden

(1960a,b2 ), von Leden et al. (1960 3 ), von Leden and Moore (19613), Perella
(19622 ) Hirota (mucoelastic aerodynamic theory; 19662 ), Ishizaka and Flanagan
(two-mass model; 19722 ), Ishizaka and Matsudaira (1972 2 ), Hirano (body and
cover; 19742), and Titze (1976 2 ).

Stratified squamous epithelium

propria
]~r
Superficial layer
y t. " " " , " , , - -

Intermediate layer]
Deep layer Transition

Vocalis muscle ] Body

Fig. 2.5. Schematical presentation of the layer structure of the human vocal cord (Hira-
no's body-and-cover theory 1972)

Vocal tract
Ug

Fig. 2.6. Ishizaka's two-mass model of the vocal cords. The cranially divergent shape of
the glottis at the initial moment of closing creates greater negative pressure at the lower
edge, facilitating glottal closure. Ug Volume velocity of air flow through the glottis, Ps
Subglottal pressure, ml/m2 vibrating masses of the lower and upper portions of the vocal
cord
Glottal Sound 11

Hirano demonstrated the layer structure of a human vocal cord histologically

and proposed the notion of a cover-body complex (1974 2 , 19812; Hirano and
Kakita 19852 ) (Fig. 2.5).
This phase lag in vocal cord vibration is entirely inexplicable if the closing
force is only a recoiling one due to elasticity. It seems clear that the role played
by the Bernoulli effect is greater in chest register than in falsetto. In falsetto, in
which the mucosal mobility is much reduced by stretching, the phase lag is no
longer noted, and the closing force is largely derived from elasticity.
Actual measurement of the intraglottal pressure during vibration is impracti-
cal, but theoretical estimates are available. Based on aerodynamic equations
which incorporate subglottal pressure and physical conditions of the vocal cords,
Ishizaka et al. (Flanagan, Matudaira; 19722 ) simulated vocal cord vibration with
the use of a computer. The simulated vibratory pattern incorporated the upper
and lower edges of the vocal cords opening and closing with a phase lag to reflect
the real situation, given that the coupling of the two masses, upper and lower
edge portions (mucosal mobility), is sufficiently loose. Another important point
suggested in Ishizaka's two-mass theory is that the cranially divergent shape of
the glottis at the initial moment of closing, see 5, 6 in Fig. 2.4 and in Fig. 2.6,
creates greater negative pressure at the lower edge than the cylindrical shape
(one-mass model) does. In short, the Bernoulli effect is a dominant factor in
closing the glottis in chest register, while in head or falsetto register, the elastic
recoiling force becomes increasingly important.

2.4 Glottal Sound

Before going into details of the nature of glottal sound, acoustic terminology will
be briefly described.
Sounds can be classified into tone and noise (Fig. 2.7). Tone is periodic, while
noise is aperiodic. A tone consisting of a single sinusoidal wave is called a simple
or pure tone, such as that produced by a tuning fork. All other tones are com-

Tone (periodic)
Pure tone

Complex tone

Noise (aperiodic)

Fig. 2.7. Classification of sound

12 Physiology of Speech Production

Vowel/a
fa = 1BB.7Hz

10 20 30
Time (msec)

Frequency spectrum

500 1000 1500

Frequency (Hz)

Fig.2.S. Decomposition of a complex periodic tone (vowel [a]) into an array of harmon-
ics, and its expression in the frequency spectrum
Glottal Sound 13

Amp.

III
Large OQ

J\J\J\J\ (dB) III1I1

I I
fro (Hz)

SmallOQ

~ IIIII11I111 I 1

Fig. 2.9. Open quotient (OQ) and frequency (fr) spectrum. The smaller the OQ, the less
the decay in intensity of harmonics as a function of frequency. The glottal sound with
smaller OQ is more efficient, i.e., greater intensity for the same flow rate.

posed of many sinusoidal waves and are termed complex tones. The frequency
components of a complex tone are called partials. Among the partials, the lowest
natural frequency is termed Fa, fundamental frequency or fundamental tone. If
the partials are all integral multiples of the fundamental frequency, they are
named harmonics, and the tone thereby composed is a musical tone (single tone).
The fundamental frequency equals the first harmonic. Partials higher than the
fundamental frequency may be referred to as overtones. The second harmonic
therefore equals the first overtone. Overtones are not always harmonics; they
may also be noise. A complex tone consisting of a plural number of single tones
is a multiple tone.
Noise contains no harmonics. Any complex periodic vibration (musical tone)
can be decomposed into a harmonic array of component frequencies by Fourier
analysis (Fig. 2.8). The composition of a musical tone, which corresponds to the
tone quality or timbre, is expressed by a frequency spectrum or amplitude level
as a function of the frequency.
The glottal sound wave approximates to an asymmetrical triangular form. Its
frequency spectrum is such that the harmonics decrease their amplitudes with
frequency at a rate of 12 dB per octave. If the glottis is closed with a greater force,
the closed phase becomes longer, withstanding the mounting subglottal pres-
sure. The ratio of the open phase to one whole cycle is called the open quotient
(OQ). (Timcke et al. 19582). In other words, a greater closing force of the glottis
results in a shorter open period or small OQ, which means a sharper plosion of
air. The change in the wave form with a small OQ as shown by (b) in Fig. 2.9
gives rise to transformation in the spectrum, that is, less decay of the harmonics
as a function of frequency and consequent increase in efficiency (Fletcher 19502 ;
Flanagan 19582 ).
14 Physiology of Speech Production

2.5 Resonance and Articulation of the Vocal Tract

Given a rigid spherical enclosure with a small opening (Holmholtz resonator),
when tuning forks of varying natural frequencies are brought near the opening of
this hollow ball, the sound is sometimes amplified and sometimes damped (Fig.
2.10). If a graph is drawn to express the sound pressure level for each frequency
obtained under controlled conditions , a resonance curve results (Fig. 2.11). If
the inside wall of the resonator is rigid, the range within which the sound is
amplified is narrow, and the curve obtained is sharp or represented by a high Q
value .
Since the wall of the vocal tract is soft, the resonance curve for it is rather dull,
with a low Q value. The resonant frequency (a peak of the resonant curve) is
mostly decided by the resonator volume: The smaller the volume, the higher the
resonant frequency. The vocal tract, more complex than the Helmholtz resona-
tor in configuration, has many resonant frequencies, which vary with the vowels
(Fig. 2.12). This vowel-distinctive resonant frequency region is called formant, F1 ,
F2 , F3 , from low to high frequency (Fig. 2.13) .
The glottal sound S(f) is modified by the vocal tract resonance (transfer func-
tion) T(f), and the resultant sound at the mouth opening P(f) is expressed by
the product of S(f) and T(f) in terms of the frequency spectrum (Fant 1960)
(Fig. 2.14).
P(f) = S(f) T(f)

Fig. 2.10. Resonance: a rigid spherical enclosure with a small opening amplifies or damps
the sound produced by the tuning fork , depending on the frequency of the tuning fork
Resonance and Articulation of the Vocal Tract 15

w
1.0 .••.•...••..•.••......•............

II

0 .5

fr f
Fig. 2.11. Resonance curve: the most intense sound is produced at the resonant frequen·
cy (fr). The sharpness of resonance is expressed by Q (quality factor).
fr
Q=-
h-fl
The hand /1 are the frequencies, above and below the resonance, respectively, where the
intensity at resonance is halved or decreased by 3dB. I Resonance curve of high Q, II
Resonance curve of low Q

Fig. 2.12. Tongue positions

for vowels [iJ, [aJ, and [ul
16 Physiology of Speech Production

F2 Fig. 2.13 Relation between the first

(Hz) (F1 ) and second (F2 ) formant
frequencies for the vowels
2000

1000
a

500 1000 F, (Hz)

dB

S(f)
Glottal Sound ~
~
~
~

2 f (kHz)
dB

T(f)
Vocal Tract
Resonance

2 f(kHz)

dB

P(f) ~ T(f)
Sound at the ~
Mouth Opening ~

I
1 2 f(kHz)
P(f)=S(f)+ T(f), in logarithmic scale

Fig. 2.14. The glottal sound S(f), the transfer function of the vocal tract T(J) , and conse-
quent sound at the mouth opening prJ)
Resonance and Articulation of the Vocal Tract 17

If expressed in a logarithmic scale, P(f) becomes the sum of S(f) and T(f), as
illustrated by Fig. 2.14.
20 10glO P(f) = 20 10glO S(f) + 20 10glO TU)
A difference can be observed in the spectrum shape between the vocal tract
resonance characteristic (vocal tract transfer function) and the radiated sound.
This is because the glottal sound has a spectrum of decaying harmonics with
frequency. The shape of the vocal tract for vowels and their formant frequencies
are shown in Figs. 2.12 and 2.13.
Plosive consonants are produced by closing the vocal tract, at both the
velopharynx and each articulation site, building up air pressure, and then releas-
ing that compressed air suddenly. It is similar to the sound produced when a
balloon is burst by a pin. Fricative consonants are produced by closing the
velopharynx, making a narrow stricture at each individually different articula-
tion site, and sending the air flow to the stricture strongly to produce turbulence
there. Nasal consonants are produced with the velopharynx open, combining the
nasal and oropharyngeal cavities, otherwise, the manner is similar, though
weaker, to that for plosive consonants. The articulation sites for each consonant
are shown in Fig. 2.15.

Fig. 2.15. Articulation sites of consonants: 1 p, b, m; 2 f, v; 3 8, 6; 4 t, d, n, s, z; 5 J, 3; 6 k,

g,1)
18 Physiology of Speech Production

The coupling (mutual influence) between the vocal cord vibration and the
vocal tract does exist theoretically but is negligible due to the dull resonance of
the vocal tract. Practically, it can be said that the vocal cord vibration is not
disturbed by the effect of resonance at any fundamental frequency phonation.

2.6 Quality of Voice

The quality or timbre of voice, normal or hoarse, primarily depends upon the
wave shape of the glottal sound, how periodic it is, or how much noise it con-
tains. The manner of glottal opening and closing, e.g., OQ, also affects the tim-
bre and is a factor in individual voice identification. Differences in the voice
timbre, especially the aspect that is important for voice identification, come,
however, more from individual differences in the vocal tract shape and move-
ment. The theory and application of voice identification were intensively studied
by Tosi (1979 1).

2.7 Intensity of Voice

The intensity of voice as recorded at the mouth opening is regulated mainly by
three factors: (a) glottal power, (b) glottal efficiency, and (c) vocal tract transfer
function (resonance).
Glottal power is defined as the product of subglottal pressure and air flow
through the glottis (van den Berg 1956a,b2 ). Neglecting the phase relationship
for the sake of convenience, the product of mean subglottal pressure and
mean glottal air flow rate often replaces real glottal power. Increased glottal
power, or an increased energy source per unit time, is provided by an in-
creased effort of exhalation.
More forceful closure of the glottis, which leads to greater glottal resistance,
not only increases the glottal power but also enhances glottal efficiency via a
reduced OQ or sharpening of the glottal pulses (Fig. 2.9). If the mouth is opened
wider, the voice intensity measured outside the mouth is increased, because
more energy is radiated from the mouth (Fairbanks 19502 ). When the harmonics
of the glottal sound happen to hit the peak frequency of vocal tract resonance,
the sound is amplified more than otherwise. The amplification effect due to reso-
nance is, however, not so great, because the resonance is rather dull. The way of
increasing vocal intensity is individually different, but the general tendency is to
exert greater exhalatory effort for an intenser voice in synergy with more force-
ful closure of the glottis. In falsetto register though, it is controlled almost exclu-
sively by increased effort of exhalation.

2.8 Fundamental Frequency of Voice

The fundamental frequency of voice is equal to the frequency at which the vocal
cords vibrate to cut the air flow into glottal pulses. Roughly, it ranges from 100
Fundamental Frequency of Voice 19

Fig. 2.16. Stiffness is the ratio of

change of force (f) to the corresponding
change in translational displacement (d)
of an elastic element

-
,, ,,
I ,

, ,

:di

Stiffness =-t-
to 150 Hz for men and from 200 to 300 Hz for women during speech. Pitch is, in
a strict sense, a perceptive quantity corresponding to the fundamental frequen-
cy, but it is usually used as a synonym of the latter, because they are practically
the same within the range of fundamental frequency and intensity of voice.
The pitch is expressed by frequency in Hz (hertz), musical scale in note, or
musical frequency level in semitone. The semitone is the interval between two
tones defined by the formula:

semitone = 39.86 x log ~

For calculations such as averaging the pitches, the semitone scale rather than
the linear scale in Hz is preferable because the use of semitones makes the statis-
tical distribution closer to normal, and not skewed; this also corresponds better
to the perceptive scale.
The vocal pitch is regulated mainly by three factors: tension, mass, and length
of the vocal cords. In the case of a violin, a more tense, thinner string, a shorter
portion of string, or a combination of both produces higher pitch. The pitch
control mechanism employed in the human voice is analogous, in consequence
but not in theory, to that in a violin. The vocal pitch is elevated by stretching the
vocal cords, i.e., increasing the tension (stiffness): A major role is played here
by the cricothyroid muscle. Tension is more explicitly defined by the physical
term stiffness, which means the ratio of change of force to the corresponding
change in translational (rotational) displacement of an elastic element (Fig.
2.16). (The term stiffness does not necessarily mean being stiff, but can be used
to denote pliancy with the expression of a low stiffness value.) As the vocal cords
are stretched, they may also be somewhat thinned, reducing the vibrating mass a
20 Physiology of Speech Production

little. However, a sudden and marked reduction in the vibrating mass, limited
only to the vocal cord margin, occurs when the voice shifts to a falsetto register.
Thickening of the vocal cords, such as that induced by the administration of
anabolic or male hormone, leads to a lowering of the vocal pitch, especially in
women, and is known as androphonia.
As the vocal pitch is elevated, the vocal cords elongate. Theoretically, this is
in apparent contradiction to the above finding: the longer the vocal cords, the
lower the vocal pitch should be. This holds true and accounts for individual
differences in vocal pitch. The vocal cords in men are longer and thicker than
those in women or children. The vocal cord length almost parallels the type of
voice: From bass to soprano, they become increasingly shorter. The laryngo-
scopic finding of elongation of the vocal cords with raising of the pitch may ap-
pear contradictory, at first sight, to the above individual differences in the vocal
cord length. With the structure of the vocal cord, the only effective way to in-
crease the tension is to stretch (elongate) the vocal cord. The effect of ele-
vating the pitch by stretching surpasses the effect of lowering the pitch by
consequent elongation of the vocal cord.
When the vocal cords are maintained in a constant condition, the pitch is
elevated slightly by increased subglottal pressure alone, because the higher sub-
glottal pressure and higher velocity of glottal air flow opens and closes the glottis
at a higher rate. It is assumed that while producing crescendo (increasing intensi-
ty) at a constant pitch, the vocal cords are gradually relaxed to compensate for
the pitch increment brought about by the increased sub glottal pressure. The
pitch increment per unit pressure rise (1 cm H 2 0) is reported to be between 2
and 7 Hz.

2.9 Conditions for Normal Phonation

Normal phonation occurs only within a certain range of the related parameters.
The parameters are: (a) initial glottal area (Ago), i.e., the glottal area under
conditions of no subglottal air flow; (b) subglottal pressure; (c) stiffness of the
vocal cords; (d) coupling between the upper and lower portion of the vocal cord
edges or, in a physiological sense, mobility of the vocal cord mucosa.
Supposing the Ago is nearly zero, below the critical value where the voice
changes from normal to hoarse (the glottis is almost closed by the adductor
muscles) and the stiffness is medium, the increasing subglottal pressure will initi-
ate vocal cord vibration (Fig. 2.17). Too high a pressure, which is unlikely to
happen in usual voice production, would blow up the vocal cords, causing vocal
break (Fig. 2.17).

2.10 Summary
Voice is produced at the glottis as the subglottal air flow is cut into puffs of air by
vibration of the vocal cords. During the vibration, the glottis is opened by
mounting subglottal pressure and closed by elasticity of the vocal cords and the
Bernoulli effect (suction of the vocal cords by negative pressure at the glottis).
Summary 21

0.5

0.05

O~_II
10 20 30 40
Ps (em H20)

Fig. 2.17. Area of normal and hoarse voices as a function of initial glottal area (Ago) and
subglottal pressure (Ps). (Stiffness of the vocal cords is medium .) Under the condition of
Ago being below the critical value, the increasing subglottal pressure initiates vocal cord
vibration

For this suction force to be effective in closing the glottis, the vocal cord mucosa,
especially along the edges, must be quite mobile.
The voice produced at the glottis, the glottal sound, is modulated into speech
sound by the resonance effect of the vocal tract and sound production there,
e.g., plosive or fricative sound. The intensity of voice is increased usually by
greater exhalatory effort in synergy with more forceful closure of the glottis. The
pitch of voice is elevated mainly by increasing the tension of the vocal cords. The
most important muscle for stretching the vocal cord is the cricothyroid muscle.
3. Pathophysiology of Voice Production

As mentioned above, voice production at its final stage is a purely mechanical

phenomenon, in which several parameters are involved. Cardinal among them
are: (a) subglottal pressure; (b) initial or neutral glottal area, or glottal area at
resting position Ago; (c) stiffness of the vocal cords; (d) coupling between the
upper (cranial) and lower (caudal) portion of the vocal cord edge, which corre-
sponds to the mobility of the vocal cord mucosa; (e) mass of the vocal cord in
vibration, the upper and lower portion considered separately.
Subglottal pressure per se is rarely responsible for voice disorders except for
functional aphonia and some neurogenic voice disorders. Most frequently re-
lated to hoarseness would be imperfect closure of the glottis, stiffness or mobility
of the vocal cord mucosa, and imbalance between the mechanical parameters or
between the two cords. Increased mass of the vocal cord will be discussed in
Chap. VIII under surgery to elevate vocal pitch.

3.1 Imperfect Closure of the Glottis

Laryngoscopic or more accurately stroboscopic examination usually reveals im-
perfect closure of the glottis during phonation in patients with dysphonia, what-
ever the dysphonia may be-paralysis, tumor, or atrophy of the vocal cord.
Many laryngologists believe that the glottal chink during phonation accounts
entirely for the dysphonia and try to eliminate the chink to restore the voice to
normal. What takes place at the glottis when it is imperfectly closed? There must
be a constant leakage of air, which makes modulation of the air stream into
pulses incomplete (Fig. 3.1).
Air flow is classified into laminar and turbulent types. In laminar flow the flow
lines are parallel to each other at all points, while in turbulent flow (turbulence)
they cross randomly, creating collision of the air particles and consequent noise.
Whether the air flow becomes laminar or turbulent depends upon Reynolds
number as defined by the following formula.
Re = p. V· h = V· h
f.L v
24 Pathology of Voice Production

Fig. 3.1. Air flow during phonation: abscissa is time , ordinate is flow rate. Upper graph,
normal voice: air flow is cut into periodical train of puffs. Lower graph, hoarse voice:
constant leakage of air, the flow wave is aperiodic

where Re = Reynolds number; h = effective width of the stricture; V = velocity

of the air flow; p = density of air (fluid); JL = coefficient of viscosity; v = JLlp,
kinetic viscosity.
When the Reynolds number exceeds a certain value (critical Reynolds num-
ber), laminar flow turns into turbulent flow (Meyer-Eppler 19533 ; Isshiki et al.
19783 ). As seen from the formula, the degree of turbulence is related to the
speed of the air flow and the size and shape of the tube, stricture, or nozzle. The
turbulence is enhanced by the presence of a rough-surfaced obstacle amid the air
flow, vocal cord carcinoma, for instance (Fig. 3.2). The voice of vocal cord carci-
noma, therefore, sounds more breathy than that of polyp.
At the glottal chink, if the air flow is sufficiently strong, turbulence is pro-
duced, probably with a dual effect on voice: first, the vibration of the vocal cords
is disturbed by the irregular aerodynamics, losing some periodicity; and second,
turbulent, high-frequency noise is produced. These physical phenomena that are
assumed to arise from constant leakage of air through the glottis correspond well
to two distinctive aspects of distorted voice-rough and breathy natures.
With inefficient function of the glottis in cutting the air flow, the glottal air
pulses become less sharp, reducing the level of the harmonic components.
Briefly, there are three key features of hoarseness: (a) less periodicity of the
vocal cord vibration; (b) high-frequency noise components; and (c) reduced har-
monic components. These are explainable mostly by what would occur at the
imperfectly closed glottis.
Imperfect Closure of the Glottis 25

Laryngeal cancer Laryngeal polyp

:~\
'~,
o B R A

Fig. 3.2 Difference in quality of hoarseness between vocal cord carcinoma (left) and
polyp (right). D degree, B breathy, R rough, A asthenic

Pitfall. There is a big pitfall, though, in identifying or interpreting the glottal

chink. If the glottal condition is set for phonation but there is no air flow supply,
then the vocal cords stand still and do not vibrate. The glottal area under such a
special condition may be termed a neutral glottal area, glottal area at resting
position, or Ago. With imperfect closure of the glottis during vibration on laryn-
goscopy, it is assumed that the glottis must have been incompletely closed from
the beginning prior to subglottal flow supply, i.e., Ago> O. But this is not always
true. If the vocal cords, initially set at the midline without gap (Ago = 0), are stiff
like hard rubber, they are more likely to be continuously "blown apart" without
vibration. The consequent glottal gap produced under such conditions (Ago = 0)
cannot be distinguished visually from the one which existed from the beginning,
i.e., Ago>O.
These two forms of glottal gaps, apparently identical but entirely different in
genesis, should be approached in different ways. The clinical significance of this
fact, which has often been overlooked, cannot be overemphasized. The latter,
blown-apart type of glottal gap with Ago being zero is most frequently associated
with a stiff and less mobile vocal cord mucosa due, for instance, to scarring or
sulcus vocalis. The ineffectiveness of Teflon or silicone injection for such a glot-
tal gap is evident from this blown-apart concept as well as from bitter clinical
experiences with treating sulcus vocalis in such a way.
Another point we should pay attention to with regard to glottal area is that
excessively tight closure of the glottis (Ago < 0) can produce a rough (harsh)
voice such as the one in spastic dysphonia or childrens' or youngsters' yelling.
26 Pathology of Voice Production

High
speed
camera
)l_F_il_m_-,~
_ analyzer I Ag

Camera Initial glottal area Ago

Tape
recorder Sound
wave S

o
~
»
JJ
~ Pressure Ps
oJJ
o
m
JJ
Hot-wire
...... .' II-------i
flow sensor ..... ~;<. . ..
Flow U

Airflow --+

Fig. 3.3. Experimental set-up for artificial voice production. The critical glottal area for
normal voice production was investigated with this experimental set-up

Critical Ag.,. Normal voice production does not always require complete closure
of the glottis at the resting position. The glottis may be closed completely during
the vibratory cycle by the Bernoulli effect, even though it was not set at complete
closure initially, i.e., Ago> O.
When this Ago exceeds a certain value, though, the glottis does not come to
complete closure at any moment, producing a hoarse voice. The Ago value
beyond which the glottis does not close during vibration or the voice changes
from normal to hoarse may be referred to as the critical Ago' Under physiologi-
cal conditions, it is not possible to determine the critical Ago' Using the ex-
perimental procedure with the excised larynx again, the critical Ago for normal
voice production was investigated (Fig. 3.3). When the Ago exceeded 0.05 cm2 ,
the voice was always hoarse regardless of the tension and subglottal pressure
(Fig. 3.6). An Ago below 0.01 cm2 usually does not produce a hoarse voice
unless other factors deviate extremely (Fig. 3.4). Experimentally, the critical
Imperfect Closure of the Glottis 27

Fig. 3.4. Initial glottal area Ago and

quality of voice. Canine larynx,
Ago = 0.009 cm 2 . The voice produced
under such a condition (Ago < 0.01 cm 2 )
is usually not hoarse

Fig. 3.5. Canine larynx. Ago = 0.03 cm 2 .

The voice produced with this glottal area
would be slightly hoarse. Unless stiffness
of the vocal cords is extremely high, the
voice is rough rather than breathy

Fig. 3.6. Human larynx, Ago = 0.188

cm 2 . The voice produced with this glottal
area is always quite breathy
28 Pathology of Voice Production

Ago ranged from 0.01 to 0.05 cm 2 (Fig. 3.5), which would be somewhat greater
under physiological conditions. Some examples shown in Figs. 3.4-3.6 give a
rough concept of the critical Ago'
It is important to note that strictly complete closure of the glottis (Ago = 0) is
not always necessary for normal voice production. With falsetto or a low (soft)
normal voice, the glottis often does not close completely during the vibratory
cycle.

3.2 Stiffness and Mobility of the Vocal Cord Mucosa

Voice production is conditioned by adequate stiffness and mucosal mobility of
the vocal cords. Excessively lax vocal cords would easily be blown apart under
sub glottal pressure, causing vocal cord vibration to cease (Fig. 3.7). Conversely,
over-tense (stiff) vocal cords, as in falsetto, vibrate only under limited condi-
tions, narrowing the range for voice production (Fig. 3.8). Increased stiffness of
the vocal cords generally involves reduced mobility of the vocal cord mucosa, as
when the vocal cords are maximally stretched in falsetto. However, lax vocal
cords, with almost no cricothyroid muscle contraction, for example, can have
reduced mobility when the cord is superficially scarred.
Assessment of the stiffness of the vocal cords often presents great difficulty,
because it is invisible and cannot be determined by using any instrument in vivo.
The details will be described in the following chapter (Sects. 4.1,4.6).

Ago
(cm2)

0.5

0.05

10 20 30 40

Fig. 3.7. Areas of normal and hoarse voices as a function of initial glottal area (Ago) and
sub glottal pressure (Ps) , when the stiffness of the vocal cords is very low. N normal voice,
R rough voice, B breathy voice
Imbalance Between the Two Vocal Cords 29

3.3 Imbalance Between the Two Vocal Cords

There are basically two kinds of imbalance between the two vocal cords-in
tension (stiffness) and mass. Under clinical conditions, multiple factors are in-
volved and assessing the effect of individual imbalances on the vibratory pattern
and voice is almost impossible. We have studied the problem in two different
ways-use of canine and human excised larynges (Fig. 3.3), and simulation of
the vocal cord vibration using Ishizaka's computer model (Isshiki et al. 19773 ;
Ishizaka and Isshiki 19763 ). The results obtained by these two independent
approaches coincide quite well. To summarize, the effect of an imbalance either
in tension or in mass on the voice is not great unless there is a glottal gap. The
voice thus produced would most probably sound quite normal. If one vocal cord
becomes more tense than the other, the tenser cord opens and closes at a greater
speed and waits for the less tense vocal cord to come into contact; both cords
then start opening again at the same moment (Fig. 3.9). In short, tension im-
balance between the two cords causes only a phase lag, but neither hoarseness
nor diplophonia results (Fig. 3.10). Two vocal cords imbalanced in tension
vibrate at the same frequency. Almost the same applies to imbalance in mass;
phase lag occurs with the lighter cord preceding the heavier, but there is no
dysphonia. This is consistent with personal clinical experience that a fairly large
polyp on the vocal cord does not cause any hoarseness, unless it blocks perfect
closure of the glottis. An increased vibrating mass of one vocal cord lowers the
vocal pitch.

Ago
(cm2)

0.5

0.05

10 20 30 40

Fig. 3.8. Area of normal and hoarse voices as a function of initial glottal area (Ago) and
subglottal pressure (Ps), when the stiffness of the vocal cords is extremely high
30 Pathology of Voice Production

Fig. 3.9. A sequence of high-speed motion picture frames showing the vibration of
tension-imbalanced vocal cords. The tenser cord (right) starts opening and dosing earlier
than the opposite cord

The situation is entirely different if the tension imbalance is complicated by

imperfect closure of the glottis, i.e., Ago> O. The vibratory pattern obtained in
the case of a medium-sized glottal chink added to a tension imbalance indicates
complex dicrotic, tricrotic, or other quasiperiodic types with less phase-lag be-
tween the two cords. The glottis may close only momentarily (Fig. 3.11). The
vibratory pattern under this condition is quite unstable and sensitive to subglot-
tal pressure. The voice is rough in quality or may sometimes sound diplophonic
orlike a glottal fry. lithe initial glottal chink is larger (Ago ~ 0), the glottis does
not close at any moment during phonation, and the bilateral cords vibrate rather
regularly with small amplitude and less phase lag (Fig. 3.12). The voice sounds
dominantly breathy. In short, this situation leads to further deterioration of the
voice, as compared with the condition of imperfect closure of the glottis without
the tension imbalance.
Imbalance Between the Two Vocal Cords 31

Right 10 ms a

Fig. 3.10. a Vibratory pattern of the vocal cords under tension imbalance. Note phase lag
between the two vocal cords though they vibrate at the same frequency. b Computed
vibratory pattern of the vocal cords under tension imbalance. The wave forms are similar
to those obtained from high-speed motion pictures of the excised larynx

Right b

Fig. 3.11. a Vibratory pattern of the tension-imbalanced vocal cords becomes complex
when a medium-sized glottal chink is added: analysis of the high-speed motion film. b The
computed vibratory pattern ( dicrotic) is similar to that obtained from the motion film

Left
_/'
11 mm

Right 10 ms
a
Left

Right b

Fig. 3.12. a Vibratory pattern of the tension-imbalanced vocal cords with a large glottal
chink: excised larynx. b Computed vibratory pattern under the similar condition of ten-
sion imbalance and glottal chink
32 Pathology of Voice Production

Extreme imbalance in the vibrating masses of the two cords may cause irregu-
lar vibration of the vocal cords, producing a rough voice, even when the glottis is
initially closed completely (Ago = 0). The possibility of aperiodic vibration of
the vocal cords is great when the mass imbalance is combined with lax vocal cord
tension. Combination of a mass imbalance with a medium-sized initial glottal
area causes complex, less periodic vibration of the vocal cords, producing a
rough voice. The lighter vocal cord vibrates with greater amplitude and crosses
the midline of the glottis.

3.4 Three-Dimensional Representation of Normal and

Hoarse Voice Ranges

The two most important factors causing a hoarse voice are imperfect closure of
the glottis (Ago> 0) and rheological features of the vocal cord. With the Ago
over a certain value, the voice becomes hoarse; whether it is rough or breathy
depends on the Ago, rheological features, and subglottal pressure. The voice
with a large Ago is usually asthenic or breathy. With a medium-sized Ago, the
voice is breathy when the vocal cords are too lax or too tense, and rough when
the vocal cords are lax or medium-tense. Too high a subglottal pressure usually
leads to a rough voice (vocal break). Too tight a closure of the glottis (Ago < 0)
requires high subglottal pressure for phonation and tends to make the voice
rough, as in spastic dysphonia. All the above relations between the voice quality
and the three parameters are schematically demonstrated in Figs. 2.17, 3.7, 3.8.
The range for normal and hoarse voices can be represented in a three-
dimensional diagram (Fig. 3.13). In treating the hoarse voice, it is important to
determine where the particular type of hoarse voice is located in the diagram,
and in which direction it should be returned to normal.
Tension or mass imbalance between the two vocal cords narrows the range for
the normal voice and expands the range for the rough voice, especially when
imperfect closure of the glottis coexists with the imbalance.

3.5 Summary

In treating dysphonia, we have to consider which of the following factors caused

the particular type of hoarseness and in what manner-imperfect closure of the
glottis, stiffness and mucosal mobility of the vocal cord, sub glottal pressure, and
tension or mass imbalance between the two cords.
Imperfect closure of the glottis is usually the most important of these and
under the influence of the sub glottal air flow it creates: (a) irregular (less
periodic) vibration of the vocal cords; (b) turbulent air noise; and frequently (c)
reduced amplitude of the vocal cord vibration and consequent decreased har-
monic components in the voice. Which of the above three phenomena is domi-
nant in a particular case depends upon the other factors, especially the stiffness
or mobility of the vocal cord mucosa. If the vocal cords are extremely stiff, for
instance, it is more likely that the second factor (turbulent air noise) will pre-
dominate over the first factor (less periodicity), giving a breathy rather than a
rough quality to the voice.
Summary 33

AgO

Fig. 3.13. Three-dimensional representation of normal and hoarse voice ranges as a func-
tion of the initial glottal area, subglottal pressure, and stiffness (mucosal mobility) of the
vocal cord. N normal voice, R rough voice, B breathy voice

On laryngoscopy, we can roughly estimate how large the glottal chink is dur-
ing vibration, and how much it participates in a particular hoarse voice. How-
ever, it should be kept in mind that even though the glottis is initially set at
complete closure, it may remain open during voicing if the vocal cords are too
stiff. When we see imperfect closure of the glottis during phonation, differentia-
tion is clinically important between the glottal closure which was set incomplete
initially at the resting position (Ago> 0), and the glottal closure which was set
complete initially (Ago = 0).
Hoarse voice (rough or harsh) can also result from too tight a closure of the
glottis (Ago < 0), as in spastic dysphonia.
Tension or mass imbalance between the two cords, if the glottal closure is
complete, causes only a phase lag between the two vibrating cords without pro-
ducing hoarseness. If combined with imperfect closure of the glottis, it increases
the degree of hoarseness.
The three-dimensional representation of a voice plotted along the axes of the
initial glottal area Ago, stiffness of the vocal cords, and subglottal pressure helps
in localizing a particular type of hoarse voice and in determining in which direc-
tion it should be brought back to the normal voice range.
4. Assessment of Vocal Function

Assessment of vocal function is essential in deciding the type of surgery that is

indicated, intraoperatively which procedure should be taken in response to the
vocal change, and postoperatively the effect of surgery on the voice. The de-
scription of the examinations here is confined only to those that are practical and
normally required for surgery. For details, the reader is referred to works such
as by Hirano (19811), Wendler and Seidner (19871), and Baken (1987 1). Voice
recording is made on audio or videotape together with a laryngeal video-picture
for later analysis, comparison, and discussion. The information is essential in
determining the underlying mechanism for a given hoarse voice, especially
whether any rheological change of the vocal cords, e.g., increased stiffness, is
involved or not.
Instead of recording the voice in front of the mouth, various methods have
been employed to record the sound which is close to the glottal sound (pre-
tracheal sound, Sohndi's tube) (Isshiki 19775 ; Tanabe et al. 19785 ) or to trans-
form the speech sound into the glottal sound, e.g., by inverse filtering (Mathews
et al. 1961 5 ; Rothenberg 19735 ; Davis 19765 ).

4.1 Perceptual Assessment of the Hoarse Voice

In previous studies on hoarse voice by the semantic differential method (Isshiki
19664; Isshiki and Takeuchi 19704 ; Isshiki et al. 19694 ), I and my colleagues came
to the conclusion that hoarseness can be expressed by four factors tentatively
termed rough(R) , breathy(B), degree(D), and asthenic(A). The original seman-
tic method requires a number of pairs of polar-opposite adjectives as the scales
and is a time-consuming work. For a simplified, clinically usable method, we pro-
posed to assess each hoarse voice against the scale of R ,B ,D, and A factors, using
a 4-point grading system (0 = normal, 1 = slight, 2 = moderate, 3 = extreme).
Before practising auditory assessment, it is essential to have a clear auditory
image for each factor, and for that purpose repeated audition of a representative
sample voice or voices which has a prominent score on a certain scale is most
useful. Later at a meeting of the Committee for Phonatory Function Tests of the
Japan Society of Logopedics and Phoniatrics, I proposed adding an S factor to
36 Assessment of Vocal Function

express the strained nature, as in hyperfunctional or spastic dysphonia. Voice

samples of spastic dysphonia or the like were not included in the initial study. It
should be noted that this S factor is not the one extracted on the basis of seman-
tic analysis. Later, this committee adopted the GRABS scale, which is essential-
ly the same as the above except that D (degree) was named G (grade). Repro-
ducibility of the perceptive assessment was found to differ with the factors: the
highest for "grade" and lowest for "asthenic" (Abe et al. 19864 ). Takahashi and
Koike (19764), also using the semantic differential technique, made further de-
tailed perceptual analyses of the hoarse voice and related the results to acoustic
parameters. They proposed four factors: I, inversely related to the frequency
perturbation quotient and the amplitude perturbation quotient; II, related to the
fundamental frequency; III, related to loudness; and IV, which is not clear.
Limiting the discussion here only to practical aspects, the asthenic or strained
factor seems to have special significance in some cases of functional dysphonia.
Whether the voice is rough or breathy is extremely indicative of the mecha-
nism for a given hoarse voice. In fact, the voice of a vocal cord carcinoma tends
to be more breathy than that of a polyp of the same size (Isshiki et al. 19695 )
(Fig. 3.2). Breathiness reflects high-frequency noise due to turbulence of the air
and relatively reduced harmonic components. Breathiness combined with a
rather narrow glottal chink and small amplitude of vocal cord vibration is highly
suggestive of increased stiffness of the vocal cords. This constitutes a difficult
group for surgery. If the breathiness is due to a large glottal chink, however, the
vocal cords may not necessarily be stiff. If the breathy voice contains any har-
monic components with an identifiable, pitch, the pitch level of the voice and its
range provide an indication as to the stiffness of the vocal cords. A high-pitched
breathy voice points to a high degree of stiffness, but a low-pitched breathy voice
does not always means the contrary. The range of pitch variation in the breathy
voice may be related to the proportion of functional to organic factors: the wider
the range, the more likely it is that functional elements are being retained.
Based on comparative studies Wendler and Anders (19864 ) concluded that
auditory assessment of a hoarse voice is much superior in reliability to acoustic
analysis by means of long-term average spectral analysis (LTAS). Wendler and
Seidner (19874 ) presented their basic chart to describe diverse qualities of dys-
phonia, on which the normal voice was described as thick and clear (dicht und
klar).
Hoarseness has been discussed from wide viewpoints by Sonninen (19703 ),
including psychological, acoustical, pathophysiological, and pathoanatomical
components.

4.2 Acoustic Analysis of the Hoarse Voice

An overall picture of hoarseness is still probably best obtained by a sonagram

(sound spectrogram) (Figs. 4.1-4.3). On a narrow-band sonagram for sustained
vowels produced by a hoarse voice, noise emerges as a cloudlike shadow, while
harmonics appear as horizontal bars equally spaced (Fig. 4.1). Rough compo-
nents, or pitch perturbation, are better represented on a wide-band sonagram as
Acoustic Analysis of the Hoarse Voice 37

irregularly spaced vertical bars (pulses) corresponding to each puff of air through
the glottis (Nessel 19605; Hiroto 19675 ; Yanagihara 1967a,b5 ; Isshiki et al. 19665 ;
Rontal et al. 19755 ; Iwata and von Leden 1970a5 ) (Fig. 4.2). From these sona-
graphic features we can determine whether a given hoarse voice is predominantly
of R or B type.
On the basis of visual dominance of either noise or harmonics in formant
regions on a sonagram, Yanagihara (1967 3 ) classified hoarse voices into four
types, with increasing hoarseness from grade 1 to 4 (Fig. 4.3). Hiroto (1967 5 )
and Isshiki et al. (19694 ) demonstrated that factor R is related to pitch or ampli-
tude perturbation, while factor B is characterized by a marked nosie component
and a reduced harmonic component.
With the widespread use of the computer, various attempts have been made to
quantify pitch or amplitude perturbation for rough quality, and the noise-
harmonic ratio for breathy quality. Because of the current increasing interest in
objective assessment of hoarseness, the pertinent subjects are described in some
detail.
Fluctuation of the period of each cycle was first measured and expressed as
pitch perturbation factor by Lieberman (1963 5 ). The pitch perturbation P was
defined as the value obtained by subtracting the duration of a period from the
period immediately preceding it. Then pitch perturbation factor is calculated
according to the following formula:

P1·tch per t ur b a t·Ion fac t or = Frequency of P of 0.5

. ms. or greater
Total number of P III a gIven sample

The pitch perturbation factor was measured clinically by Iwata and von Leden
(19705 ) and Hiki et al. (1975 5 ).
In an attempt to exclude a normal slow variation of the pitch period and to
normalize several fundamental frequencies, Koike (1973 5 ) and Takahashi and
Koike (1975 5) introduced the relative average perturbation (frequency perturba-
tion quotient).
From the standpoint that pitch perception is more closely related to the logar-
ithm of fundamental frequency (semi tone ) rather than the period, my colleagues
and I (Kitajima 19735 ; Kitajima et al. 19755; Isshiki 19775 ; Honjo and Isshiki
19805) utilized semitone scale for obtaining the pitch perturbation factor as
shown below:

where Fi is the instantaneous fundamental frequency corresponding to each

cycle in semitones, and N is the sample number. The tlF is therefore a mean
value of the difference in semi tone of the fundamental frequencies of the two
cycles nex to each other.
The normal range of F for sustained vowels is 0.08-0.23 semitones for men
and 0.14-0.25 semitones for women. Pitch perturbation over 1 semitone, for
example, implies a severely rough voice such as that encountered with a large
 38 Assessment of Vocal Function

Fig. 4.1a, b. Voice of predominantly breathy quality. It contains high frequency noise
which looks like a cloudlike shadow on a narrow-band sonagram (a) and is usually high in
pitch, that is wide spaces between the horizontal bars (a) or narrow spaces between ver-
tical bars on a wide band sonagram (b)
Acoustic Analysis of the Hoarse Voice 39

Fig. 4.2a, b. Voice of predominantly rough quality. It is characterized by pitch and am-
plitude perturbation and is usually low in pitch. It may contain rather low-frequency
noise. The pitch perturbation is noted on the wide-band sonagram (b) as irregularly
spaced vertical bars. On a narrow band sonagram (a), it is displayed as blurred wide
horizontal bars
40 Assessment of Vocal Function

kc kc
6 Type 1 6 Type 2

4 4

u o a e
kc kc
6

.· ··,:,i$~~~~;~#~~~f
Type 3 Type 4
6

4 ...!:.f~(/l~·i;'~ ~~~~ .~;:~:';'::: ~\ ;:.!/ ~." 4

.; .;:·?;~~~i.~:~~1~~~~~li.·i.':~;:M:.::.
2 ~~~~~~

u o a e
Fig. 4.3. Classification of hoarseness according to the intensity of the noise component
relative to that of the harmonic component in different frequency regions (Yanagihara
1967). Type 1, slightest degree of hoarseness, shows the distinct harmonic component
mixed with the noise component which is limited within the formant region of the vowels
[u, 0, a, e, i]. In Type 2, slight noise component appears in the high frequency region
(3000-5000 cps) and the noise component in the second formant of [e] and [i] predomi-
nates over the harmonics in that region. Type 3 shows only noise in the second formant of
[i] and [e] and further intensified noise in the frequency region higher than 3000 cps. Type
4 is characterized by noise in the second formant of [e], [i] and [a] and in the first formant
of [a], [0] and [u]. In these formant regions, the harmonic components are hardly notice-
able

vocal cord tumor. Breathy voices show a relatively low value of pitch perturba-
tion in semitone.
At low frequencies, the voice tends to fluctuate more in frequency and ampli-
tude than at higher frequencies. Horii (1979 5 ) demonstrated that jitter decreases
as the fundamental frequency increases. Based on the acoustical assessments of
aperiodicities in functional dysphonia, Klingholz and Martin (1983 5 ) state that
the variations of period and amplitude are inversely proportional to "k" (the
spring constant or vocal cord tension), i.e., the magnitude of pitch perturbations
is expected to be lower at high tension than at low tension. They further sug-
Acoustic Analysis of the Hoarse Voice 41

gested the significance of assessing the aperiodicity in differential diagnosis be-

tween hyper- and hypofunctional dysphonia.
Perturbation in peak amplitude during sustained vowel production, known as
shimmer, has also been found to indicate somewhat the degree of hoarseness,
especially the rough aspect (Koike 19695 ; von Leden and Koike 19705 ; Taka-
hashi and Koike 19755 ; Kitajima and Gould 19765 ). Emanuel and his coworkers
(19695, 19735, 19795, 1981 5 ) estimated the noise level in the spectrum of sus-
tained vowels, which was defined as the lowest peak marking of a graphic level
recorder stylus in each 100-Hz section of the vowel spectrum, and found a linear
relationship between the spectral noise level (SNL) and the perceived degree of
vocal roughness. Kitajima calculated the "noise ratio" of voice which is defined
as follows.
. . _ rms of Y(f)
NOIse ratIO - rms of N(f)
where N(f) = Z(f) - Y(f), Z(f) is the voice signal, Y(f) is the filtered voice
signal, N(f) is the residual signal (mostly noise). The actual filtering process
was performed by FFf (fast Fourier transform) and IFFf (inverse fast Fourier
transform). Kojima et al. (19805 ) separated harmonic components from noise
components by means of the Fourier expansion technique. Three pitch periods
extracted from the voice wave form were analyzed by Fourier series expansion.
Since it offers a dispersal spectrum with good frequency resolution, the acoustic
energy of the harmonics is calculated separately from that of the noise compo-
nents. The ratio of harmonics to noise (Ra) ranges from 15.4 to 23.3 dB in 95%
of normal voice and permits differentiation between normal and pathological
voices. The ratio of harmonics to low-frequency noise components (below 1.38
kHz; RL) corresponds well with the R factor (roughness) of the auditory im-
pression, while that of harmonics of high-frequency noise components (above
1.38 kHz; RH) correlates well with the B factor (breathiness).
For separation of harmonics from noise, the averaging and subtraction tech-
nique of the acoustic waves was utilized by Yumoto et al. (19825 ), Yumoto
(19835 ), and Yumoto et al. (19845 ). Consecutive pitch periods of a sustained
vowel fa! are averaged; H is the energy of the average waveform, while N is the
mean energy of the differences between the individual periods and the average
waveform. The HfN ratio can be measured with a small computer. The results
are highly consistent with those of auditory perception and spectrographic
findings.
In the hoarse voice, the intensity of the first harmonic (fundamental) is much
stronger than the other higher harmonics. Based on this tendency, the relative
intensity of the second and higher harmonics was also put forward as an indicator
of hoarseness by Hiraoka et al. (19845). Kasuya et al. (19865 ) proposed a nor-
malized noise energy as a measure of hoarse voice.
Utilizing the voice synthesizer, the effect of jitter and shim1p.er of the voice
signal on its auditory perception was widely studied by Wendahl (1963,
1966a,b5 ), Coleman and Wendahl (19675), Emanuel and Sansone (19695 ), Cole-
man (1971 5), LaBelle (19735 ), and Deal and Emanuel (1978 5 ). These studies,
together with clinical studies, have clearly shown that the roughness is correlated
with the perturbations in voice waves.
42 Assessment of Vocal Function

Breathiness in hoarseness (dysphonia) is known to derive from high-frequency

noise while roughness, from low-frequency noise or pitch and amplitude per-
turbation. Utilizing this difference, Fukazawa et al. (1988 5 ) attempted to quan-
tify breathiness and its separation from roughness by summing squared second
order differentiation of the voice wave as normalized by the sum of the wave
energy. The results matched well to the perceptive level of breathiness, pointing
up the clinical usefulness of the method.
The same research group (Mori et al. 19875 ) demonstrated that this index is
highly correlated with perceptual breathiness and is a more sensitive indicator of
slight hoarseness than the pitch perturbation index.
Multifactorial analysis of hoarseness appears also predictive in objective
assessment of hoarseness. The residue signals after inverse filtering were used
for acoustic analyses of hoarseness (Davis 19765 ) to extract six acoustic para-
meters, which were then evaluated in terms of diagnostic significance of patho-
logical voice (Hiki et al. 19755 ; Hirano et al. 19775 ).
Without using a rather complicated inverse filtering technique, Imaizumi et al.
(19805 ) demonstrated that several cues were obtainable from the analyses of the
sonagram, including fundamental or amplitude fluctuation, level ratio of high-
frequency harmonics to the lower ones, and relative noise level.
As mentioned above, a number of objective methods are now available for
assessing hoarseness. Table 4.1 summarizes which method is suited for assessing
which factor of hoarseness. Digital sonagraph will soon become more and more
popular.

4.3 Aerodynamic Test for Vocal Function

Voice production is an aerodynamic phenomenon that transforms the air flow
from DC to AC (Fig. 3.1). Aerodynamic tests can therefore reveal some aspects
of the phonatory function of the glottis.

4.3.1 Air Flow Measurement

The air flow through the mouth during phonation is determined by the degree of
respiratory effort and the glottal condition, that is, how tightly it is closed, and
whether or not there is any glottal chink. The exhalatory effort varies fairly
greatly among individuals as well as with each attempt at phonation. Instruction
on the proper manner of phonation, e.g., easy or comfortable, does not ensure
the same exhalatory effort every time. Due to this variability in the exhalatory
effort, measures of air flow during phonation are usually widely varied both
within and among subjects, and are therefore of limited significance in assessing
glottal function.
If there is a glottal chink over a certain size during phonation, the air flow will
always exceed a normal range in spite of the variable exhalatory effort. Exces-
sive air flow during phonation generally implies a glottal chink, while that below
the normal means excessively tight closure of the glottis or discoordinated
exhalation, which is significant in diagnosing spastic dysphonia or functional
dysphonia.
Aerodynamic Test for Vocal Function 43

Table 4.1. Objective assessment of hoarseness

Physiological Acoustic Auditory Objective
phenomenon features perception assessment
Irregular vibration Perturbation in Roughness Lieberman (~P: pitch
of the vocal pitch and perturbation factor)
cords amplitude Koike (normalized ~ P)
(jitter and Takahashi and Koike
shimmer) (frequency perturbation
quotient)
Kitajima (~Fsemitone)
Emanuel et al. (SNL:
spectral noise level)
Kojima (RL: ratio of
harmonics to low-
frequency noise)
Decreased Hiraoka (relative intensity
harmonics of overtone)
Turbulent noise High-frequency Breathiness Fukazawa (Br index: the
noise second derivative)
Kojima (RH: ratio of
harmonics to high-
frequency noise)
Degree Kojima (Ra: log SIN by
Fourier series expansion)
Yumoto CHIN ratio,
averaging and
subtracting)

For assessing the effect of surgical medialization of the vocal cord, air flow
measurement can be a useful objective method. Because of a great variation in
air flow measures, at least three measurements under as similar conditions as
possible are advisable. A number of reports have been made on the mean flow
rate during easy or habitual phonation for normal people and patients with va-
rious dysphonias (Isshiki and von Leden 19643; Isshiki 19652 ; Isshiki et al. 19676 ;
Yanagihara and von Leden 19662 ; Hirano et al. 19686 ; Yoshioka et al. 19776 ;
Shigemori 19776 ; Schutte 19807 ; Bastian et al. 1981 6 ; Terasawa et al. 19876 ).
Normal values of the mean flow rate during phonation for adults ranges
roughly from 80 to 200 mIls. A mean flow rate over 200 mIls can be regarded as
abnormal. The normal range largely depends on the instructions given to the
subject.
More reliable information as to the glottal function, i.e., glottal resistance,
can only be obtained by simultaneous recording of the air flow and subglottal
pressure.
44 Assessment of Vocal Function

Maximal Phonation Time. Though largely dependent on the other factors as

well, such as the subject's effort to phonate as long as possible, the maximal
phonation time is roughly in inverse relation to the mean flow rate during phona-
tion. This rather crude method can be utilized, however, intraoperatively, be-
fore and after the medialization procedure for instance, when no instruments are
available.

Spirometric Measurement. A spirometer with a pen recording system for reg-

istering the volume of exhaled air as a function of time permits calculation of the
mean flow rate during phonation. It is simple and reliable enough for pre- and
postoperative examinations. Disadvantages include not being able to record
the voice and the very slow response of the system (Isshiki et al. 19676 ; Hirano
19753 ; Shigemori 19776 ; Yoshioka et al. 19776 ).

Pneumotachograph. The most common instrument for recording the air flow
rate during phonation is the pneumotachograph. If the intensity of the voice is
recorded simultaneously with the air flow rate, special attention should be paid
to the size of the mouth opening and of the mask or tube, because the acoustic
energy radiated from the mask or tube opening changes with the size of the
orifice. The distance between the orifice and the microphone should be kept
constant, usually 15 or 20 cm (Fig. 4.4).

Hot-Wire Flow Meter. A regular hot-wire flow meter is too slow in response
time; once the heated wire is cooled by the air flow, it takes time for the wire to
be heated again to the standard temperature. Owing to improvements in the
system, i.e., introduction of a feedback system (constant temperature type) and
use of a fine hot wire, this problem of poor response time has been reduced
considerably. The frequency response characteristics in a system is exemplified
in Fig. 4.5. The disadvantages of this type of flow meter include: The incapability
of detecting the direction of air flow, and at a very low flow rate, calibration of
the system is difficult.
One of the solutions to this problem is the superposition of a constant gas flow
on the exhaled air flow as shown in Fig. 4.6 (Isshiki 19837 ). The air flow is
thereby maintained as exhalatory at a fairly high flow rate.
The air flow and other relevant data are generally widespread among normal
subjects and sometimes fairly inconsistent at each attempt at phonation even
from the same subject. This great variability must be accepted as one aspect of
phonatory physiology and should not easily be attributed to the inconsistency of
the instrument.

4.3.2 Vocal Efficiency

Efficiency of Voice. Vocal efficiency was first defined by van den Berg (19567 ) as
the ratio of the acoustic power to the subglottal power.

Efficiency of voice = ~
where W is the sub glottal power or the product of sub glottal pressure and trans-
Aerodynamic Test for Vocal Function 45

Integrator
~me
Flow rate

Voice
AC-Amp.

Fig. 4.4. Measurement of air flow during phonation using a pneumotachograph

8,w1 .. Kl-'
.. " ..

-- --7o'r- - ' 1-
-- .

- ....... .
- .-
-"-1-
--
1-
I---
r--; "
- r- k.
1- f- '~~--'b i-' -
- fl
-, - .- ,- ---
... 1--1- .. - f-- -- '1'
- .- '~ ' -I- -. ._--
- ---t---
-
T'
r-- ~ ,

r--o - - -- - , - - .-
-- - '- 1- -- - .- .
f---- - - .- - 1- '- --1-- -
1---- '-- ' --
._ .
r-' -!- ' - .- . - - . 1- - .-

llJ.
-r- - ~
. l- .- ' j '
t- .
- --
--
I--- - I - 1- .

- - 1- '- Wf T,

-~ _. If "fII~'+-+-'''''''l
'--r- - - f!-
_. -- 1- ' ~I--
.-
" II •• '00 ••• ••• loeo .OOD 1000 J iii

Fig. 4.5. Frequency response of a hot-wire flow meter of a constant temperature type.
The measurement was made with DC flow at 200 cels

glottic mean flow, and V is the acoustic power at the mouth opening calculated
from the sound pressure level in front of the mouth.
This relation was further studied (Isshiki 19647 ) through simultaneous record-
ings of subglottal pressure, air flow rate, and sound pressure level. The size of
the mouth opening was maintained constant during phonation. The following
formula was postulated:
1= W Eg Etr
46 Assessment of Vocal Function

Phonation Analyzer

D.C. flow
AC/DC
Intensity
Pitch

Mic

Constant air flow

Voice production with constant DC flow added

Fig. 4.6. Superposition of a constant gas flow on the exhaled air flow so that the measure-
ment of the AC component can be made in a good frequency response region

where I is the intensity of the voice measured at a given point outside the mouth,
W is the sub glottal power, Eg is the glottal efficiency, and Etr represents the
transfer and radiation efficiency. When the mouth opening and the point of
measurement of vocal intensity are kept constant, e.g., Etr is constant, the glot-
tal efficiency can be deduced from the data of subglottal pressure, air flow rate,
and acoustic intensity of the voice (SPL). Difficulty or discomfort imposed on
the subject associated with the measurement of sub glottal pressure restricted
clinical use of the concept of vocal or glottal efficiency.

Glottal Flow Efficiency. Air flow measurement during phonation is much easier
and much less uncomfortable for the subject than that of sub glottal pressure . A
new efficiency, the ACIDC ratio, was postulated by Isshiki (19775 ,19817).
Glottal flow efficiency = A c/DC
where AC is the effective value of the alternating current component of exhaled
air flow during phonation, and DC is the direct current of air flow, i.e., the mean
flow rate (Fig. 4.7). The glottis functions to transform DC air flow into AC plus
DC air flow. The root mean square value (rms) or effective value of the AC
component corresponds to the intensity of the sound. The above relation seems
to justify glottal flow efficiency, instead of the commonly accepted power
efficiency. Efficiency is defined by the Acoustical Society of America as follows:
Aerodynamic Test for Vocal Function 47

o~~----------~----~--------~~----~--------~--

Fig. 4.7. Glottal flow efficiency is defined as the ratio of AC to DC of the glottal air flow

"The efficiency of a device with respect to a physical quantity which may be

stored, transferred, or transformed by the device is the ratio of the useful output
of the quantity to its total input." It is added that unless otherwise stated, this
implies the power. In the above statement, it is important that efficiency should
be a ratio, which is without dimensions. The glottal flow efficiency seems com-
patible with the above definition, when it is specifically stated as flow efficiency,
not power efficiency.
Several problems are encountered, when glottal flow efficiency is used in prac-
tice. If one of the harmonics hits the formant peak, the sound is louder than it
would be otherwise. Some counter measure must be taken to minimize or keep
constant the vocal tract resonance effect which should be excluded to obtain a
correct value of the glottal flow efficiency.
Also, a new type of hot-wire flow meter, which has a fairly good high-
frequency response, can be used for this purpose. The problem regarding this
flow meter and its partial solution has been mentioned above (Page 44).
Measuring the ACIDC ratio (without gas superposition), Kitajima (1985 7 ) re-
ported that vocal cord paralysis is characterized by a large DC with a small
ACiDC percentage while acute laryngitis showed a normal DC in spite of a small
ACIDC percentage. His reported normal range of ACiDC in both sexes was
from 41 % to 76%.
Using a similar instrument, Wilson and Starr (1985 7 ) stated that it is unlikely
that ACIDC ratios or glottal flow measures, by themselves, will prove to be
effective in identifying subjects with laryngeal pathology, because of the high
variability in measurement. When the cutoff ratio of ACIDC was set at 0.5,33%
of the 105 subjects were misidentified.
The purpose of developing a new diagnostic tool is not necessarily to match
the data to those obtained by the previous methods. Complete agreement im-
plies that no new information would be provided by the new instrument. What is
important in developing a new instrumentation is probably theoretical rational-
ity, and accuracy and consistency in calibration of the instrument. Discrepancy
between those established criteria (voice, etc.) and the new instrumentation in
the normal-abnormal grouping, as found by Wilson and Starr, seems interesting
or rather encouraging in that it leaves the possibility of providing new informa-
tion, or revealing new aspects of dysphonia, which would not be obtained other-
wise. Although the threshold value between the normal and the pathological
would probably need further modification as the data accumulate, the factors
responsible for the discrepancy seem to be an interesting issue to be studied
further. Because of the inconsistency and diversity in aerodynamic aspects of
48 Assessment of Vocal Function

individual voice production, the data in human subjects cannot be used for
assessing the instrument.
Kakita (1987 7 ) proposed the wave-flow index instead, which is defined as
E=I-kV
where E is wave-flow index, I is speech intensity in dB, V = 20 log (V/Vo) or
relative level of mean flow rate in dB, and k is a constant. The actual data from
which the index is derived are vocal intensity and mean flow rate. Therefore, the
problem of frequency response of the system is obviated. However, the dis-
advantage would be that two arbitrary figures, i.e., k and V o, are involved in
deriving the index.
Vocal efficiency cannot be expressed by the ratio of dB value divided by cm2/s.
Theoretically this does not fit the above-mentioned definition, and empirically it
is strange to say that the efficiency of a 90-dB voice produced with 180 cm2/s is
equal to that of a 70-dB voice produced with 140 cm2/s. It is apparent that the
former is more efficient than the latter.

Implication of Vocal Efficiency. In the normal subject vocal efficiency is general-

ly higher than that from the pathological larynx (Schutte 19807 ). At first sight,
it may seem that the better the efficiency, the better the larynx. It should be
noted, though, that efficiency is not the only index reflecting functional excel-
lency of the device. However high the efficiency of a machine may be, it would
be useless if the machine makes errors and tends to fall into trouble easily. In
fact, a hyperfunctional voice disorder can exhibit a higher efficiency than the
normal voice.
In discussing the efficiency of a voice, the words useful output are the key
issue. In a hoarse voice, the harmonic components excluding the noise may logi-
cally be the only useful output, but any noise (very hoarse voice) is better than
no noise (aphonia) and can be useful under extreme conditions.

4.4 Recording of Vocal Intensity and Pitch

4.4.1 Vocal Intensity

Vocal intensity during sustained phonation can be analysed by various instru-

ments employed to measure the sound pressure level (SPL). The SPL of a sound
in decibels is 20 times the logarithm of the ratio of the pressure of the sound to
the reference pressure. The reference pressure is explicitly stated and is most
commonly 2 x 10- 4 microbars (0.0002 dyne/cm2). Sound level (SL) is a weighted
sound pressure level, obtained by the use of metering characteristics and the
weightings A,B,C. The weighting employed must always be stated. If a sound
level meter is used to measure SPL, weighting network C should be used to
eliminate compensation for loudness level. The mouth to microphone distance is
usually set at 15 or 20 cm.
Measurement of vocal intensity of a sustained vowel /a/ is much easier than
that of a running speech. Usually, an introduction passage is pronounced prior
Recording of Vocal Intensity and Pitch 49

7
1:" " II II ,II II IIII I I II III I II II II II III I
I " ~
CD I:: 1\ :

\\
6
(J)
·0 I:: -
c:
I:: :
-
-
«i 5
(5 r: -
-
-
I:: -
oE 4 I- :
.!::
""0
r:
I-
\~ --
~ I:: -
~
3
.... I:: :

---
15 2
e
.... :l
(J) I::
f-
f-
~
i'-.- r--
:
--
Q; ~ 1
CO 0 ~ ~
O~
1="11 II I II I II II IIII IIII II II IIII I I II IIII II 11- )

o
~

1 2 3 4 5 6 7 8 9 10
DB difference between total noise and background alone
Fig. 4.8. Correction of total value to obtain the value of signal alone without ambient
noise. (From Beranek 1954)

to /a/ so that the /a/ is more likely to be a part of conversation such as, "Say the
letter /a/."
If the ambient noise level is not far from the total sound pressure level (signal
plus ambient noise), subtraction of a certain value from the total value is neces-
sary (Fig. 4.8). Here is an example of the addition of two sound sources. The
SPL reading for sound source A and ambient noise B together was greater by 4
dB than that for the ambient noise B alone. How much should be subtracted
from the reading for A plus B to obtain that for A alone? Assuming the sound
pressure from sound source A to be Pm and that from the ambient noise B to be
P b , the difference in decibels between A plus Band B is

10 log (Pb p:ta

2 2
) =4

p2
1 +~=2.512,
Pb
The decibel value to be subtracted is the ratio of P} to Pa + Pb 2 2. Therefore,

1.512
= 10 log 2.512 = -2.2
Supposing the ambient noise is 60 dB, and the total is 64 dB, then the SPL for A
alone is 64 - 2.2 = 61.8 dB.
50 Assessment of Vocal Function

It should always be kept in mind that the intensity of the voice measured
outside the mouth is greatly influenced by the size of the mouth orifice (Fair-
banks 195(2).
The dB values for the same acoustic signal are the same regardless of the
expression of either intensity level (IL) or SPL if equivalent reference power and
pressure have been used.

4.4.2 Vocal Pitch

Measurement of the vocal pitch is essential before and after surgery aiming to
change it.

Sustained Vowel Phonation. Vocal pitch of sustained vowel production can easi-
ly be measured with various instruments: stroboscope, which usually shows the
vocal pitch (Hz) on a meter; display of the sound wave on a cathode ray oscillo-
scope permitting calculation of the fundamental frequency; pitch calculation on
sonagram; and various types of pitch indicator.

Conversational Speech. The vocal pitch in conversational speech changes rapid-

ly according to intonation and is rather difficult to express in a single figure.
Special instruments are available for recording changing vocal pitch (Glottal fre-
quency analyzer: Teltec, Sweden; Visi-pitch: Kay Elemetrics, Inc., USA;
PM100 Pitch-analyser: Voice Identification, Inc., USA; F-J FFM 650 Fun-
damental frequency analyer: FJ Electronics, Denmark).
Vocal pitch is more easily detectable with the use of a pretracheal contact
microphone or electroglottograph than the use of a microphone in front of the
mouth. Askenfelt and his colleagues recommend the use of the electroglotto-
gram (Askenfelt et al. 198OS; Fourcin 1981 8 ; Kitzing 19778 , 19828 ).

Expression of Vocal Pitch. Either fundamental frequency in Hz or musical notes

is usually used to express vocal pitch. There are quite a number of manners to
express the vocal pitch in musical note. Standard musical notes adopted by the
American Standard Association is shown in Table 4.2.
In statistical analysis of the vocal pitch, when obtaining, for example, the
mean value from a number of vocal pitches, it is advisable to convert them into
semitones for ease of further calculation.
The musical frequency level in semits of a sound is 12 times the logarithm to
the base 2 of the ratio of the frequency of the sound to the reference frequency.
The reference frequency is 16.352 Hz, corresponding to Co.

Semitone = 12 log2 f, = 39.86 x log f,

The frequency level in semits for A4 = 440.00 Hz is 57. (Co> A4 are names of the
musical note, f is the frequency of a given sound in Hz, fr is the reference fre-
quency, 16.352 Hz.)
For more details about the measurement of fundamental frequency, refer to
Chap. 5, Baken (1987 1), for instance.
Recording of Vocal Intensity and Pitch 51

Table 4.2. Note name, frequency level, and frequency

Note Frequency Frequency (Hz) Note Frequency Frequency (Hz)
name level name level
(semits) (semits)

Co 0 16.352 A3 45 220.00
1 17.324 46 233.08
Do 2 18.354 B3 47 246.94
3 19.445
Eo 4 20.602 C4 48 261.63
Fo 5 21.827 49 277.18
6 23.125 D4 50 293.66
Go 7 24.500 51 311.13
8 25.957 E4 52 329.63
Ao 9 27.500 F4 53 349.23
10 29.135 54 369.99
Bo 11 30.868 G4 55 392.00
56 415.30
CI 12 32.703 A4 57 440.00
13 34.648 58 466.16
DI 14 36.708 B4 59 493.88
15 38.891
EI 16 41.203 Cs 60 523.25
FI 17 43.654 61 554.37
18 46.249 Ds 62 587.33
GI 19 48.999 63 622.25
20 51.913 Es 64 659.26
Al 21 55.000 Fs 65 698.46
22 58.270 66 739.99
BI 23 61.735 Gs 67 783.99
68 830.61
C2 24 65.406 As 69 880.00
25 69.296 70 932.33
D2 26 73.416 Bs 71 987.77
27 77.782
E2 28 82.407 C6 72 1046.5
F2 29 87.307 73 1108.7
30 92.499 D6 74 1174.7
G2 31 97.999 75 1244.5
32 103.83 E6 76 1318.5
A2 33 110.00 F6 77 1396.9
34 116.54 78 1480.0
B2 35 123.47 G6 79 1568.0
80 1661.2
C3 36 130.81 A6 81 1760.0
37 138.59 82 1864.7
D3 38 146.83 B6 83 1975.5
39 155.56
E3 40 164.81 C7 84 2093.0
F3 41 174.61 85 2217.5
42 185.00 D7 86 2349.3
G3 43 196.00 87 2489.0
44 207.65 E7 88 2637.0
(Table 4.2 continued on following page)
52 Assessment of Vocal Function

Table 4.2. (continued)

Note Frequency Frequency (Hz) Note Frequency Frequency (Hz)
name level name level
(semits) (semits)
F7 89 2793.8 99 4978.0
90 2960.0 Es 100 5274.0
G7 91 3136.0 Fs 101 5587.7
92 3322.4 102 5919.9
A7 93 3520.0 Gs 103 6271.9
94 3729.3 104 6644.9
B7 95 3951.1 As 105 7040.0
106 7458.6
Cs 96 4186.0 Bs 107 7902.1
97 4434.9
Ds 98 4698.6

4.5 Manual Test

In practical terms, this is the most important test in determining the indication
for laryngeal framework surgery. The details are given in Sect. 6.3.1 (Page 83).

4.6 Stroboscopic Examination

Any rapid periodic phenomenon can be visualized as a standstill or slowed down
by casting a light which has the same as, or a slight shift (f) away from, the
frequency of the vibrating object. A stroboscope permits visualization of the
vocal cord vibration in slow motion. It is useful in detecting any local reduction
of amplitude of vibration, or mucosal mobility at the margin of the vocal cords.
It helps diagnose early stages of laryngeal carcinoma or increased stiffness of the
vocal cord mucosa.
Howerver, it should be borne in mind that stroboscopy is, in principle, based
on periodical phenomenona. The finding of vocal cord vibration in a hoarse
voice may be partly false or not fully reliable, because the vibration is not exactly
periodic anymore.

4.7 Videolaryngoscopy
Video documentation of the laryngeal examination with a flexible fiberscope
(Fig. 4.9) or with a rigid telescope (Fig. 4.10) is of prime importance in the voice
clinic. Various improvements have been made in laryngoscopes, including a nar-
rower scope with a brighter light, higher resolution, stereovision, and combining
it with a stroboscope or high-speed motion film (Gould 1973 12 , 1977 12 , 1983 12 ;
Blaugrund et al. 1983 12 ; Davidson et al. 1974 12 ; Sawashima and Hirose 1968 12 ;
Sawashima et al. 1967 12 ; Kakita et al. 1983 12 ; Fujimura 1977 12 ; Fex 19709 ; Saito
Video laryngoscopy 53

Fig. 4.9. A flexible fiberscope connected with a video-recording system

Fig. 4.103, b. A rigid telescope (side-view type laryngoscope). 3 Berci-Ward, Storz.

b Nagashima SFf-l
54 Assessment of Vocal Function

et al. 19789 ; Yoshida 19799 ). Saito et al. (19811 2 ) devised a new curved laryn-
gotelescope (Fig. 4.11).
For precise evaluation and high quality documentation of structural changes
of the larynx, the rigid telescope is superior to the flexible fiberscope (Yanagisa-
wa 198212 , 1987 12 ; Yanagisawa et al. 1983 12). The fiberscope is convenient for
intraoperative examination of the larynx. The fiberscope can more easily be used
with sensitive subjects than the telescope and allows visualization of the larynx
during speech.
For assessing the effect of surgery, recording of the laryngeal finding on
videotape before and after surgery has now become one of the indispensable
diagnostic means. Video laryngoscopy greatly facilitates communication between
the patient and doctor or voice therapist.
A small videocamera as shown in Fig. 4.12, is useful for taking videopictures
during an operation, because it can be introduced into the visual field without
interfering much with the surgeon's vision.

4.8 Electromyography
Electromyography (EMG) is of particular value in diagnosing (a) vocal cord
paralysis, especially to determine whether misdirection of the recurrent nerve
fiber exists or not; (b) spastic dysphonia for involvement of the central nervous
system; and (c) cricothyroid muscle paralysis.
Except for physiological study of the laryngeal muscles, the vocalis-thyro-
arytenoid complex is usually selected as the representative adductor and ap-
proached by percutaneous insertion of an electrode through the cricothyroid
membrane (Hirano and Ohala 1969 11 ). This approach was first used by Seiffert
(1919 11 ) for injecting paraffin into a paralyzed vocal cord (Fig. 4.13). EMG is
also used to identify the muscle prior to intramuscular injection of a chemical
substance, e.g., botulinum toxin (Blitzer et al. 19882°), or electrostimulation
(Friedman et al. 198720) in treating spastic dysphonia.

4.9 X-ray and MRI

Laryngography with a radiopaque substance, laryngotomography, xerolaryngo-
graphy, computed tomography (CT), and magnetic resonance imaging (MRI)
may be used for diagnosing laryngeal diseases.
Laryngography has often been used for detecting early carcinoma. A laryngo-
tomogram can reveal any difference in the level and thickness of the paralyzed
vocal cord (Fig. 4.14). Most frequently, the paralyzed vocal cord is higher than
the intact one if the former is fixed at the intermediate or lateral position. Xero-
laryngography is capable of clearly demonstrating the contour of a laryngeal
inner cavity and is particularly useful for diagnosing laryngeal trauma.
More and more quantitative data together with their computer analysis are
being provided by CT and MRI (Fig. 4.15).
X-ray and MRI 55

Guard late

l-----++------------'~-_I_---. --- --1

essor

Gri

L. To Light source b

Fig. 4.11a, b. A curved laryngoscope (Saito), produced by Asahi K6gaku

 56 Assessment of Vocal Function

Fig. 4.12a,b. A videocamera system for surgery. A tiny camera with coaxial fiberoptic
light does not interfere much with the view of surgical field. a A fixed type for taking
stable videopicture. b A head-set type for less intervention in surgeon's view
 X-ray and MRI 57

Fig. 4.13. Approach to the vocal cord through

the cricothyroid membrane (Seiffert)

R L R L

a b
Fig. 4.14. Tomograms of left vocal cord paralysis. Atrophy and high position of the para-
lyzed cord (a during phonation), and expansion of the ipsilateral laryngeal ventricle
(b during respiration)
 58 Assessment of Vocal Function

a b

c
Fig. 4.15a, b. Magnetic resonance image of larynx (coronal view; TR = 2000 ms, TE = 40
ms). The false vocal cord (arrowhead) and vocal cord (arrow) are recognizable. c Magnet-
ic resonance image of larynx (axial view; TR = 600 ms, TE = 25 ms). Arrow indicates
right vocal cord

4.10 Ultrasonic Measurement

By ultrasonic measurement, many attempts have been made to reveal the vibra-
tory pattern and mechanical property of vocal cords by researchers at Chiba
University (Asano 1968 13 ; Kitamura et al. 1967 13 , 1969 13 ) and others (Beach and
Kelsey 1969 13 ; Hamlet and Reid 1972 13 ; Hamlet 1973 13 ; Hamlet and Palmer
1974 13 ). A mechanically scanning acoustic microscope (SAM) has also been util-
ized for studying the rheological characteristics of the vocal cords (Quate 1979 13 ;
Chubachi 1983; Kakita et al. 1984 13). The problems in the use of this technique
for laryngeal studies pertain mostly to resolution factors (Baken 1987). Improve-
Ultrasonic Measurement 59

ments in the resolution factors have been made: high repetition rate of emission
of the ultrasound (Hertz et al. 1970 13 ; Holmer et al. 1973 13 ), use of two probes
for examining the two vocal cords simultaneously (Kaneko et al. 1981 13 ), use of
a narrow ultrasound beam as a transmitting continuous wave (Hamlet 1972 13 ),
or combined use of echo and transmission techniques (Kaneko et al. 1976 13 ).
Despite all this progress, much remains to be further improved until it can be
utilized clinically.

To those who are interested in further details of the acoustics, physiology, and
pathology of voice production, the following textbooks are recommended: Vocal
Rehabilitation (Brodnitz 1971 19 ), Physiology of the Larynx (Pressman and Kele-
men 1955 1 , revised by Kirchner 1986 1 ), Lehrbuch der Phoniatrie (Wendler and
Seidner 1987 1), Handbuch der Stimm- und Sprachheilkunde (3rd edn, Luchsinger
and Arnold 1970 1), Voice and Articulation (van Riper and Irwin 1958 1), Speech
Science Primer (Borden and Harris 1984 1), Analysis, Synthesis and Perception of
Speech (2nd edn, Flanagan 1972 1), Acoustic Theory of Speech Production (Fant
1970 1), and Acoustics (Beranek 1954 1).
5. Anatomy for Laryngeal Framework Surgery

5.1 Projection of the Anterior Commissure

After exposure of the thyroid cartilage, design in laryngeal framework surgery
starts with marking the projection point of the anterior commissure on the thy-
roid cartilage. Anatomical studies trying to locate the projection point from
various landmarks have all revealed quite a large individual variation, whatever
landmark is selected. According to Seiffert (1943 14), the projection point is 7-10
mm above the lower margin of the thyroid cartilage (d in Fig. 5.1). Based on the
measurements of 100 cadaver larynges (65 male, 35 female) Gurr (1948 14) re-
ported that it is 3.5-6.0mm below the thyroid prominence (Pin Fig. 5.1) in males,
and 3.0-5.0 mm in females. Minnigerode (1955 14) described the point as a
relative measure, i.e., the lower two-fifths of the distance between the upper-
most and lowermost margins of the thyroid ala (Fig. 5.2). If a variation of ±1.5
mm is taken into account, 97% of the examples falls within that range. With the
thyroid incisure and lower margin taken as the reference points, the relation is
reversed to the lower three-fifths of the distance in 79% of cases, and with ±0.75
mm, 92% falls within that range (Fig. 5.2). This can be converted to a thyroid
prominence (Adam's apple)-oriented measurement, according to Minnigerode
(1955 14), by taking into account the fact that the distance between the notch and
the prominence is always about 3 mm. From 12 male and 18 female cadaver
larynges Hiroto and Toyozumi (1968 14) reported that the mean distance from
the thyroid notch to the anterior commissure is 9.0 mm in males and 7.9 mm in
females, and the distance from the lower margin is 10.5 mm in males, and 9.8
mm in females.
Data (Hiramoto 1977 14 ; Isshiki 19775 ) based on 28 male and 23 female
larynges are shown in Table 5.1. The projected point is located a little (1 mm in
males, 0.5 mm in females) higher than the midpoint between the notch and the
lower margin. In this measurement, the direction of projection is perpendicular
to the cartilage plane. If the projection is done parallel to the vocal cord, the
projected point on the cartilage is 1 or 2 mm higher than this point.
62 Anatomy for Laryngeal Framework Surgery

Fig. 5.1. Anterior view of the thyroid cartilage. a from the thyroid notch to the lower
margin; b depth of the thyroid notch; c from the thyroid notch to the projection of the
anterior commissure; d from the projection of the anterior commissure to the lower mar-
gin; p Adam's apple

Fig. 5.2. Projection of the vocal cord on the thyroid ala (Minnigerode 1955) I thyroid
incisure, UM, LM the uppermost and lowermost marginal line of the thyroid lamina. The
numerals represent the length proportion
Projection of the Anterior Commissure 63

Table 5.1. Projection of the anterior commissure

Minimum (mm) Maximum (mm) Mean (mm) Variance

Male
a 15.5 20.0 18.1 1.82
b 8.5 13.5 11.2 2.21
c 7.0 11.0 8.6 2.18
d 7.5 11.0 9.5 0.82
d-c -2.0 3.0 0.8 1.70
d/c 0.82 1.4 1.1 0.020
Female
a 11.0 15.5 13.3 1.12
b 5.0 10.0 7.3 1.38
c 5.5 7.5 6.5 0.29
d 5.5 8.5 6.8 0.62
d-e -1 1.5 0.4 1.35
d/c 0.85 1.21 1.1 0.0079

die Male cases Female cases

0.80-0.84 2
0.85-0.94 2 2
0.95-1.05 5 9
1.06-1.15 7 5
1.16-1.25 10 7
1.4 1

d-c (mm) Male cases Female cases

-2 2
-0.5--1 3 2
0 2 8
0.5- 1 9 11
1.5-2.0 10
3.0 1
64 Anatomy for Laryngeal Framework Surgery

Fig. 5.3. Lateral view of the thyroid cartilage. The level of the vocal cord is indicated by
line i. It is parallel to the transverse line drawn at the lower margin of the thyroid ala so as
to cross the inferior thyroid tubercle. h transverse length at the level of the thyroid inci-
sure, i transverse length at the level of the vocal cord, k distance between the median line
and the point where the cricoid crosses the lower margin of the thyroid cartilage, j dis-
tance between the lower margin of the thyroid ala and the tip of the lower horn, I distance
between the lower margin of the thyroid ala and the uppermost level of the cricoid

5.2 Projection of the Upper Surface of the Vocal Cord

The projection line for the vocal cord (upper surface), starting from the prede-
termined anterior commissure point, runs parallel to the transverse reference
line drawn at the lower margin of the thyroid ala so as to cross the inferior
thyroid tubercle, as shown in Figs. 5.3,5.4. Minnigerode (1955 14 ) described the
vocal cord projection as lying on the lower two-fifths' line of the distance be-
tween the uppermost and the lowermost marginal lines of the thyroid lamina, as
in Fig. 5.2. Note that the lower reference lines are different between the above
two methods. Furthermore, since Minnigerode does not specify the level of the
vocal cord as either the upper surface or the core, comparison between the two
results seems impossible.
Thyroid Cartilage 65

Fig. 5.4. Projection of the vocal cord.

The level of the vocal cord is indicated
by 3 needles. The broken line below
shows the lower margin of the thyroid
ala as defined in the text and in Fig. 5.3

5.3 Thyroid Cartilage

A sex difference is notable in the size, angle, prominence, thickness, and cal-
cification of the thyroid cartilage. Figure 5.5 shows the cross section of the larynx
at the level of the vocal cords. As is well-known, the angle between the thyroid
laminae is sharp in men and rather obtuse in women. If we define the angle as
that formed by two lines, each of which represents the middle third of the thy-
roid lamina at the level of the vocal cord (Fig. 5.5), the angle ranges from 58° to
88° with a mean of 74° in men, and from 80° to 100° with a mean of 90° in women
(Table 5.2).
Maue and Dickson (1971 14 ) reported that the mean transverse size of the
thyroid cartilage was 36.99 mm in men and 29.11 mm in women. In my mea-
surements , the transverse size of the thyroid lamina was represented by the
two shortest distances, each at different levels, hand i (Fig. 5.3). The mean
value for h was 40.3 mm in men and 30.6 mm in women (Table 5.3), while that
for i was 36.9 mm and 27.9 mm, respectively. These data seem to coincide fairly
well with those of Maue and Dickson.
Briefly, the male thyroid ala is wider by about 1 em than the female, implying
clinically a more difficult approach to the muscle process, or inside the lamina
from behind, in men.
66 Anatomy for Laryngeal Framework Surgery

Fig. 5.5. Cross section of the larynx at the level of the upper surface of the vocal cords.
The angle (e) between the thyroid laminae is defined as that formed by two lines, each of
which represents the direction of the middle one-third of the thyroid lamina at the level of
the vocal cords. [, g membraneous and cartilageous portions of the vocal cord respective-
ly; v, w, w'the position of the muscle process in relation to thyroid ala. These data of
distances become less significant during surgery because of rotation of the larynx by re-
traction

Table 5.2. Angle between the thyroid alae (e)

Minimum Maximum Mean Variance
Male 75.25
Female 32.54

The thinckness differs according to the location of the thyroid cartilage (Fig.
5.6; Table 5.4). In cutting the thyroid cartilage, information on the thickness at
different sites is helpful in preventing an inadvertent incision into the inner
perichondrium. If a piece of cartilage is used as a wedge during the operation,
details on the thickness are also useful in judging the site from which the piece
should be taken.
At the upper margin level, the thickness increases posteriorly, reaching a max-
imum at the oblique line (d in Fig. 5.6; Table 5.4). At the vocal cord level, the
cartilage also becomes thicker posteriorly, in both men and women.
Thyroid Cartilage 67

Table 5.3. Thyroid ala and inferior horn

Minimum Maximum Mean (mm) Variance

(mm) (mm)
Male
I 30.0 45 .0 40.3 9.75
h
r 38.0 44.0 40.6 3.67
28 .5 41.5 36.9 6.59
r 34.0 43.5 37 .1 3.85
6.0 13.0 8.8 2.24
r 5.0 12.0 8.6 2.17
Female
I 27.0 34.5 30.6 2.41
h
r 27 .5 33.5 30.3 2.93
25.25 32.0 27.9 2.83
r 24.0 32.0 28.0 3.51
5.5 11.0 7.6 1.85
r 5.0 11.0 7.6 1.59
The transverse distance measured at the level of hand i in Fig. 5.3 and the vertical length
of the inferior horn j

Fig. 5.6. The sites where the thickness of the thyroid cartilage was measured. Thickness
of the thyroid lamina increases posteriorly (see Table 5.4). The upper line indicates the
level of the thyroid incisure (a), and the lower one that of the vocal cord. c,fthe middle
of the upper and lower transverse lines; d, g along the linea obliqua; h, i see Table 5.4
 0'\
Table 5.4. Thickness of the thyroid ala 00

Male Minimum Maximum Mean Variance Female Minimum Maximum Mean Variance
(mm) (mm) (mm) (mm) (mm) (mm)

a I 1.75 3.50 2.46 0.28 a I 1.50 2.70 1.85 0.16

r 1.75 3.55 2.31 0.28 r 1.25 3.00 1.89 0.22
b 2.00 3.90 2.68 0.19 b 1.50 3.00 2.16 0.15
r 2.00 3.25 2.67 0.13 r 1.50 3.00 2.19 0.17
c I 2.00 3.80 2.77 0.19 c I 1.50 3.25 2.30 0.18
r 2.25 3.40 2.77 0.14 r 1.75 3.85 2.41 0.26
d 3.00 5.00 3.79 0.42 d 2.50 4.50 3.29 0.25
r 2.50 5.00 3.76 0.41 r 2.50 4.00 3.34 0.24
e I 1.50 4.00 2.23 0.54 e I 1.00 2.35 1.71 0.14
r 1.50 4.10 2.27 0.46 r 1.00 2.15 1.70 0.11
f 1.25 4.00 2.82 0.39 f 1.50 3.15 2.28 0.16 :>
r 2.00 4.00 2.96 0.32 r 1.50 3.25 2.36 0.19 ~
=
...
0
g I 2.25 4.90 3.55 0.49 g 2.25 3.90 3.14 0.18 S
r 2.50 4.85 3.64 0.40 r 2.50 4.50 3.32 0.31 '<

h 1.5 3.0 2.09 0.15 h 1.0 3.0 1.83 0.32

...8'
t'"'
~
2.5 5.0 3.34 0.41 2.3 4.5 3.02 0.38 ...
'<
(JQ
=
G
Thickness ofthe thyroid lamina increases posteriorly, reaching a maximum at the oblique line (d). The h denotes the thickness of cartilage at e:.
the anterior commissure, while the i signifies the thickness of cartilage and soft tissue there
...'Tj
~
S
G
~
...0
:00;'
til
...s::
(JQ
...G
'<
Projection of the Cricoid Cartilage on the Thyroid Lamina 69

5.4 Projection of the Cricoid Cartilage on the Thyroid Lamina

The cricoid cartilage lies just behind the lower posterior portion of the thyroid
lamina. Thyroplasty type I, fenestration, which aims at shifting the vocal cord
medially, would be obstructed by the presence of the cricoid cartilage, if it were
made too far posteriorly.
The manner of overlapping of the two cartilages may be defined by two points
(Fig. 5.7): (a) where the two cartilages overlap at the lower margin of the thyroid
cartilage, and (b) where the cricoid cartilage projects over the thyroid cartilage
at the posterior margin. To locate these two cross points, measurements were
made of k, a horizontal distance from the median point and I, a vertical distance
from the horizontal line drawn on the lower margin of the thyroid lamina (Fig.
5.7; Table 5.5). At the lower margin (horizontal line) of the thyroid cartilage,

Fig. 5.7. Projection of the cricoid cartilage

on the thyroid lamina. Marks a and b de-
note the points where the cricoid overlaps
the thyroid at the lower and posterior mar-
gin of the thyroid respectively. j, k, I see
Fig. 5.3

Table 5.5. Projection of the cricoid cartilage on the thyroid ala

Minimum Maximum Mean Variance

(mm) (mm) (mm)
Male
k 10.0 18.5 13.6 4.72
I 7.0 11.0 8.6 1.08
Female
k 7.5 18.0 11.0 9.45
I 4.0 9.0 7.0 1.69
70 Anatomy for Laryngeal Framework Surgery

the cricoid cartilage starts to overlap the thyroid cartilage at a point about 11-13
mm, on average, from the median line. If the window is too posterior, it cannot
effectively be pressed inward due to obstruction by the cricoid cartilage.

5.5 Cricoid Cartilage

The measures for various distances on the cricoid cartilage are shown in Fig. 5.8
and Table 5.6. The mean A-P external diameter (J in Fig. 5.8) is 24.5 mm in men
and 21.6 mm in women, while the mean transverse external diameter is 28.2 mm
for men and 22.5 mm in women.

Fig.5.S. Lateral view of the cricoid cartilage.

The distance Fis usually less than 1 cm. Slight
prominence P may be misjudged as the muscle
process on finger palpation during surgery

Table 5.6. Cricoid cartilage measurements

Minimum Maximum Mean Variance
(mm) (mm) (mm)
Male
J 21.5 26.5 24.5 1.86
K 22 28.0 24.0 1.82
L 26.0 31.0 28.2 3.27
F 6.0 11.5 8.8 1.33
Female
J 18 26 21.6 4.66
K 18.5 24.5 21.6 3.69
L 19.0 29.5 22.8 6.84
F 5.0 11.0 7.3 2.30
J anteroposterior external diameter, K height, L transverse external diameter, F distance
from the upper corner of the cricothyroid joint to the lower corner of the cricoarytenoid
joint surface
Cricoarytenoid Joint 71

Fig. 5.9. The cricoarytenoid joint. The

joint surface is cylindrical, permitting
rocking and sliding motions

5.6 Cricoarytenoid Joint

Snell's description (1947 14 ) of this join surface as a cylinder seems to be sup-
ported by many researchers (Sonesson 1959 14 ; Frable 1961 14 ; von Leden and
Moore 1961 14 ; Maue and Dickson 1971 14 ; Takase 1964 14 ; Dickson and Maue-
Dickson 1982 14). Although the joint movement consists of rotation (rocking)
and sliding, judging from the anatomical structure of the joint the main motion
would appear to be a rocking motion around the long axis of the cylinder (Fig.
5.9). From the motion, it is quite conceivable that the vocal process or vocal cord
moves down on adduction and up on abduction.
The distance from the upper corner of the cricothyroid joint to the lower
corner of the cricoarytenoid (F in Fig. 5.8) was 8.8 mm on average (range 6.0-
11.5 mm) in men, and 7.3 mm (range 5.0-11.0 mm) in women. This distance of
just less than 1 cm is a useful guide in locating the muscle process.
The joint surfaces are different in shape and area between the arytenoid and
cricoid sides. The data of Maue and Dickson and ourselves appear to be fairly
similar and are presented in Table 5.7. The cricoid side is oval convex (cylindri-
cal), while the arytenoid side is round concave. All the literature referred to
above is consistent with the longitudinal axis of the cricoid joint surface being
much longer than that of the arytenoid surface and the transverse axis of the
cricoid surface being shorter than that of the arytenoid.
72 Anatomy for Laryngeal Framework Surgery

Table S.7. Joint surface size of the cricoarytenoid joint (mean value in mm)
Maue and Dickson Ourselves
Male Female Male Female
Cricoid articular Longitudinal
facet length 7.38 6.07 7.36 6.18
Transverse length 4.48 3.73 3.86 3.43
Arytenoid Longitudinal
articular facet length 5.68 5.00 5.23 4.41
Transverse length 5.75 4.52 5.59 4.46

TableS.8. Distance in mm between the muscle process and the vocal process
Minimum Maximum Mean
(mm) (mm) (mm) Variance
Male 12.0 17.0 14.1 1.83
r 13.0 17.0 14.8 1.59
Female 9.5 14.75 11.6 1.51
r 9.75 14.5 12.2 2.63

5.7 Muscle Process

The muscle process is located almost at the level of the vocal cord projection
(Fig. 5.3). The topographical relations between the posterior margin of the
thyroid ala and the muscle process (V, W, W in Fig. 5.5) cease to be important
during an operation because the posterior margin must be lifted by a hook to
secure access to the muscle process.
The distance between the muscle process and the vocal process has surgical
significance, especially when Woodman's operation to lateralize the arytenoid,
arytenoidectomy, or arytenoidopexy must be performed safely without entering
the airway. It is 14.1 mm on average (12-17 mm) in men, and 11.6 mm (10-15
mm) in women (Table 5.8). The corresponding values obtained by Maue and
Dickson (1971 14 ) are 14.33 mm and 10.52 mm, respectively.

5.8 Asymmetry of the Thyroid Cartilage

The thyroid cartilage often manifests marked asymmetry especially in men (Fig.
5.10). In one extreme example, the transverse length h was 45 mm on the left
and 39 mm on the right. In female examples in our series, the largest difference
was only 3 mm. Despite the great asymmetry noted in some calcified thyroid
cartilages, the vocal cords in cadavers showed no notable asymmetry. This
would indicate that there is some limitation in estimating the state of inner struc-
tures from the outer cartilage framework.
Soft Tissue Behind the Thyroid Cartilage 73

Fig. 5.10. Asymmetrical thyroid

alae

In our clinic, asymmetry in laryngoscopic findings was also occasionally en-

countered, e.g., glottal axis deviation with bilateral good vocal cord mobility, or
asymmetrical bulging of the false vocal cord without any local lesion. Glottal axis
deviation can occur as a symptom of unilateral paralysis of the cricothyroid
muscle-deviation of the arytenoid region toward the paralyzed side. In most
cases of glottal axis deviation, however, the lesion responsible for the deviation,
e.g., cricothyroid muscle paralysis, cannot be found.
Unilateral protrusion of the false vocal cord may result from inward depres-
sion of the ipsilateral thyroid ala, especially when the thyroid cartilage is at a
sharp angle. Honjo et al. (1985 14) demonstrated such a situation in ten patients
using CT.
The effect of an asymmetrical framework on the vocal cords requires further
investigation, especially in connection with glottal deviation and soft tissue
asymmetry.

5.9 Soft Tissue Behind the Thyroid Cartilage

As illustrated in Fig. 5.5, the soft tissue behind the thyroid cartilage is thin near
the anterior commissure compared with the posterior portion. This implies that
surgical intervention around the anterior commissure should be avoided if possi-
ble so as to prevent accidentally entering the airway. The soft tissue behind the
anterior portion of the cricoid cartilage is even thinner.

5.10 Summary
The projection of the anterior commissure on the thyroid cartilage is most fre-
quently found slightly (1 mm or less) higher than the middle point between the
74 Anatomy for Laryngeal Framework Surgery

Fig. 5.11. Life-size models of the larynx

Interarytenoid muscle

Muscle process

Thyroarytenoid muscle

Cricoarytenoid mucle

~ Posteeioe ceicoarytenoid
muscle

Recurrent Jaryngoal
nerve

Thyroid cartilage

Fig. 5.12. Fresh excised larynx inside the thyroid ala

Summary 75

thyroid notch and the lower margin of the thyroid cartilage, though the indi-
vidual variation is great: ±2.5 mm in men and ±1.5 mm in women. The upper
surface of the vocal cord is projected roughly to the line which, starting from the
extension of the anterior commissure, runs parallel to the "horizontal" line at
the lower margin of the thyroid lamina, as in Fig. 5.3. The muscle process is also
at the same level as this projection line of the vocal cord.
The cricoarytenoid joint with a cylindrical joint surface is characterized by a
motion that consists of (a) rocking around and (b) sliding along the long axis of
the cylinder. On the cricoid cartilage, the lower corner of the cricoarytenoid
joint surface is situated less than 1 cm (8.8 mm on average in men and 7.3 mm in
women) from the upper corner of the cricothyroid joint surface. Asymmetry of
the thyroid cartilage is fairly frequent and severe, especially when the calcifica-
tion is advanced. Therefore, estimating the position of the inner structure from
the outer framework is of limited precision. The soft tissue behind the thyroid
lamina is thin near the anterior commissure, and surgical intervention should if
possible be avoided in this area.
For surgical performance, it is important to have a clear three-dimensional
image of the laryngeal cartilages at each step, to see whether they are twisted or
rotated for instance. Life-size models of the laryngeal cartilages were made to
answer this problem (Fig. 5.11). Their contours should be memorized through
not only visual but tactile sensation as well. The anatomy of the intrinsic
laryngeal muscle and recurrent laryngeal nerve inside the thyroid ala is shown
with the use of fresh excised larynx (Fig. 5.12).
6. Medial Displacement of the Vocal Cord

In 1911, Briinings15 first described a method of narrowing the glottal chink by

paraffin injection in cases of unilateral recurrent nerve paralysis. Despite his
success, this method was abandoned for a long time, probably because of the
adverse side effects such as paraffinoma. Recently, Arnold (1962 15 , 19642 ) and
many others revived this approach with new synthetic materials such as Teflon,
tantalum powder, and silicone (Fig. 6.1).
In 1915, Payr 15 , using a transverse, V-shaped incision in the thyroid cartilage,
made an anteriorly pedicled cartilage flap, which was then depressed inward to
displace the vocal cord medially. Probably because of the pedicle, the effect was
limited, and the technique did not gain popularity.
Seiffert (1942 15 ) pointed out four disadvantages of the Payr method: The car-
tilage is fragile and not easy to handle especially when calcified; the degree of
displacement is difficult to determine; fixation of the cartilage at a desired posi-
tion is uncertain; and the surgical intervention required is fairly great. As an
implant to be inserted inside the thyroid cartilage, Seiffert utilized a rib cartilage
piece taken from a fresh cadaver. It was fabricated to 25 mm long and 5-6 mm
thick for men and 20 mm x 4-5 mm for women. Under local anesthesia, the
thyroid cartilage was holed anteriorly by a burr to insert the cartilage piece at the
level of the vocal cord, according to him 7-10 mm above the lower margin of the
thyroid cartilage.
Meurman (1952 15 ) also utilized a cartilage implant for medialization of the
vocal cord. The implant, which was taken from the costal rib, was inserted be-
tween the thyroid cartilage and inner perichondrium. Opheim (1955 15 ) used an
incised segment of the thyroid cartilage instead, and this was placed inside the
inner perichondrium at the level of the vocal cord. In a case of unilateral vocal
cord paralysis complicated by an aspiration problem, Parker (1955 15 ) inserted
cartilage pieces taken from the anterior portions of the thyroid cartilage into the
space created between the soft tissue of the larynx and the thyroid and cricoid
cartilages. Smith (1972 15 ) utilized a cartilage piece taken from the upper portion
of the contralateral thyroid ala. Sawashima et al. (1968 15 ) inserted an incised
segment of the thyroid cartilage between the thyroid ala and inner perichon-
drium through an anterior vertical incision of the ala. Kamer and Som (1972 15 )
inserted a piece of the thyroid cartilage from the lower rim of the thyroid cartil-
age in cases of traumatic vocal cord paralysis.
78 Medial Displacement of the Vocal Cord

Fig. 6.1. Payr's operation. An anteriorly pedicled cartilage flap is produced and de-
pressed inward to medialize the vocal cord

Tucker (1979 15 , 1983 15 ) described a method of inserting a piece of cartilage

taken from the ipsilateral upper margin of the ala into a pocket produced be-
tween the inner perichondrium and the cartilage at the level of the vocal cord
(Fig. 6.2). The proposed route was cleared from above the place where the
cartilage was taken by advancing the elevation of the inner perichondrium from
the cartilage down below the level of the vocal cord.
Morrison (1948 15 ) described a surgical technique called the reverse King
operation, which displaces the arytenoid cartilage toward the midline along the
partially removed posterior superior border of the cricoid cartilage under gen-
eral anesthesia. Kressner (1953 15 ) proposed the "mediovertical fixation" tech-
nique for unilateral vocal cord paralysis especially when attended by a level dif-
ference between the two cords, namely the insertion of two cartilage pieces, one
for medial shift of the paralyzed vocal cord, and the other smaller piece into
the cricoarytenoid joint space to lift the arytenoid. Westhues (1973 15 ) utilized
the above technique in 12 patients with satisfactory results. Denecke (1964 15 )
devised a surgical procedure for unilateral vocal cord paralysis, in which the
cricoarytenoid tendon is divided and the arytenoid displaced medially and su-
tured in position against a wedge taken from the posterior edge of the thyroid
cartilage.
Montgomery (1966 15 ) reported cricoarytenoid arthrodesis through a thyro-
tomy approach, in which the arytenoid cartilage is fixed to the cricoid cartilage at
the new position with a pin. Miindnich (1970 15 ) pulled the arytenoid cartilage
 79

c d
Fig. 6.2a-d. Tucker's operation. A cartilage piece which is removed from the upper
portion of the ala is shaped to a wedge and transplanted between the cartilage and the
inner perichondrium to displace the vocal cord towards the midline

toward the lower horn of the thyroid cartilage and sutured it in treating dyspho-
nia due to unilateral vocal cord paralysis. In experimental animals, Bernstein
and Holt (1967 15 ) corrected the abducted position of the paralyzed vocal cord by
transposition of the sternohyoid muscle.
All these methods which have been previously reported appear to be effective
in reducing or eliminating a large glottal chink without the adverse effects of
foreign body injection. The disadvantage is the inability to carry out fine intra-
operative adjustment to the voice. The major interventions inside the ala that
are required in most of those operations actually make fine intraoperative con-
trol impossible.
80 Medial Displacement of the Vocal Cord

II

III IV

Fig. 6.3. Four types of thyroplasty. Type I medialization of the vocal cord; type II
lateralization; type III relaxation (A-P shortening); type IV stretching (cricothyroid
approximation)
Teflon Injection Versus Laryngeal Framework Surgery 81
,...r--------
:' I I

,
: I I

:. :::.::::::...?I
I : I

Fig. 6.4. Prototype thyroplasty type 1. A shim is used. At present, a plug type is pre-
ferred for window fixation (see Fig. 6.22)

In 1974, Isshiki et aP5 proposed various types of thyroplasty as a treatment

for dysphonia (Fig. 6.3). Thyroplasty type I, medial shifting of the vocal cord by
pressing inward a window in the thyroid ala, was successfully utilized for uni-
lateral vocal cord paralysis or vocal cord atrophy (Isshiki et al. 1975 15 ) (Fig. 6.4).
Koufman (1986 15 ) also reported success in the use of medial displacement of the
paralyzed vocal cord by means of the window displacement.
For medialization of the paralyzed vocal cord, Kleinsasser et al. (1982 15 ) pre-
ferred surgical medialization-either subperichondrial cartilage implantation or
thyroplasty type I which they named wing door thyroplasty-to Teflon injection.
The results in 19 patients showed an obvious improvement with regard to voice
and aspiration. There were no complications.
Wendler et al. (1984 15 ) successfully utilized thyroplasty type I for unilateral
vocal cord paralysis with dysphonia. Lee et al. (1986 15 ) performed a variety of
thyroplasties in 81 patients with voice disorders including sulcus vocalis (41),
unilateral vocal cord paralysis (21), spastic dysphonia (3), and others. The
general success rate was 88%. They modified the method for fixing the cartilage
window in decompression by using a network suture to replace a silicone shim
(Figs. 6.23, 6.24). In China, Wang, et a. (1968 15 ) reported excellent results of
various thyroplasties in 157 cases of voice disorders.

6.1 Teflon Injection Versus Laryngeal Framework Surgery

Cordal injection of Teflon is the most popular surgical technique used for dys-
phonia due to unilateral vocal cord paralysis. The results are generally good.
Lewy (1976 16 ) in his mass survey on the results of Teflon injection reported that
improvement of the voice was obtained in over 90%. The possibility of carci-
nogenesis of this material has been almost completely ruled out now after over
20 years of clinical use (Kirchner et al. 1966 16 ; Stone et al. 197016 ; Boedts et al.
1967 16 ; Harris and Hawk 1969 16 ).
The greatest advantages of cordal injection are its surgical simplicity and the
satisfactory results obtained in most cases. There are a number of disadvantages,
though, with the technique. It may migrate into the nearby tissues such as the
82 Medial Displacement of the Vocal Cord

cricothyroid membrane, thyroid gland, or subcutaneous neck region (Stephens

et al. 197616). Based on the histological finding of the larynx after Teflon in-
jection, Schmidt et al. (1980 16) state that the anterior region including the
cricothyroid membrane represents a major point of weakness in the laryngeal
structure. The technique is very delicate and extremely difficult. Overdosing by a
fraction of a drop or using the wrong injection site may deteriorate the voice.
The results are unpredictable before injection, and intraoperative adjustment of
the injection to the voice is impossible. To make matters worse, it is thought to
be irreversible. The injected material can be removed through intracordal inci-
sion or safely with the use of laser (Koch et al. 1987 16), but it leads inevitably to
scar formation. Among these problems, inaccessibility of the intraoperative
adjustment and irreversibility of the technique would matter most. Kresa et al.
(1973 16 ) inserted a fine, stick-shaped implant of hydrophilic gel, Hydron, into an
atrophic or paralyzed vocal cord with satisfactory results. Recently, injectable
collagen has been used (Page 178).
The greatest advantage of laryngeal framework surgery is that the surgical
procedure is adjusted to obtain the best voice, so there can be no failure. The
largest disadvantage is the cervical skin incision. It also requires some basic
knowledge on voice physiology, surgical expertise, and utmost care.

6.2 Motivation for and Classification of Laryngeal Framework

Surgery

About 15 years ago, a young man who practised karate came to my clinic com-
plaining of asymmetrical prominence of the Adam's apple. His voice sounded
entirely normal, and laryngoscopic examination revealed a twisted larynx but
perfect closure of the glottis. Manual attempts to correct the twisting temporari-
ly induced less deformity but severe hoarseness. Simple shaving of the promi-
nent portion proved to be sufficient to satisfy the patient. However, this patient
gave me the idea that in converse manner to this case deliberate deformation of
the laryngeal framework may improve the voice in certain patients. In an
attempt to assess the effect of various deformations on the voice, experimental
work was carried out using canine and human excised larynges.
From the functional viewpoint, the effects could be classified into four types:
(a) medial displacement (medialization), (b) lateral displacement, (c) shortening
(relaxation), and (d) elongation (stretching) of the vocal cords (Fig. 6.3). The
first type, as achieved by surgical deformation of the thyroid cartilage, was desig-
nated thyroplasty type I.

6.3 Thyroplasty Type I (Medialization)

6.3.1 Principle and Indications

To displace the vocal cord medially, a portion of the thyroid ala at the level of
the vocal cord is moved inward. The indications for this type of surgery include
unilateral vocal cord paralysis and vocal cord atrophy or bowing, sometimes
Thyroplasty Type I 83

Fig. 6.5. Manual compression test

combined with sulcus vocalis.

In deciding whether this procedure is indicated, besides general physical tests,
the essential examinations are voice recording, laryngoscopic examination,
preferably with the combined use of fiberscopy and video recorder, and a man-
ual test (see below). Optional examinations include auditory assessment of the
hoarse voice, pneumotachographic examination, stroboscopic examination,
tomography and CT.
In the case of vocal cord paralysis, the first step is of course to search for the
pathological entity responsible. If no treatments of the original disease were
indicated for the paralysis, this should be followed up for at least 6 months to see
whether any change in the paralysis or voice occurs. Should the contralateral
cord have a high potential risk of paralysis, there is no indication for such
surgery. In patients under 10 years of age, the effect of surgery on cartilage
growth should be taken into account, though we have not experienced any such
surgical cases.
The manual test is extremely useful in predicting the outcome of surgery and
helping the patient understand the manner of operation that will be carried out
(Fig. 6.5). When the thyroid alae are compressed medially at various sites, any
change thereby induced in the voice and larynx can be thoroughly assessed.
More specifically, the thyroid alae are repeatedly compressed toward the mid-
line by the thumb, index, and middle fingers with varying force at different sites
near the anterior-middle third to middle portion of the ala around the level of
the vocal cords. The changes induced by the procedure are best recorded on
videotape. If much improvement is brought about by the procedure, the patient
can be assured of a good prognosis with the voice after surgery. If not, there are
five main possibilities to explain the lack of a significant change: (a) inadequate
manual compression-wrong site or inadequate force; (b) the thyroid cartilage
is too stiff to be manually deformed due to calcification as is often the case in
older men, (c) other problems are involved, including rheological changes (too
stiff) of the vocal cord as in sulcus vocalis or atrophy and possible pathological
84 Medial Displacement of the Vocal Cord

changes in the contralateral vocal cord; (d) inadequate manner of phonation due
to pain from manual pressure; and (e) too wide a glottal chink during phonation.
Special attention should be paid to whether such pathological conditions as sul-
cus vocalis, atrophy, bowing, and stiffening after Teflon injection are also in-
volved, either ipsi- or contralaterally. The patient should be informed that with
such a complication, surgery may not be able to restore the voice to normal,
though some improvements can be expected. If scarring or stiffening of the vocal
cord rather than imperfect closure of the glottis is the prime factor in a breathy
voice, the prognosis is poor, and there may be no indication for surgery.

6.3.2 Premedication

Usually, a subcutaneous injection of atropine sulfate and the administration of a

tranquilizer are sufficient premedication for thyroplasty type I. With the effect of
atropine sulfate to dry the mucosa taken into consideration, it may not be ad-
ministered or minimized in dosis. Sedatives may be added during the operation
as needed.

6.3.3 Anesthesia

The patient lies supine with the neck extended; a pad is placed underneath the
shoulder. First, the surgical reference points, such as the cricoid cartilage and
thyroid notch or prominence, are identified by palpation and marked according-
ly. In women, the thyroid cartilage may lie rather high and the position of the
tracheal rings should also be confirmed to avoid confusion of the cricoid with the
hyoid. After marking the lower margin of the thyroid cartilage and the thyroid
notch at the midline, the midpoint between the two denotes the level of inci-
sion. Crossing the point, a line of incision is drawn horizontally, 4-5 cm in length
with a shift to the involved side (Fig. 6.6).
Local anesthetics, usually 10 ml 0.5% lidocaine with epinephrine, are infil-
trated subcutaneously. For later precise apposition of the incised skin edges, a
pair of points across the incision line are marked at several sites with an inked
needle. While waiting for the injected epinephrine to work as a vasoconstrictor,
the instruments are checked, and silicone shims, plugs, or plates of various sizes
maybe made.

6.3.4 Skin Incision and Exposure of the Thyroid Ala

The skin is horizontally incised, and the wound is widely opened by a retractor
or wound opener. After a vertical incision at the midline, the raphe of the strap
muscles, the connective tissue is bluntly separated laterally to expose the thyroid
ala. The vena mediana colli is identified and ligated prior to this procedure. The
strap muscle on the operation side is usually cut at least partially to provide a
wide surgical field.
Exposure of the laryngeal cartilage, at the level of supraperichondrial layer,
should extend from the thyroid notch above down to the lower margin of the
cricoid cartilage and cover two-thirds or three-quarters of the horizontal width of
the ala laterally.
Thyroplasty Type I 85

Fig. 6.6. Skin incision for thyroplasty

type I on the left

6.3.5 Design of the Window

After identifying the thyroid notch and lower margin of the thyroid cartilage, the
midpoint is marked as the supposed location of the anterior commissure , from
which a line is drawn horizontally to indicate the upper surface of the vocal cord.
The details have already been decribed in Chap. 5. If these landmarks are not
very clear due to a previous operation such as a laryngofissure or trauma, a fine
needle is inserted through the cartilage at the point inside which the anterior
commissure is supposed to be located, so that pernasallaryngofiberscopy can be
used to check whether or not the point is correct.
The vocal cord line constitutes the upper line of the rectangle. The anterior
vertical line should be about 5-7 mm from the median line of the thyroid cartil-
age (Fig. 6.7) because the most anterior portion of the vocal cord does not usual-
ly need to be displaced medially.
In addition, the soft tissue behind the cartilage is thin near the anterior com-
missure; it would appear to be better to avoid medial displacement of the car-
tilage fragment near the anterior commissure. If the glottal chink is notable
anteriorly, however , this distance (anterior margin) should be adjusted accord-
ingly to less than 5 mm .
The window should be 4-6 mm high and 8-14 mm wide, and should always be
large for a large thyroid ala. On average, the windows are 6 x 12 mm in men and
4 x 10 mm in women.
86 Medial Displacement of the Vocal Cord

Fig. 6.7. Design of the window. The anterior vertical line of the window is about 5 mm
apart from the median line. Direction of the upper transverse line of the window, which
corresponds to the upper surface of the vocal cord, must be carefully decided after iden-
tifying the line of lower margin of the thyroid ala as shown in Fig. 5.3. Too high a position
or a posteriorly upward shift of the window will result in unfavorable bulging of the false
vocal cord. The thickness of the ala cartilage varies with the location: it is thickest around
the posterior lower corner of the window and thinnest around the anterior upper corner.
The width of the rectangular drawn lines represents the thickness of cartilage there

Koufman (1986 15 ) proposed a formula to decide the window size:

. d h' h ( )
WIn ow elg t mm = thyroid alar height
4
(mm) -4

. d 'd h
WIn ow WI t = thyroid alar width
2
(mm) -4

The width of the window should also be adjusted, according to the width of
the anterior margin . If the margin is wide, the window should be smaller hori-
zontally. If a combination of thyroplasty type I and cricothyroid approximation
is anticipated , the window should be quite narrow and perhaps 3-4 mm high,
leaving more cartilage space caudally for the cricothyroid approximation proce-
dure.
If the window is located too high, this may result in bulging of the false vocal
cord. Excessive lateral extension of the window, however, would result in the
cricoid cartilage blocking the medial displacement of the window. If this obstacle
is noticed at the lateral corner while pressing down on the window, the width of
the window can be made smaller by means of another cut; in this way, the block
can be avoided.
Thyroplasty Type I 87

Fig. 6.8. Incision is made in the thyroid ala first with BP No. 11 blade

6.3.6 Cutting the Cartilage Window

In young or female patients, the cartilage is cut with a knife (BP No. 11) (Fig.
6.8); care has to be taken not to go too deep beyond the inner perichondrium.
The cartilage is always thin anteriorly. After a single cautious stroke, gentle
pressing on the window with a fine elevator reveals where the cut is not com-
plete, and another stroke can then be placed precisely on the site of the previous
cut (Figs. 6.9,6.10). The alternate incision and probing procedures are repeated
until the window is free of the frame.
In adult or male patients in whom calcification of the thyroid cartilage is ad-
vanced, cutting is done with a fine burr (Maillefer 700 or 699) (Figs. 6.11,6.12).
In some patients, the anterior portion is cut with a knife and the posterior one
with a burr. Again, the cut should not be made with a single stroke. The safest
way is to cut 80%-90% of the entire thickness, leaving a paper-thin layer for the
final cut with a very fine chisel, fine raspatory, or knife (Fig. 6.13). The alterna-
tive way to crack the last thin layer is to hammer a bone hemostatic chisel gently
at the window. If bleeding occurs during the procedure, an epinephrine-
impregnated small sponge is applied at the site for a short time. Thrombin pow-
der or hemostatic collagen or fibrin glue may be applied locally. The window
must be free enough so that when easily pressed medially the outer surface of the
window is level with or deeper than the inner surface of the frame. If resistance
is great, meticulous separation between the inner perichondrium and cartilage is
done along the frame to a width of about 2-3 mm with an elevator or triangular
knife, such as Rosen's instruments for cutting the external meatus or elevation of
the eardrum (Fig. 6.14).
88 Medial Displacement of the Vocal Cord

Fig. 6.9. Elevators for thyroplas-

ties, selected from the Rosen's in-
struments for stapes surgery

In practice, during the procedure , the inner perichondrium has to be cut at

least partially for the window to gain the latitude required, but it is important to
cut and undermine so as not to invade across the inner perichondrium.
Cutting only the cartilage without damaging the soft tissue inside may soon be
realized more easily by the use of an ultrasonic burr.

6.3.7 Adjustment of Medial Displacement of the Window

Before adjusting medial shift of the fragment, the patient is returned to a suit-
able posture for phonation with the pad removed. Complete freeing of the win-
dow from the cartilage frame is essential to carry out appropriate medialization
of the vocal cord. As the patient phonates, the mobile fragment is pressed
medially at various sites and with various forces so as to find the conditions
giving the optimum voice.
After complete freeing of the window from the cartilage frame, a flexible
fiberscope is introduced through the nostril to monitor laryngeal behavior. It
should be carefully examined to see whether there is any glottal chink or edema
Thyroplasty Type I 89

Fig. 6.10a, b. After cautious strokes of cutting with the scalpel, or with a burr in old
males, a window is pressed inward using an elevator to find where the cut is incomplete
90 Medial Displacement of the Vocal Cord

Fig. 6.11. In adult or older males in whom the cartilage is always partly calcified, a fine
burr, e.g., Maillefer 700 or 699 as shown here is required for precise cutting

Fig. 6.12. Cutting the cartilage must be made layer by layer by gentle moving of the burr
back and forth on the same line. The cut is better to be incomplete leaving the last
paper-thin layer uncut
 91

Fig. 6.13. The last thin cartilage layer is gently cracked with a fine chisel, a bone
hemostatic chisel, or a fine elevator

Fig. 6.14. After the complete cut , the margin of the window frame is separated between
the cartilage and inner perichondrium with a fine elevator. Never break through the inner
perichondrium
92 Medial Displacement of the Vocal Cord

of the involved vocal cord. Any change in the vocal cord shape in response to
pressing in the window at various sites is carefully watched on a video screen
connected to the fiberscope. This probing procedure, when practised in each
case, provides an accurate idea of the geographical correspondence between the
window and the vocal cord.
The optimal displacement of the window may not be parallel to the ala plane.
Accordingly, sometimes deeper posteriorly or sometimes anteriorly, a silastic
implant is individually fabricated.
Maximum phonation time can be a good indicator of the glottal condition,
especially the size of the glottal chink during phonation.
Cricothyroid approximation combined with medial pressing of the window is
another intraoperative test that should be carried out, especially in female pa-
tients. The lower margin of the cricoid cartilage is pushed up with an elevator or
flank of forceps. This certainly elevates the vocal pitch and the voice usually
sounds better, but it should also be borne in mind that cricothyroid approxima-
tion requires a higher subglottal pressure for phonation. It is necessary to ensure
that the patient has no greater difficulty with phonation.
Overcorrection never occurs in my experience, rather, over a long period of
time, undercorrection may sometimes become noticeable, probably because
of the vocal cord atrophy in progress. In the light of probable intraoperative
development of vocal cord edema, together with possible progressive atrophy,
slight overcorrection seems advisable. Details are described on Pages 102-104.
Most frequently, the posterior portion is depressed by 4-5 mm from the external
surface of the thyroid ala, while the anterior portion is depressed by 2-3 mm.

6.3.8 Fixation of the Window

There are several ways to fix the window at a desired position, with a shim
(wedge) or with a plug.

Silicone Shim (Wedge). The window is displaced more medially than the inner
plane of the thyroid ala by placing a shim, either made of an elastic solid silicone
or a cartilage piece taken from the upper margin of the ipsilateral thyroid ala.
For immobilizing the implant in place, the silicone implant has a middle square
projection that just fits in the window height (Figs. 6.15,6.16).
The thickness of the flange is designed according to the depth of the window to
be placed from the inner surface of the ala, but usually varies from 2 to 4 mm.
Since most of the solid silicone is to some extent pliable, the window may not be
medialized exactly as far as the thickness of the flange from the alar inner sur-
face; most likely it is less than that.
In order to make the medial displacement of the window as precise as desired,
the inner perichondrium should be sufficiently elevated from the cartilage
around the window frame. After being fitted in the window frame, the shim is
moved back and forth in search of the best place to put it while the patient
phonates.
For firmer placement of the implant, sutures may additionally be used, e.g., a
mattress suture through the silicone and cartilage or a simple overlying suture.
Thyroplasty Type I 93

Fig. 6.15. Fixation of the window with shim. A shim is made of silicone to fit the size of
the window and the desired depth of displacement of the window. This technique, though
simple to perform, cannot make fixation of the window so precise as the plug technique
can, because the shim tends to bend when inserted
94 Medial Displacement of the Vocal Cord

Fig. 6.16. Instruments and materials for fixing the window. A needle holder, small
curved needles, silicone shims, silicone block from which a shim or a plug is fabricated,
and a silastic tube outside an injection needle to be used for passing a suture through a
hole in the thyroid cartilage (see also Fig. 6.20). An aluminum needle, which is quite
pliable, may be used instead

Silicone Plug. The cartilage window can be fixed in an optimal position by a

silicone plug. This technique, though more time consuming than the shim tech-
nique, allows more delicate adjustment and secures more stability, especially
when the window frame is not strong enough to hold the shim. This occurs for
instance when the ala frame below the window is too thin and too narrow to hold
down the shim. The plug technique is utilized when a delicate depression pattern
of the window is required, e.g., anteriorly shallower and posteriorly deeper than
the alar inner surface. Plugs come in two basic forms, with or without flanges.
The first form has a projection and flanges on both sides (Fig. 6.17) The pro-
jection is exactly the same as the window in shape, and its depth is adjusted
according to the pattern of medialization of the window. The flanges are wide
and thick enough to tolerate the mattress suture and the possible outward coun-
terpressure from the window. Figures 6.17 and 6.18 illustrate the various ways of
suturing which fix the plug to the alar cartilage frame. One is a simple mattress
suture, the other is a special mattress suture passing through silicone, cartilage,
and silicone, permitting firmer and deeper fixation (Fig. 6.18).
The difficulty is in passing a suture near the edge of the window frame. For
calcified cartilage, after perichondrial elevation from the cartilage around the
window frame for about 2-3 mm, two to four holes are made by a very fine burr
under the protection of a fine elevator placed between the cartilage and
Thyroplasty Type I 95

Fig. 6.17. Fixation of the window by a plug with flange. This technique ensures firm
fixation of the window, though it is a little complicated and produces a small prominence
over the surface of the thyroid ala

Fig.6.18. Order of threading the

cartilage and silicone in the tech-
nique of plug with flange
96 Medial Displacement of the Vocal Cord

Fig. 6.19. Making a hole for threading a calcified cartilage. The site to be drilled must be
carefully selected, not too close to and not too far from the edge. Inadvertent breaking of
the edge of the window makes further surgical steps extremely difficult. The inner
perichondrium is protected with an elevator while drilling

perichondrium (Fig. 6.19). A 4-0 nylon suture is passed through the hole from
outside, taking great care not to break the hole, preferably with the use of an
aluminum injection needle with a bent tip (Fig. 6.20). Then it is passed through
the inward projection portion of the plug horizontally and again through the
other hole toward the outside. The two ends of the suture are fed through the
flange of silicone to make a mattress suture (Fig. 6.21).
The plug without flanges is made to the size that just fits in the window tightly
(Fig. 6.22). It is smaller and thinner than the one with flanges, and the technique
to fix the plug is simpler. The thickness is most frequently 3 mm anteriorly and
4-5 mm posteriorly. The plug is fixed level with the cartilage window frame with
1 or 2 nylon 4-0 sutures which pass through the holes made near the edges of the
window frame. The intraoperative impressions accumulated so far are that the
Thyroplasty Type I 97

Fig. 6.20. Passing a suture (4-0 nylon) through the hole. An aluminum or a silicone outer
tube of an instillation needle is used as a guide for the threading

Fig. 6.21. The plug with flange is fixed in place by mattress sutures
98 Medial Displacement of the Vocal Cord

1 !

. ~
. : : ..
, .~:

..... ,

a
Fig. 6.22a,b. Fixation by plug without flange. The plug is made to fit the window precise-
ly and tightly. The depth is adjusted to the desired displacement of the cartilage window,
most frequently 2-3 mm anteriorly and 4-5 mm posteriorly (a). Usually it is fixed with
the frame by two through-cartilage sutures, e.g., at the anterior inferior and posterior
superior corners. Superficial sutures which grasp the perichondrium and superficial por-
tion of the silicone may be added to supplement the above sutures. The other type of plug
with posterior wedge extension is used when medialization of the posterior portion of the
vocal cord is particularly required (b)

technique will provide firm and stable fixation of the window. This technique is
the one most frequently used at present.
The plug may have a thin posterior wedge-shaped extension (Fig. 6.22b)
which is put beneath the posterior portion of the cartilage window frame in order
to enhance medialization of the posterior part of the vocal cord.
Tbyroplasty Type I 99

Cartilage Shim or Plug. Although no complications with the use of silas tic im-
plants have been experienced so far, cartilage transplants are also used on occa-
sion. Silicone is not a single chemical product but is graded according to the
medical or industrial purpose. Unless the quality of silicone is warranted, the use
of cartilage is preferable. If the cartilage frame is thin and narrow inferiorly to
the window, or is less likely to tolerate the long-term pressure, a cartilage trans-
plant is advisable. The ala cartilage at the upper edge is thick enough (2-3 mm)
for this purpose, but it can be made thinner as needed. Fixation of the cartilage
transplant with nylon mattress sutures is essential. For calcified cartilage, two
pairs of fine holes have to be made by a burr. Cartilage is slippery and more
difficult to manipulate than silicone.

Other Methods. The use of fibrin glue is recommended for fixation by Wendler
because it is easy to handle, permits delicate control, and dispenses with many of
the complicated procedures. Whether or not it is firm enough against the re-
bound due to contracture remains to be seen in long-term follow-ups.
A cyanoacryl glue should, however, never be used due to complications such
as inflammation and excretion, which have been demonstrated in total ear re-
construction.
For fixation of the cartilage window, Lee et al. (1986 15 ) used the network
suture method: One or more sutures are passed through the cartilage window
frame, crossing from one corner to the opposing corner so that the window piece
is depressed (Fig. 6.23). They also utilized the perichondrium around the win-
dow as a pedicle flap to plug the window (Fig. 6.24).
A combination of medial shift and stretching of the vocal cord (thyroplasty
type I and cricothyroid approximation) is often indicated in vocal cord paralysis
caused by a central nervous lesion. There are various procedures to accomplish
this, but there is no one established technique. This is discussed in greater detail
in Chap. 9 after surgical methods elevating the vocal pitch are described.

6.3.9 Closure of the Wound

After confirming vocal improvement to the satisfaction of both the patient and
surgeons, the voice is recorded on a videotape together with the laryngeal
finding. Antibiotic powder may be locally applied, and the sectioned muscle
ends are sutured together. The incised skin edges are accurately brought
together with buried sutures (nylon 4-0) so that the corresponding marked
points come into exact apposition (Fig. 6.25). If the edges have been eroded by
the wound retractor or opener or appear rather convex in section, with protrud-
ing subcutaneous fat tissue, it is better to refresh or excise them by a marginal
fine incision. The approximated edges should be everted according to the
amount of redundant skin or age of the patient. More eversion is, of course,
needed in younger patients.
Finally, precise coaptation of the edge wound is done using 7-0 or 6-0 nylon
sutures. Slight compression of the wound with a small gauze pad covered by tape
is generally preferable to prevent hematoma or seroma.
100 Medial Displacement of the Vocal Cord

-L:....:..~---'-:---c:-'-':--':-:-'--:'-c-;'-:-;''-:'~
, :: : : : ', ' ." . ' . . ..

Fig. 6.23. Lee's network technique for fixation of the window. One or two sutures are
placed from corner to corner of the window to maintain the cartilage piece in the de-
pressed position

Fig. 6.24. Lee's perichondrium technique for fixation of the window. The perichondrium
around the window is elevated as a posteriorly pedicled flap, stuffed in the hollow of the
window, and fixed in level with the cartilage frame by sutures
Thyroplasty Type I 101

Resection

Fig.6.25a,b. Closure of the wound in layers:

muscle sutures, subcutaneous or partially
cutaneous buried sutures (4-0 nylon), and
adaptation sutures (6-0 or 7-0 nylon) b

6.3.10 Postoperative Care and Course

The patient, kept on complete vocal rest, is treated with antibiotics for a week.
Swelling of the vocal cord usually lasts for 2-3 weeks, during which time the
voice will be rather rough. A good normal voice at this postoperative time may
imply that some regression will occur as the swelling subsides. Figure 6.26 shows
the CT finding of the larynx after operation .
102 Medial Displacement of the Vocal Cord

Fig. 6.26. Postoperative CT

finding

6.3.11 Reversion of Voice

Some reversion of the voice can occur several or more months after medializa-
tion of the vocal cord. Possible factors responsible for this tendency include: (a)
gradual subsidence of the vocal cord edema caused by the operation; (b) con-
tracture of the scar tissue near the inner perichondrium of the thyroid cartilage;
(c) atrophy of the soft tissue inside the inner perichondrium due to a constant
pressure by the medialized cartilage window; (d) progressive atrophy of the
vocalis-thyroarytenoid muscle by denervation; (e) change in the position of the
cartilage window once fixed with shim.
From the findings in revision, which has been performed in three patients so
far, a change in the position of the cartilage window or the silastic implant can be
wholly denied. Most likely to be responsible for the regression is the progressive
atrophy of the muscle and perhaps other soft tissues.
In order to prevent the relapse of dysphonia a slightly excessive medialization
of the window at the time of surgery is recommended. The voice may sound
rather rough or pressed, but the fiberscopic finding that there is no glottal chink
during phonation should be more significant. The overcorrection results in a
rough voice which lasts for a couple of months, and this postoperative course
should be explained to the patient.

6.3.12 Complications

No complications such as dyspnea, stridor, or infection have ever occurred after

thyroplasty type I. In earlier attempts the cartilage piece was taken from the
upper edge of the contralateral thyroid ala, and livid red swelling of the intact
false vocal fold, probably due to hematoma, was noted in two patients. Sub-
Thyroplasty Type I 103

cutaneous seroma has thus far occurred in three instances, and it could be simply
remedied by puncture. Migration and extrusion of the silastic implant have not
been observed. Two patients with vocal cord paralysis whose vocal improvement
after thyroplasty type I had been unsatisfactory underwent additional arytenoid
adduction and gained an almost normal voice.
In three patients who had undergone thyroplasty type I, the second operation
was performed 1, 1.5, and 5 years after the initial operation, because of the
increased glottal gap during phonation.

6.3.13 Second Operation

Surgical Procedure. An incision is made on the previous incision line to expose

the window in the thyroid ala. The silastic material looks slightly dark through
the capsule formed over the window. After incision and elevation of the capsule,
the silicone implant is lifted up from the bottom with a fine respatrium and
removed without difficulty. The cartilage window piece at the bottom is further
pushed in to find the optimal depth for the voice. Usually it is easily mobile, but
when the thyroid cartilage is thick and ossified as in old men, and the postopera-
tive period will be long, a knife, fine chisel, or bone hemostatic chisel may be
required to cut a new osseous conncetion between the window and window
frame.
According to the depth of medialization required, a new silicone plug is made
precisely to fit in the window cavity. If the fitness is accurate, suture fixation of
the plug with the cartilage frame is usually unnecessary. The secondary readjust-
ment of medialization can be done in much shorter time and with much less
bleeding than the first operation.

Local Finding. In all of the three cases, the silastic implant was found to be quite
stable in the original position, covered with a thick firm capsule, without any sign
of inflammation. The pushed-in rectangular cartilage piece was not eroded at all
macroscopically.

6.3.14 Results of Thyroplasty Type I

The results of thyroplasty type I are exemplified by sonagrams (Fig. 6.27). Sig-
nificant improvements were obtained in all cases, but after over 1 year some
regression occurred in three cases and reenhancement of medialization by using
a different plug was performed with much improvement in the voice. The de-
tailed results will be reported separately.

6.3.15 Summary

This method of surgery features intraoperative adjustment of the procedure

according to the voice produced under testing. Vocal cord edema or swelling
should be minimized to make the tuning very accurate. Bleeding inside the inner
perichondrium must be avoided by all means. Every step of the surgical
procedure-cutting the window, undermining around the frame, displacement
 104 Medial Displacement of the Vocal Cord

KHz
8 -

7-
6-
5 -
4-
3-
2-
1-

0,
a 0
KHz
8-

7-
6-

5-
4-
3-

2- --
1 -

--_._---
_ _- _ _ - -_.c· - -c·
- - - - - - - - - - - - - - ------- -
--=-_~

-
0"1
b 0

Fig. 6.27a-f. Sonagrams of the voice before and after thyroplasty I, vowel [a]. a 54-year-
old male, left vocal cord paralysis before surgery, narrow-band sonagram; b after surgery;
c before surgery, wide band sonagram; d after surgery. e 27-year-old male, right vocal
cord paralysis, before surgery, wide-band sonagram; f after surgery

of the window, fabrication of a shim or plug, and its fixation-requires exper-

tise, skill, and the utmost care.
A very fine burr is necessary for cutting through calcified cartilage as precisely
as planned. Several standard silicone shims or plugs may be prepared for slight
modifications to match individual needs, which will save operation time. Most
frequently, however, a silicone plug is individually fabricated during operation.
Generally, slight overcorrection of the position of the paralyzed vocal cord is
desirable. The combined use of fiberscopy facilitates adjustment by providing
more information, especially when the voice does not become normal upon ini-
tial examination.
Thyroplasty Type I 105

KHz
8-
7-
6-

5 -

4-

3-

2 -

1 -

0-,-
0 C

KHz
8-
7-
6-

5 -

4-
3-
2-
1-

0 1
0 d

Fig. 6.27c,d

6.4 Vocal Cord Atrophy

Bowing or atrophy of the vocal cord is not so infrequent, especially in elderly
patients (Fig. 6.28). Such deformation results in a narrow, oval glottal chink
during phonation, producing a breathy, weak, and inefficient voice. Thyroplasty
type I (medialization through the window) is indicated also for such cases . Basi-
cally, the surgical technique is identical to that for vocal cord paralysis, but fur-
ther medial displacement of the window is usually required for the mobile vocal
cord to be slightly bulged or medialized than for the paralyzed cord. After the
unilateral procedure is finished, the voice and laryngoscopic findings should be
assessed to decide whether or not the contralateral procedure is also necessary.
As long as the vocal cords are mobile, there is almost no chance of dyspnea or
too much swelling of the vocal cord being induced by bilateral excessive
medialization.
 106 Medial Displacement of the Vocal Cord

KH.
8-
7-
6-
5-
4-

3-

2-
1 -

0-,
e 0
KH.
8 -
7-
6-
5-
4-

3-
2-
1 -

0-,
f 0

Fig. 6.27e,f

If the vocal cord is not only bowed but stiff as well, and possibly accompanied
by sulcus vocalis, a certain technique to reduce the tension of the vocal cord
should be attempted. More detail of the combined technique will be described in
Chap. 9.
The surgical effect on this type of dysphonia is frequently remarkable in the
ease with which the patient can phonate or in the vocal efficiency, more so than
in the quality of the voice. Phonosurgery will find wide application in the treat-
ment of the inefficient voice due to bowed or atrophic vocal cords.

Definition. There seems to be some objection to the use of the term vocal cord
atrophy without histological evidence of atrophy of the vocalis muscle . It has
been proposed that bowed vocal cord be used instead for such conditions. I feel
that atrophy is not necessarily a histological term but that it could be used clini-
Vocal Cord Atrophy 107

Fig. 6.28. Sulcus vocal is with

attendant vocal cord atrophy

cally on the basis of macroscopic findings, as hypertrophy is often used for what
looks larger than it is supposed to be.
Vocal cord atrophy does not necessarily mean atrophy of the vocalis muscle,
but of the mucosa, ligament, or connective tissue. Bowed designates a concave
edge of the vocal cord, whether the vocal cord mass appears small or normal in
size. Atrophy here means the condition in which the vocal cord appears thin. In
a strict sense, these two terms should be differentiated from each other, but since
in most instances the bowed vocal cord looks atrophic, they are used here as
synonyms, unless specifically stated.
Bowed vocal cord is often misunderstood as indicative of the reduced longitu-
dinal tension resulting from inactivity of the cricothyroid muscle. This hypoth-
esis seems to be based on the analogy of the dangling string loosely set between
two points.
Relaxation or reduced longitudinal tension of the vocal cord, however, never
produces a bowed edge but only shortens the vocal cord, in personal experience.
It may be compared to an extremely stretched rubber string, which would not
dangle even if slightly unstretched (Fig. 6.29).
The experimental basis is too weak to state conclusions, but it seems most
likely that the bowed state results predominantly from atrophy or mass reduc-
tion of the vocal cord and perhaps also from scar contracture inside the vocal
cord.
From this viewpoint, stretching of the vocal cord (AP elongation) does not
seem to be indicated, especially when the voice is high pitched.
The manual cricothyroid approximation will predict the outcome of the surgi-
cal AP elongation.
108 Medial Displacement of the Vocal Cord

(1)
-Unstretched -- (2) (3)

~f- ___
t _ _ _~

Fig. 6.29 Relaxation of the vocal cords such as in paralysis of the cricothyroid muscle
usually does not result in bowing, similar to the rubber string illustrated. A stretched
rubber string does not always dangle even when unstretched, if it is still equal to or longer
than the natural length (l) without being stretched. The vocal cords would not be bowed
even in paralysis of the cricothyroid muscle

6.5 Surgical Correction of Dysphonia Associated with Aging

One of the vocal characteristics associated with aging is the weak, breathy, and
quavering quality. The laryngeal finding for such a voice is usually bowed vocal
cords. Interpretation of the bowed state, whether due to atrophy or laxness of
the vocal cords, remains controversial.
Tucker (1988b 15 ) employed anterior commissure advancement for such dys-
phonia as mentioned above, but the results were poor when performed in elderly
patients. The surgical correction lasted only for a short period-7 months at the
longest. He ascribes the poor results to the characteristics of aging skin or mu-
cosa, i.e., a tendency to relax again after tensing. His results of the same surgery
employed in younger patients were much better in terms of the effective post-
operative period.
My understanding is that the bowing is more likely to result from atrophy than
from laxness, because the bowing does not emerge even in temporary paralysis
of the cricothyroid muscle induced by local anesthetics.
The results of a medialization operation (bilateral thyroplasty I) for bowing of
the vocal cords are excellent when it is performed in excess of medialization.
Regression of the symptom, however, can occur after 6 months, as in Tucker's
Arytenoid Adduction 109

cases. It may be interpreted that the relapse takes place as the edema subsides
and the scar tissue gradually contracts, both of which reduce the effect of
medialization of the vocal cords . Hence, in treating bowed vocal cords,
medialization should be done rather in excess in order to maintain the effect. If
both vocal cords are mobile, relatively excessive medialization does not threaten
the airway, even if carried out bilaterally.

6.6 Arytenoid Adduction

6.6.1 Indication-Advantages and Disadvantages

Surgical adduction of the arytenoid cartilage is indicated in unilateral vocal cord

paralysis with a breathy voice, especially when the glottal chink is large or the
paralyzed cord is fixed at a lateral position (Fig. 6.30). If the tomogram shows
the paralyzed vocal cord higher than the intact one (Fig. 4.14), arytenoid ad-
duction is preferable to thyroplasty type I. The advantage here is twofold: It
provides more effective adduction of the fixed cord than would be achieved by
thyroplasty type I, and it can correct any level difference that may be present
between the two cords. Due to the rotational motion around the long axis of
the cylindrical cricoarytenoid joint, a large glottal chink is more liable to be
associated with a higher position of the paralyzed cord.
The disadvantages of arytenoid adduction seem to be due mainly to technical
problems-difficulty in locating the muscle process and longer surgical time.

Fig. 6.30. Principle of arytenoid adduction. A large glottal chink during phonation result-
ing from unilateral vocal cord paralysis can be effectively eliminated or much reduced by
arytenoid adduction
110 Medial Displacement of the Vocal Cord

Fig. 6.31. Skin incision for arytenoid

adduction

However, these problems become less important once the techniques have been
mastered. I use arytenoid adduction very often, because of its reliability
obtained thus far without any complications. Arytenoid adduction is ineffective,
however, with bowed vocal cord. If this is further combined with paralysis, some
modification or the combined technique with thyroplasty type I is recommended
(Fig. 6.51).

6.6.2 Exposure of the Thyroid Ala

Techniques of preoperative sedation and local anesthesia are similar to those

used in thyroplasty type I. A skin incision is usually made horizontally at the
level of the vocal cord, but it extends 1 or 2 cm further laterally than in thyro-
plasty type I; however, this can be added later as required (Fig. 6.31). For expo-
sure of the posterior edge of the thyroid ala, usually more than half of the ster-
nohyoid muscle has to be cut. With a small hook, the posterior edge is retracted
anteriorly, and the attachment of the thyropharyngeal muscle near the posterior
edge is incised. Starting from this incision line the muscle is elevated supra-
perichondrially down to the posterior end of the thyroid ala (Fig. 6.32).

6.6.3 Dislocation of the Cricothyroid Joint

After reaching the posterior edge, the cartilage and the inner perichondrium
should be separated sharply (Fig. 6.33). This separation proceeds further down
to dislocate the cricothyroid joint. If the joint is located so inferiorly such that it
cannot be reached without damaging a great deal of the soft tissue, section of the
inferior horn near its root may be an alternative, if the joint surface on the
cricoid cartilage is identifiable. In the case of a transversely wide thyroid ala, as
often occurs in men, a vertical cartilage incision along the line, say, 1 cm anterior
Arytenoid Adduction 111

Fig. 6.32. Separation of the thyropharyngeal muscle from the thyroid ala

Fig. 6.33 The inner perichondrium is ele-

vated from the cartilage, starting at the
posterior edge. This procedure prevents
entering the airway

from the posterior edge may be advisable to facilitate access to the muscle pro-
cess (Fig. 6.34). Then the incised cartilage portion of the posterior edge should
be removed to secure a sufficiently large surgical field. Through this channel, the
muscle process of the arytenoid may be found higher and more posterior than
expected. A tiny prominence on the cricoid cartilage which lies caudal and ante-
rior of the cricoarytenoid joint has been misjudged on palpation as the muscle
112 Medial Displacement of the Vocal Cord

a b c

d e

Fig. 6.34a-e. Various modifications of the incision in the thyroid ala. For a wide ala as in
men, some short-cut approaches to the muscle process (b-e) are preferable

process (P in Fig. 5.8, C in Fig. 6.35). The superior horn, after isolation from the
surrounding soft tissue, is usually cut near its root to obtain greater rotation of
the larynx by retraction. Whichever procedure is used, either dislocation or up-
per incision of the inferior horn, freeing the cricothyroid joint is the first essen-
tial step. If a cartilage incision at the inferior horn or a vertical incision anterior
to the edge as in Fig. 6.34b, c, e is used, the cricothyroid joint surface, which is
an important signpost in locating the muscle process, should be clearly iden-
tified, perhaps by further soft tissue separation (Figs. 6.35, 6.36).

6.6.4 Approach to the Muscle Process

A sufficient field for locating the muscle process is now obtained by retraction
of the posterior edge (Fig. 6.37). The muscle process, hidden beneath the ap-
parently homogeneous muscle layer, is difficult to identify. There are four clues
to its localization. First, it always lies at the level of the vocal cord (Fig. 6.38).
The vocal cord projection line is therefore drawn as a reference line on the thyroid
ala down to the posterior edge, as described on Page 64. Second, the muscle
process is less than 1 em from the upper margin of the cricothyroid joint (Fig.
6.39). Third, it naturally lies on the upper ridge of the cricoid cartilage. Before
digging in or bluntly separating the muscle layer by an opening motion of the tips
of a pair of fine scissors, it is important to make sure that the cartilage is under-
neath by probing with a fine raspatory. If the surgeon cuts into the soft tissue
Arytenoid Adduction 113

Fig. 6.35. Oblique view of the cricoid cartilage with surrounding muscles. B cricothyroid
joint; C upper ridge of the cricoid cartilage; D cricoarytenoid joint (muscle process); Lat
lateral cricoarytenoid muscle; Post posterior cricoarytenoid muscle

Fig. 6.36. Dislocation of the cricothyroid joint

114 Medial Displacement of the Vocal Cord

Fig. 6.37. After dislocation of the cricothyroid joint, a wider surgical field inside the ala
cartilage is obtainable

Posterior sectioned edge

of the thyroid cartilage

Fig. 6.38. The muscle process is located at the level of the vocal cord (dotted line)
Arytenoid Adduction 115

Fig. 6.39. The distance between the up-

per margin of the cricothyroid joint and
the lower margins of the cricoarytenoid
joint is usually less than 1 cm in both men
and women

where there is no underlying cartilage, it is possible to enter the airway , which

would complicate the surgery by contamination. Fourth, if the surgeon palpates
the region carefully with an index finger, a tiny prominence about the size of a
small grain of rice will be felt (Figs. 6.40,6.41). The finger used for the palpation,
however, will completely block the view, and it is necessary to have a clear
impression of where the prominence is located before separation of the soft
tissue is started. The manner of retraction , which greatly affects the topogra-
phical relationship, should be maintained as constant as possible during the
procedure.
A large portion of the muscle fibers visible inside the thyroid ala belongs to the
posterior cricoarytenoid muscle . Tracing the convergent muscle fibers may be
helpful in finding the process in some cases.
The mucosa covering the pyriform recess is lower than the level of the muscle
process (Figs. 6.42-6.44). The elevated mucosa from the posterior crico-
arytenoid muscle, which separates the surgical field from the airway, is so thin
that it often moves to and fro in synchrony with the respiratory air flow . Probing
the muscle process should be started from below, from the circothyroid joint,
and not high above the vocal cord line, where the soft tissue is thin and without a
hard ground layer.
If too much time is spent in searching for the muscle process, edema could
develop in the vocal cord, with consequent maladjustment of the voice during
surgery.
116 Medial Displacement of the Vocal Cord

Fig. 6.40. The muscle process is often palpable by fingertip as a tiny prominence at the
level of the vocal cord

6.6.5 Opening the Cricoarytenoid Joint

Opening the joint immediately reveals a white, highly reflective, oval structure
sloping downwards, which is unmistakably the undersurface of t!te crico-
arytenoid joint (Figs. 6.41, 6.44b, 6.45, 6.46). Opening of the joint facilitates
firm suturing through the muscle process and secures stable results by ankylosis,
A 4-0 or 3-0 nylon suture is pierced from above through the joint surface,
sufficient muscle and cartilage are held to tolerate the long-term tension, and
then the suture is tied (Fig. 6.47). If it is felt that the first suture is insecure, a
second one should be done more deeply, taking a larger amount of tissue, while
pulling the first suture ventrolaterally. When two sutures are pierced, usually
only the second one need be used.
If greater adduction is needed for a large glottal chink, the joint opening is
extended posteriorly along the lateral side to gain more freedom for rotation,
and the suture should also be placed more lateroposteriorly (Fig. 6.48). How-
ever, excessive opening of the joint posteriorly may result in a short vocal cord;
excessive lateral placing of the suture will cause too much medial shift of the
vocal cord across the midline, producing a rough and pressed voice.
Arytenoid Adduction 117

'" ....I.,
.\11/. .

a b
----------------+-~~~----.---.-------------------------

,.':I.,
......
Ab /
"'1' I"~
I
...". .:';:...../
.:~ : :':;" ,
.\1/'1:-.... .

'"
,.".
,.'

_.1" .
..
'~'.
....~
,.' .......
..
, ".
• "/iii':,,

,.... 1" ,"111.

c d
Fig. 6.41a-d. Clues to locating the muscle process. a The muscle process lies at the level
of the vocal cord and less than 1 em from the upper margin of the cricothyroid joint. b
Before opening the cricoarytenoid joint, ensure that you are on the hard ground (that the
cricoid cartilage is underneath). Otherwise, you may fall into the swamp called the air-
way. c The muscle process is often palpable as a tiny prominence. d A white glittering
surface is an unmistakable sign of the joint when opened
118 Medial Displacement of the Vocal Cord

2~

3 4
F'ig. 6.42. The mucosa lining the pyriform recess (1) is elevated to reach the muscle pro-
cess (4).2 level of the vocal cord; 3 the posterior cricoarytenoid muscle

a---L,i,-.....
b-..... - " -'''''.JI ·

Fig. 6.43. The muscle process (a) is located superior to the pyriform recess (b). Care
must be taken not to enter the airway at the pyriform recess during the surgical process to
reach the muscle process
Arytenoid Adduction 119

Fig. 6.44. a the mucosa of the pyriform recess is turned up to reach the muscle process.
b the cricoarytenoid joint surface is exposed
120 Medial Displacement of the Vocal Cord

Fig. 6.45. To open the joint, the posterior cricoarytenoid muscle fibers are carefully sec-
tioned at the muscle process

Bleeding during the procedure inside the ala is usually minimal, and requires
neither electrocoagulation nor epinephrine soak. If it does occur, probably due
to inadvertent sectioning of the muscular fibers, packing for a few minutes with
an epinephrine-impregnated gauze strip is usually effective. If bleeding con-
tinues slightly even at the terminal stage of the operation, fine and weak bipolar
electrocoagulation may be used. Accumulation of blood inside the ala, however,
is more often likely to be from the sectioned extrinsic laryngeal muscle and
should be thoroughly controlled.
If the patient complains of discomfort or pain during rotation of the larynx,
the administration of an additional intravenous tranquilizer, though not such as
to put the patient to sleep, is generally effective enough. In the case of frequent
pain, anesthesia of the internal branch of the superior laryngeal nerve would be
a solution, though I have had no personal experience of this. In any event, local
infiltration anesthesia inside the thyroid ala should be avoided, as this would
entirely change the condition of the vocal cord.

6.6.6 Suture Traction

The direction in which the muscle process should be pulled to bring the para-
lyzed cord back to the normal phonatory position is of critical importance. The
Arytenoid Adduction 121

Fig. 6.46. Topographical anatomy in the vicinity of the cricoarytenoid joint: A cricothyr-
oid joint; B cricoarytenoid joint; C posterior cricoarytenoid muscle; D interarytenoid
muscle; E lateral cricoarytenoid muscle; F thyroarytenoid muscle; I recurrent laryngeal
nerve; 2-3 abductor branch; 4-5 adductor branch

Fig. 6.47. A suture (4-0 nylon) is passed through the muscle process of the arytenoid
cartilage. The tip of the needle is seen in the joint cavity
122 Medial Displacement of the Vocal Cord

Fig. 6.48. The site where the suture is passed makes a difference in the degree of adduc-
tion. Point B produces more adduction of the vocal cord than point A, probably bringing
the vocal process across the median line

optimal direction and location of the holes through which the suture should be
pulled out was studied by Taira (1986 15 ), using both fresh excised human
larynges and those from cadavers.
As illustrated in Fig. 6.34d, the conclusion of Taira is that one hole should be
made at the anterior middle third and the other at about the middle of the ala, a
little (1-2 mm) lower than the level of the vocal cord. In women, the sutures tied
through the muscle process can be passed through the thyroid ala by the use of a
long dull-curved needle while the ala is retracted anteromedially. In men,
however, a fine-tipped burr (e.g., Maillefer 700) is usually used to make the
holes. The holes should be made toward the muscle process to avoid the curved
course of the suture. After the holes are made, a needle with a core is bent and
inserted through the hole so as to pass almost parallel to the inner plane of the
thyroid ala until the tip emerges at the posterior edge (Fig. 6.49). The internal
core is then withdrawn and the nylon suture is passed through the needle by
suction. This needle technique was suggested by Lin, New York.
An alternative method is to make two pairs of holes (TA, CA), as illustrated
in Fig. 6.50, each simulating the function of the thyroarytenoid and cri-
coarytenoid muscles. This technique, which involves making four holes in close
vicinity to each other, may make the cartilage portion between the holes more
fragile and less tolerable to the tension of the suture. The holes should be made
at an appropriate distance apart.

6.6.7 Adjustment of Vocal Cord Adduction

After superficial anesthesia of the nasal mucosa, a flexible fiberscope is inserted

through the nose to monitor the laryngeal findings on TV as they change during
test maneuvers. The intraoperative adjustment consists of four procedures: trac-
Arytenoid Adduction 123

Fig. 6.49. The suture passed through the muscle process is tied there and withdrawn
anteriorly through the alar cartilage. A injection needle may be used for threading the ala
cartilage

tion of the muscle process; manual compression of the thyroid ala toward the
midline; cricothyroid approximation; and anteroposterior relaxation of the vocal
cords by pressing the middle of the thyroid cartilage dorsally. During these pro-
cedures, the larynx should be repositioned without rotation, and it is better to
remove the pillow beneath the shoulder to allow an easier posture for phona-
tion. Any saliva should be suctioned out.
Frequently just a gentle upward (ventral) pull of the sutures during phonation
(say, with a force of 30-50 g) improves the voice substantially. If the voice is to
the patient's satisfaction, and no glottal chink is noted, the operation can be
ended at that point by tying the sutures with a tension of 50 g or a little more. It
is recommended that the surgeon have an idea what a 50-g force is like as applied
to sutures. Usually, the force with which a suture is tied fairly tightly is about
100-200 g (force is expressed by mass times acceleration).
It seems to be worthwhile to try mechanical cricothyroid approximation even
though the voice may be almost normal to see whether further improvement is
produced. Cricothyroid approximation in such a case would depend more on the
124 Medial Displacement of the Vocal Cord

Fig. 6.50. One or two sutures are used to pull the muscle process anteriorly: One simu-
lates the thyroarytenoid, the other the cricoarytenoid muscle. When the ala cartilage is
calcified, holes must be drilled by a burr at the points indicated as TA and CA.

individual preference as to the voice, but the ease with which the patient can
phonate should also be taken into account.
If the voice improvement resulting from the suture traction is not satisfactory,
it is necessary to start looking for the cause and its solution. The possible factors
responsible for a slight hoarseness still remaining include: imperfect glottal clo-
sure due to insufficient adduction; imperfect glottal closure due to vocal cord
atrophy or a bowed margin; inadequate tension of the vocal cord (unilateral or
bilateral); vocal cord edema, either preoperative or intraoperative; too tight a
closure of the glottis due to either excessive adduction of the paralyzed cord or
overcompensatory adduction of the intact cord; any other pathological condi-
tion, such as scarring, previous Teflon injection, sulcus vocalis, or a tumor.
A breathy weak voice combined with a short maximum phonation time sug-
gests that a glottal chink is still present; it is, however, best to assess this careful-
lyon fiberscopic TV display. If stronger traction of the sutures does not improve
Arytenoid Adduction 125

the linear chink and voice, it is probably best to choose one of the following
three procedures as the next step.

6.6.8 Slight Medial Displacement of the Vocal Cord

If the arytenoid is rotated too much, the vocal cord becomes bowed, with the
vocal process projecting over the midline. The narrow slit due to this bowing
cannot be corrected by further rotation of the arytenoid. The vocal cord must be
displaced medially without rotation. There are three ways of accomplishing this.

Cricothyroid Approximation. Contraction of the cricothyroid muscle brings the

vocal cord slightly in to a medial direction. The first procedure that should be
attempted is cricothyroid approximation, which is done by thrusting up the low-
er margin of the cricoid with, e.g., an elevator. Besides elevation of the vocal
pitch, any consequent change in the glottal gap and voice should be carefully
evaluated together with the ease with which the patient can phonate. If the effect
is satisfactory in all these respects, cricothyroid approximation (Fig. 8.3) should
be added to arytenoid adduction.
This type of combination is often efficacious for combined superior and in-
ferior laryngeal nerve paralysis such as may be caused by a lesion of the central
nervous system. If this maneuver only elevates vocal pitch, sometimes accom-
panied by greater effort for phonation, without improving the voice quality sig-
nificantly, it is recommended that the other steps be carried out.

Further Dislocation of the Cricoarytenoid Joint. Opening along the lateral por-
tion of the cricoarytenoid joint capsule results in a slight medial shift of the vocal
cord, thereby reducing or eliminating the remaining glottal chink. Unless sec-
tioning of the capsule extends too far posteriorly, shortening of the vocal cord
does not occur.
The lateral capsule should be cut step by step while checking any change in the
larynx and the voice. The procedure can be reversed by suturing the capsule to
the original position, should the cutting yield an unfavorable result. This tech-
nique is indicated for a narrow chink remaining after arytenoid rotation.

Combination with Thyroplasty Type I. A combined technique is especially rec-

ommended for vocal cord paralysis with atrophy or for a bowed margin. The
standard technique for thyroplasty type I can be used if the holes for the pull
sutures are made at the center of the window or not too close to the planned
rectangular incisions. In a case of marked atrophy in which combined thyroplas-
ty is planned beforehand, the holes and the rectangular incisions should not be
placed too close to each other. Thus, the rectangular window may have to be
made higher or in the shape of a rectangle with an opening at the bottom (Fig.
6.51). When a high window has to be made, only a narrow strip of cartilage is left
caudally, which cannot tolerate a wedge pressure.
In both cases, a shim is often inserted transversely; occasionally this is only
undertaken on the posterior side of the window. The sutures connecting the
window with the muscle process are instrumental in maintaining the thyroid car-
tilage window oriented toward the midline like a shim. The plug overlying the
126 Medial Displacement of the Vocal Cord

Fig. 6.51. Combination of arytenoid adduction with thyroplasty type I. The window is
made in the shape of rectangle with an opening at the bottom. After the suture connect-
ing the muscle process to the window is tied, a plug is placed over the window and fixed by
a suture to the window frame

cartilage window may be utilized for this purpose. If the operation time exceeds
1.5 h, some edema in the vocal cord is likely, and median shifting of the vocal
cord should be done slightly in excess of what would normally be permissible.
Disregarding this time factor could lead to the wrong impression that regression
of the voice, which may occur after surgery, is due to the surgical maneuver. The
reader is referred to Sect. 6.3.11 and Chap. 12 for further details.

6.6.9 Excessively Tight Closure of the Glottis

The laryngeal findings indicating excessive adduction of the arytenoid include:

(a) the vocal process projecting over the midline with a bowed vocal cord mar-
gin; (b) the vocal cord margin as a whole crossing the midline; or (c) the vocal
process slightly edging under the contralateral vocal process.
If the glottis is closed too tightly, the voice sounds rough, pressed, and
strained as in spastic dysphonia, and no glottal chink is visible on the fiberscopic
TV display. Slight loosening of the traction sutures or actively drawing them
back to the muscle process by means of forceps inside the ala may improve the
voice, which indicates that too much adduction was responsible for the pressed
voice. It is important, however, that the loosening not be excessive. Rather, a
slightly rough and pressed voice with complete glottal closure is preferred, as
some edema is assumed.
The other, more complicated problem involves the compensatory movement
of the intact cord. The sound produced is rough and strenuous, often with the
false vocal cord on the intact side coming close to the midline, vibrating and
producing a rough sound. The intact true and false cords often look edematous
Arytenoid Adduction 127

and swollen, more so than the paralyzed cords. Due to the unrestrained com-
pensatory motion, intraoperative control of the voice by adjustment only on the
paralyzed side is extremely difficult. I have experienced two such patients in
whom the immediate result of the operation was a slightly rough voice, though
without the leakage of any air. Fortunately, so far, such cases have shown a
gradual decline in the rough quality of the voice, suggesting dwindling com-
pensation by the intact cord.
If voice production with the false vocal cords is apparent, marginal resection
of the false cord by laser evaporation may be indicated later.

6.6.10 Other Pathological Conditions

The voice will not improve satisfactorily if other pathological states are also
involved, either on the paralyzed or intact side. At times, contralateral lesions
such as sulcus vocalis, edema, false vocal cord hyperplasia, ipsilateral atrophy,
scarring or stiffening after Teflon or silicone injection may be overlooked or
underestimated before surgery. Such lesions restrict the intraoperative improve-
ment of the voice, whatever procedures are taken, unless treated.

6.6.11 Closure of the Wound

The wound is closed in a similar fashion to that for thyroplasty type I, except for
inserting a drain. Hemostasis is once again confirmed, and a drain is inserted
with the tip inside the ala. The drain is usually removed on the 2nd or 3rd post-
operative day.

6.6.12 Postoperative Care

Antibiotics are administered for 7 postoperative days. Steroids may be injected

intravenously on the day of operation to minimize the postoperative swelling.
For the same purpose, various enzymes may be given. Complete vocal rest
(communication by writing) is also recommended for a week.
For over a week into the postoperative period, red swelling of the arytenoid
region is evident, but it is never present to the extent as to cause either dyspnea
or stridor, though one patient complained of stridor (or louder snorting accord-
ing to his words) the night immediately after the operation.

6.6.13 Postoperative Course

The voice changes as the inflammatory swelling subsides. If the voice is quite
normal on the 7th postoperative day when the swelling is supposedly at a peak,
the voice may regress slightly after 3-12 months. A low and rough voice at this
time is a favorable finding and indicates a good voice later.
The second factor affecting the voice in the postoperative course is whether
vocal cord atrophy progresses or not. The addition of thyroplasty type I to
counter the atrophy has been described in the previous section (Page 125). The
third factor, though rather uncommon, is related to how the overcompensation
by the intact vocal cord reverts to normal.
 128 Medial Displacement of the Vocal Cord

Fig.6.52a,b. Digital narrow-band sonagrams of the voice. a Before and b after arytenoid
adduction combined with thyroplasty I. 27-year-old male, left vocal cord paralysis

Loosening of the sutures seems unlikely, because the traction force is not that
great. The results of surgery are exemplified by digital sonagrams in Fig. 6.52.

6.6.14 Modified Operation-Deprivation of the Posterior Cricoarytenoid Muscle

I have experienced one patient with bilateral vocal cord paralysis in whom after
Woodman's operation the laterally displaced vocal cord gained some substantial
mobility; this case has been recorded on videotape. A possible explanation for
this would be the misdirection theory as proposed by Hiroto et al. (1968 11 ) and
mostly based on electro myographic findings. This states that the standstill of the
vocal cord is not always the consequence of total laryngeal muscle paralysis but
may simply be the offset effect of synchronous contraction of both the adductor
Arytenoid Adduction 129

and abductor muscles. This being the case, selective sectioning of the posterior
cricoarytenoid muscle at the site of attachment to the muscle process can be
expected to resume some adductive movement of the vocal cord. In several pa-
tients, this selective sectioning was actually attempted prior to the muscle pro-
cess traction. In two, slight adductor movement was recognized on the fiber-
scopic TV display, but it was insufficient to produce a normal voice.
Probably only a small portion of the posterior cricoarytenoid muscle fibers was
sectioned, leaving a greater portion intact which can still counterbalance the
adductor muscle. Thorough preoperative electromyographic examination of
each muscle seems essential prior to further pursuing this procedure with con-
fidence in an attempt to obtain a normal voice. Detachment of all abductor fibers
from the arytenoid cartilage, which is presumably required for resumption of the
adductive movement of the vocal cords, would be attended by a fair amount of
bleeding. Thorough electromyographic assessment of each adductor muscle to
confirm the action potential on attempted phonation is a prerequisite for this
type of fairly aggressive surgery. However, there may be great potential in this
approach.

6.6.15 Summary

Arytenoid adduction is indicated in unilateral vocal cord paralysis when the glot-
tal chink is large and there is a difference in the level between the two cords.
Locating the muscle process is the key issue in the surgical technique. Of the
clues to its localization, the most important one is to trace along the upper ridge
of the cricoid cartilage up to the level of the vocal cord. Traction of the muscle
process by a nylon suture should be adjusted to the optimal voice and laryngeal
finding. Too much adduction results in a rough, pressed voice.
If vocal cord paralysis is accompanied by atrophy, arytenoid adduction com-
bined with thyroplasty type I is the surgery of choice.
7. Surgery to Lower Vocal Pitch: A-P Relaxation

Surgery to lower vocal pitch was, to my knowledge, first reported by myself,

experimentally (Isshiki et al. 1974 15 ) and clinically (Isshiki 19775, 19803 , 19814 ;
Isshiki et al. 1983 18). The principle is, like the technique, simple. The vocal cord
is relaxed by antero-posterior (A-P) shortening of the thyroid ala, which is
achieved by vertical strip excision of the thyroid ala (Fig. 7.1). The pitch lower-
ing has been dramatic and permanent except in those patients with attendant
vocal cord scarring or atrophy, in whom the results have not been so marked.
Tucker (1985 18 ) described one patient in whom an excessively high vocal pitch
was lowered by dorsally displacing a superiorly based cartilage flap (which was
made at the anterior portion of the thyroid ala), thereby displacing the anterior
commissure backward. As a treatment for sulcus vocalis, Niimi et al. in 1973 15
reported a surgical technique to slacken the vocal cord by pressing dorsally a
square cartilage piece around the anterior commissure.
Wang Hui-Gung et al. (1986 18 ) successfully utilized various laryngeal
framework surgeries in voice disorders, in particular, thyroplasty III in 95 men
with excessively high vocal pitch and thyroplasty IV in 11 women with
androphonia.
The basic physiology of vocal pitch control, which is probably useful in under-
standing the following surgical procedure, is described in Sect. 2.8.

7.1 Indications
The first indication for this type of surgery, which is referred to as A-P relaxation
or thyroplasty type III, is in male patients with too high a vocal pitch of long
duration which has proven resistant to voice therapy. The second indication is a
type of dysphonia characterized by high pitch and a breathy voice, in which the
laryngeal findings include a very narrow glottal chink and a small amplitude of
vibration, suggesting a stiff vocal cord.

7.1.1 Mutational Voice Disorder-Functional or Organic?

This first indication has always been controversial. On many occasions at a con-
gress, the same question is asked: Why perform surgery on patients who can be
cured by voice therapy? The fact is that all patients with a high-pitched voice
132 Surgery to Lower Vocal Pitch: A-P Relaxation

a b
Fig. 7.1a, b. Thyroplasty type III: relaxation of the vocal cord by anterior-posterior
shortening of the thyroid ala. Vertical strip excision of the thyroid ala is carried out either
unilaterally (a) or bilaterally (b)

were first placed on voice therapy for 3-6 months as a trial regardless of the
history or finding, and only those who did not become permanently cured and
wanted the surgery were operated upon. A counter question to the above is: Are
the patients really always curable permanently by vocal training, or, in other
words, is the disorder purely functional without any organic background? It
seems that the only diagnosis now available for excessively high vocal pitch in
men is mutational voice disorder. This terminology has led to a misconception
that the sympton must be functional, always derived from psychological distor-
tion or an abnormal process of mutation. Once the voice therapist or ENT spe-
cialist holds this firm belief about the patient's condition, the patient may be
persuaded through a series of questions, which are perhaps difficult to answer,
into receiving a typical history of mutational voice disorder. Any organic patho-
logical condition that may be present to account for the high vocal pitch is usual-
ly invisible on laryngoscopy, which makes the diagnosis more difficult. There-
fore, organic factors in patients with excessively high vocal pitch cannot be ruled
out simply because they have not been detected. Organic factors currently im-
possible to find may become analyzable later with the advent of new instru-
ments. The diagnosis of mutational voice disorder seems often to have been
made without a positive basis for excluding organic factors. The disorder can be
functional, but it can also be organic; most probably, both factors are involved to
some extent. I have sometimes intraoperatively experienced the high pitch to be
Indications 133

fairly definitely explainable by an organic factor, e.g., the female type of thyroid
ala. Congenital or acquired slight scarring or atrophy along the vocal cord mar-
gin, which is related to high pitch, may be overlooked unless special attention is
paid.
Individual differences in the vocal pitch are primarily correlated with the
length and thickness of the vocal cords, as is the difference between men and
women. On the other hand, height, body weight, and other parameters are
usually spread in normal distribution curve with some overlapping between the
sexes. Sex-linked organs such as the larynx show much less overlapping of para-
meters. In view of the incidence of intersexual malformations, such as Klinefel-
ter's, adrenogenital, and adiposogenital syndromes, it would not be surprising if
there were some overlap in the vocal cord length between men and women, for
example, the male vocal cords being shorter than the equivalent female ones. If
this were the case, the male vocal cords would produce a very high-pitched voice
like a woman's, even with no diagnosis of hormonal disease.
Here it is proposed that the diagnosis of mutational voice disorder should be
avoided unless there is definitive documentation to substantiate the relation with
the mutation and to exclude the involvement of an organic factor. In most cases,
it seems safer to replace the term by a simpler one-excessively high male pitch
or excessively high vocal pitch syndrome.
A number of patients are referred to me from different parts of the country by
voice therapists or ENT specialists after temporary relief or long and unfruitful
treatment. This does not mean at all that voice therapy is ineffective in this
disease: At this institute about two-thirds seem to be cured by voice therapy
alone. The medical statistics are problematic here in that a temporary cure can-
not be differentiated from a permanent one, especially when the follow-up is
difficult or is not carried out actively.
What is the common basis on which one denotes the symptom as functional?
One, it must lack any organic finding. In problems of excessively high pitch,
stiffness (the most important, possibly organic factor) is extremely difficult to
assess clinically and may be overlooked.
Two, it is usually inconsistent, and may be reversible or responsive to training
as in some articulatory disorders. Normally, the vocal pitch is variable within a
certain range. A man can produce falsetto with effort, just as a woman can
produce a quasi-masculine voice temporarily. This variability in pitch may easily
be confused with articulatory inconsistency. The individual conversational pitch
level is determined dominantly, if not exclusively, by the particular structure of
the vocal cord. It would be a great effort for someone to keep the pitch at a
certain level different from the structural basis.
Such great variability is never found in a hoarse voice. This vocal pitch
variability is another factor that can be misleading in diagnosis and treatment,
resulting in a functional theory without positive grounds. It seems strange that
all the cases of excessively high pitch in men should be functional, and all those
of excessively low pitch in women organic. The possibility of a structurally
based, excessively high vocal pitch in men cannot be wholly denied. Actually,
when I visited Voice Clinic at Eye and Ear Hospital of Pittsburgh, they showed
me on video a male adolescent patient producing a strangely highpitched voice
with an apparently underdeveloped larynx. This illustrates a case undoubtedly
134 Surgery to Lower Vocal Pitch: A-P Relaxation

organic in etiology. However, the above description does not deny the function-
al factor in excessively high vocal pitch in men; rather it implies that this would
tend to be more likely in the etiology of younger patients.
In conclusion, it is next to impossible to determine definitively in an individual
patient whether the high pitch is functional or organic. The only simple solution
would be a trial and error policy, i.e, voice therapy first, and if this is ineffective
then surgery should be carried out.
In light of the above, fairly simple and promising surgery seems to be justified
as a treatment of second choice. Again, a manual test is most useful in predicting
the outcome. Pressing the anterior thyroid cartilage backward during phonation
should substantially lower the pitch. Otherwise, there may be no indication for
surgery, or both the patient and surgeon should realize that the surgical results
may not be very remarkable, though some improvement can be assured by the
surgery, as demonstrated by the previous cases.

7.1.2 Dysphonia Due to Excessively Stiff Vocal Cords

This is different from the excessively high vocal pitch in that the voice is both
high-pitched and breathy, and usually there is a narrow glottal chink during
phonation. Excessively stiff vocal cords with a narrow chink often result from
laryngeal trauma, radiation, chronic laryngitis, sulcus vocalis, vocal cord atro-
phy, or systemic hormonal imbalance such as Werner's syndrome. The laryngo-
scopic finding is more conspicuous than in the previous condition, in which the
only symptom is excessively high vocal pitch. The causes of a high-pitched and
breathy voice can be congenital or acquired. Extreme stiffness is intrinsic in
etiology rather than extrinsic; for example, it is not caused by overcontraction of
the cricothyroid muscle.
Prognosis after surgery for this type of dysphonia is in general not as good as
that in the former condition without hoarseness, because rheological deviation
of the vocal cord is greater. A preoperative manual test must be attempted to
anticipate the effect of medial displacement as well as of relaxiation of the vocal
cords. Surgery which achieves, both medialization and relaxation can be diverse
in design. The frequent indications for this combined type of surgery include
vocal cord atrophy, sulcus vocalis, bowed vocal cord, and scarred vocal cord.
The technical details are described separately in Sect. 9.1.

7.2 Surgical Procedure

7.2.1 Vertical Incision in the Thyroid Ala

Preoperative settings for this surgery are essentially the same as those for the
medialization operation mentioned above. A skin incision is made horizontally
at the level of the midpoint between the notch and the lower margin of the
thyroid ala, 4-5 cm in length, with a slight shift unilaterally toward the side
where relaxation of the vocal cord is first planned.
After retracting the strap muscle laterally, the unilateral thyroid ala is exposed
laterally to about half the width of the ala. Then, the intended vertical line of
Surgical Procedure 135

incision is drawn at about the junction of the anterior and middle one-third of
the thyroid ala. The cartilage is carefully incised with a knief (no. 11) so as not to
cut the inner perichondrium (Fig. 7.2). The caudal portion is usually thicker and
more calcified in men and requires a burr for cutting. The reasons for selecting
the anterior and middle one-third line for the vertical incision are: (a) The more
anterior portion has less soft tissue behind the ala, which means it is close to the
airway and dangerous; (b) the more anterior portion can be quite flat in shape,
and if the partial vertical strip excision is made too anteriorly, it may not be so
effective in reducing the A-P dimension of the ala; (c) if the incision is placed
posterior to that line, it would require extra lateral exposure of the ala.
In the middle or lower portion of the vertical cutting, there may occur hemor-
rhage from inside the cartilage. This bleeding from inside should be controlled
by pinpoint electrocoagulation to prevent later hematoma.
After the cut has been made, the lateral incised edge is undermined between
the cartilage and inner perichondrium at a width of 3-4 mm with a fine sharp
angulated elevator such as is used in eardrum elevation (Fig. 7.3). The second
incision is now made in the ala, parallel to and 2-3 mm posterior to the first
incision.

7.2.2 Width of Vertical Strip Excision

It cannot be predicted what width of excision will result in a certain degree of

lowering of the vocal pitch. In determining the width of the first cartilage exci-
sion, various factors should be taken into account: First, the degree of lowering
that is planned-slight or great. Slight lowering may be achieved by a unilateral
excision of 2-3 mm unless the vocal cord is very stiff. If greater lowering is
required, unilateral 4-5 mm or bilateral 2-3 mm excisions may be necessary.
One previous study (Isshiki et al. 19773 ) revealed that tension imbalance be-
tween the two vocal cords does not cause any dysphonia but produces a phase
lag in the vibratory cycle between the two. Practically, this phase lag does not
seem to do any harm to the vocal cords, though there are as yet no conclusive
long-term results. Therefore, unilateral shortening of the ala seems to be jus-
tified as the first step of surgery, even though it yields some tension imbalance.
The second factor to be taken into account is how easily the procedure can be
reversed if the pitch lowering is too great. The excised piece of cartilage can be
repositioned and fixed by suturing, but the narrower the strip, the more difficult
and unstable the repositioning. It is better to cut step by step than to cut too
much and have to reposition the cartilage.
Before actual excision of the vertical strip, phonation while overlapping the
incised edges by 1-2 mm gives an impression of how much should be excised to
reach the intended pitch level. If the pitch lowering obtained by the overlapping
test is much less than the desired level, the choice is either unilateral excision of
up to 4-5 mm (first 2-3 mm, then an additional 1-2 mm) or quite narrow,
bilateral excisions (1-3 mm each). Unilateral excisions wider than 5-6 mm are
probably best avoided, because the consequent imbalance may cause harm in
the long run. Bilateral excision should be fairly conservative, with the second
contralateral excision starting at a width of 1-2 mm, because this second excision
usually produces a dramatic drop in pitch.
136 Surgery to Lower Vocal Pitch: A-P Relaxation

Fig. 7.2. Thyroid ala is incised with a knife

or a burr at the junction of the anterior and
middle one-third line

Fig. 7.3 After completely cutting the

cartilage, the lateral incised edge is
undermined between the cartilage and
inner perichondrium at a width of 3-
4 mm so that the second parallel incision
for cartilage strip excision can be made
without injuring the inner perichondrium
Surgical Procedure 137

To summarize, the choice of the second step, either additional ipsilateral A-P
shortening or bilateral shortening, depends upon how much further pitch lower-
ing is required. More ipsilateral shortening would suffice for a slight, additional
pitch decrease. A narrow (1-3 mm) strip excision on the opposite side, i.e.,
bilateral shortening of the A-P distance, is a most effective and frequent choice
of procedure.
If the problem is limited to the vocal pitch, with no problems of vocal quality,
fiberscopic monitoring may be unnecessary.

7.2.3 Fixation

Fixation of the incised edges is done in either a face-la-face or overlapping

fashion . The choice between the two is based on the voice produced while the
edges are held by forceps in the different positions. Fixation is done by one or
two mattress sutures (4-0 nylon) (Figs. 7.4, 7.5). If the cartilage is calcified,
narrow holes are made with a very fine burr, taking particular care not to dam-
age the soft tissue inside the ala . The types of mattress suture for face-to-face
apposition and overlapping are shown in Figs. 7.5 , 7.6. It should be noted that a
very narrow (1 mm) overlap is virtually impossible because the holes for the
suture come too close to the edges.

Fig. 7.4. Undermining of the medial incised edge is also made for fixation of the edges
with sutures
Fig. 7.5. Fixation of the incised edges in face-to-face apposition

Fig. 7.6 Fixation of the incised edges for overlapping by mattress sutures
Surgical Procedure 139

7.2.4 Complications and Postoperative Care

No complications have ever been experienced. The only possibility would be a

hematoma inside the ala. Complete hemostasis should be confirmed at the end
of the operation. Local application of thrombin powder or fibrin glue may be of
some help. Voice rest for a week is sufficient. Neither special medication nor
voice training is usually needed after removal of the sutures. The intermediate
results are shown in Fig. 7.7 and Table 7.1.

Hz
500
400
300

200

100
jj 11 1
Fig.7.7. Intermediate results of pitch lowering surgery

Table 7.1. Results of operation to lower the vocal pitch

Case Age Sex Diagnosis Operation Pitch change (Hz)
1 14 m mutational V.D. Thyr III (left 1.5 mm 275-- 97
exc.)
2 17 m mutational V.D. r-Cricothy. Myotomy 287 __ 110
3 27 m V. C. atrophy Thyr III (variation) 233--193
4 27 m V.C. atrophy Thyr III (bilateral 1 mm 190 __ 144
exc. left slipping)
5 27 m mutational V.D. Thyr III (left 3 mm, r: 2 252 __ 108
mmexc.)
6 30 m mutational V.D. Thyr III (left 2 mm exc.) 202 __ 130
7 25 m V.c. atrophy Thyr III (left 2 mm exc. 213 __ 175
and slipping)
8 32 m V.c. atrophy Thyr III (left 2 mm exc., 225--165
cart. Imp!.)
9 22 m V.c. atrophy Thyr III (left 2 mm, r: 2 270 __ 120
mm, cart. Imp!.)
m male, V.D. voice disorder, V.c. atrophy vocal cord atrophy, Thyr III Thyroplasty
Type III, exc excision of the vertical strip of the thyroid cartilage of the width as noted,
Cart impl cartilage piece implantation. The mean vocal pitch while reading a standard
passage was measured with the use of sonagraph, or directly on the recorded sound waves
8. Surgery to Elevate Vocal Pitch

8.1 Indication
Excessively low vocal pitch found in women is assoicated frequently with the
side effects of hormonal drugs, such as anabolic or male hormones, and less
frequently with hormonal diseases, such as adrenogenital syndrome, Addison's
disease, myoedema, and acromegaly. It is often referred to as androphonia. It
can also be caused by reduced activity of the cricothyroid muscle or, less signif-
icantly though, of the strap muscle. It the pitch is too low and the patient wants
it corrected, surgery may be indicated. Transsexuals often desire raising of their
vocal pitch. Before deciding whether surgery is indicated, complete understand-
ing and consensus are necessary between the patient and the surgeon regarding
the probable outcome of surgery.
The manual test is essential (Fig. 8.1). During phonation, the cricoid and thy-
roid cartilages are approximated bimanually; the side of the right index finger
pushes up the lower margin of the cricoid, while the tip of the left index finger
pushes down the thyroid notch. If the vocal pitch elevation thus induced is re-
markable, well recognizable, and satisfactory to the patient, surgery may be
worthwhile; if the result is not satisfactory, it is perhaps better not to perform
surgery, particularly cricothyroid approximation. Other factors such as the pa-
tient's state of mind and eagerness for surgery must also be weighed against the
prognosis from the manual test. If the mass increase (hypertrophy) is too great,
the cricothyroid approximation will not substantially elevate the vocal pitch.

Unilateral Paralysis of the Cricothyroid Muscle. Bowing or zigzagging of the

edge of the ipsilateral vocal cord never results from unilateral paralysis of the
cricothyroid muscle. The diagnosis can be made only on the basis of thorough
electromyographic study of the suspected muscle, using the intact muscle as a
control. The telling laryngeal finding, is the shift of the posterior commissure
toward the inactive side and consequent oblique position of the glottal chink, as
reported by (Neumayer 189619 ; Mygind 190619 ; Stupka 1924 19 ; Luchsinger
1942 19 ; Hofer 194419 , 1953 19 ; Hofer and Jeschek 1940 19 ; Gregg 195619 ; Beyer
1941 19 ; Arnold 1961 19 ; Faaborg-Andersen and Jensen 1963 19 ; Tanabe, et al.
197219) (Fig. 8.2). Besides the oblique position of the glottis, Pahn and Rother
(1981 19) emphasized as a key dianostic finding that the degree of cricothyroid
142 Surgery to Elevate Vocal Pitch

Fig. 8.1. Manual cricothyroid

approximation to determine the
indication for surgical elevation of
vocal pitch

Fig. 8.2. Laryngeal finding

of unilateral paralysis of the
cricothyroid mUlicle. The
glottal axis deviates to- .
wards the side of paralysis.
(a) the side of paralysis; (b) the
intact side

,
(a) ,
~i~ (b)
,

approximation is different between the two sides, which could be confirmed

radiographically with 4 needles inserted into the thyroid and cricoid cartilages.
The glottal axis deviation, however, can also have a structural basis (Muraka-
mi 1987 19). The thyroid ala is often asymmetrical, being frequently larger on the
left, particulary in older men. Baldus (1963 19) and Heinemann (1969 19 ) reported
many cases of laryngeal asymmetry of various types and causes. Much remains
to be clarified on this point.
Cricothyroid Approximation 143

8.2 Principle of Surgery

As described in Chap. 2, the vocal pitch is controlled by the tension, mass, and
length of the vocal cord. Of these, tension and mass can safely be adjusted by
surgery. Vocal cord tension is increased by: cricothyroid approximation, A-P
lengthening of the thyroid cartilage, or scarring in the vocal cord produced by
longitudinal incisions. The vocal cord mass can safely be reduced by either intra-
cordal injection of a steroid suspension (triamcinolone) or tissue evaporation by
laser.
All the above techniques involve some diffculties to a greater or lesser extent,
including the long-term effects of surgery, the risk of eroding the cartilage which
is placed under a certain pressure, and the risk of causing deterioration of the
voice if direct intervention has to be made in the vocal cord.
Furthermore, the factor responsible for excessively low pitch is large mass,
except in cricothyroid muscle paralysis. Surgical treatment of this mass-induced
low pitch by increasing the tension is limited. An analogy of this is the violin,
where a thick string cannot produce a very high note no matter how great the
tension. The rational solution thus would seem to lie in the reduction of the
vibrating mass.

8.3 Cricothyroid Approximation

8.3.1 Surgical Technique

Cricothyroid approximation (Isshiki et al. 1974 15 , 19775 , 19803 , 19837 ) raises the
vocal pitch by simulating the contraction of the cricothyroid muscle with sutures.
As shown in Fig. 8.3,3-0 or 4-0 nylon sutures are placed, most usually at four
sites, drawing the cricoid and throid cartilages closer together. The salient points
of surgery follow.
A fairly large amount of the cricoid cartilage should be grasped by the suture
so as to tolerate the pressure. No bolsters are needed though because the cartil-
age is regarded as being thick and strong enough to withstand the long-term
pressure.
The needle should not be inserted too deeply through trying to grasp a lot of
cartilage. The mucosa may be perforated, because the soft tissue behind the
cricoid cartilage is thin. If this happens, the patient will immediately complain of
irritation in the region.
The needle should be withdrawn from the upper part or edge of the cricoid
cartilage and then inserted into the thyroid cartilage. The distance between the
two cartilages is too great to pierce both in one attempt.
The cricothyroid muscle region has a fairly abundant vascular supply. Bleed-
ing should be avoided by identifying the vessels if possible.
Bolsters, either made of silicone or a piece of cartilage taken from the upper
edge of the thyroid ala, are used to disperse the pressure imposed on the thyroid
alar plane by the suture. It is expedient to make a shallow groove at the middle
of the bolster to prevent the suture from slipping off.
The pitch-raising effect is great, if the suture is placed somewhat anteriorly.
144 Surgery to Elevate Vocal Pitch

Fig. 8.3. Surgical technique for cricothyroid approximation

However, the very anterior portion of the ala has a thin cartilage, which is less
able to tolerate pressure, and the soft tissue inside the ala is also very thin. It is
better to avoid the anterior quarter of the ala (6-7 mm wide) as the site for
suturing. The sutures are made almost parallel to the rectus part of the crico-
thyroid muscle.
After all four sutures have been inserted, they are tied alternately right and
left, while the surgical assistant pushes the cricoid cartilage up. The vocal pitch is
raised as the sutures are tied.
At the end of the operation, the vocal pitch may be too high to produce a
voice easily. However, the cricoid and thyroid cartilages should be approxi-
mated as closely as possible, because a postoperative reversion toward a lower
pitch is to some extent inevitable, being probably due to loosening of the su-
tures.

8.3.2 Results and Complications

The vocal pitch elevation is always substantial, as illustrated in Table 8.1 and
Fig. 8.4. Here the manual test is again fairly well predictive of the outcome. The
Cricothyroid Approximation 145

Table 8.1. Results of operation to elevate the vocal pitch

Case Age Sex Diagnosis Operation Pitch change (Hz)
1 22 f Androphonia C-T Approx. 120_178
2 24 f Androphonia C-T Approx. 140_164
3 29 f r-CTM paraly C-T Approx. (rt only) 212_ 312
4 21 f r-CTM paraly C-T Approx. (rt only) 232-290
5 21 f Congo Sulcus left-Thyr. Alar 216_328
Expansion, C-T
Approx.
6 21 f Androphonia C-T Approx. 146_192
7 47 f Androphonia C-T Approx. 138_170
8 21 f Adrenogenital C-T Approx. 166_220
Synd.
9 32 f Androphonia C-T Approx. 130-164
10 23 f Adrenogenital V.c. Evaporation by 175_205
Synd. Laser
11 23 f Androphonia Mult. Long. Incisions 183_220
12 28 f Androphonia C-T Approx. 145_195
13 26 f Androphonia Mult. Long. Incisions 168_204
14 42 m Transsexual C-T Approx. and 110_164
Incisions
[female, m male, CTM paraly the cricothyroid muscle paralysis, Congo Sulcus congenital
sulcus vocalis, C-T Approx. cricothyroid approximation, multo long. incisions multiple
longitudinal incisons of the vocal cord

Fig. 8.4. Intermediate results Hz

of pitch elevation surgery
500
400
300
200

100

patient with adrenogenital syndrome did not respond to surgery to a satisfactory

level. The result was also poor in the transsexual whose vocal cords were ex-
tremely loose due to a shaving operation of the thyroid prominence which he
had undergone elsewhere. No complications were noted except in two patients
in whom there was irritation of the laryngeal region after the operation. Fiber-
scopic examination revealed no blue nylon suture exposed to the subglottal air-
146 Surgery to Elevate Vocal Pitch

way region, and the symptoms subsided spontaneously after 3 months.

Quasi-aphonia may last for a week or so, which is quite a good sign and need
not be worried about. Vocal rest is necessary for a week as in other types of
phonosurgery. At present, it is uncertain which is better-silicone or cartilage-
as a bolster. No patients have ever been reexamined, because no complications
requiring reoperation have occurred. Therefore, no information is available as
to the long-term outcome of the type of bolster.

8.3.3 Lee's Modification

Lee et al. (1986 15 ) modified the cricothyroid approximation by utilizing long

sutures: a 3-0 nylon suture which is passed through the cartilage at the thyroid
notch is tied with the other opposing one which grasps the cricoid cartilage and
subcutaneous tissue at the midline (Fig. 8.5). Supplementary short sutures are
also used to approximate the cricoid to the thyroid cartilage.

Fig. 8.5. Cricothyroid approximation: Lee's modification. The cricothyroid muscle is sec-
tioned and a longer suture is also used to approximate the two cartilages
A-P Lengthening of the Thyroid Ala 147

Fig. 8.6. Anterior-posterior expansion of the thyroid ala by inserting a strip implant. A
transverse flange inside may be added if medialization of the vocal cord is also necessary.
Fixation of the silastic implant with the cartilage is made by two 4-0 nylon mattress
sutures

8.4 A-P Lengthening of the Thyroid Ala

8.4.1 A-P Expansion of the Thyroid Ala by Vertical Insertion of a Strip Implant

The vocal cords can be stretched by A-P expansion of the thyroid ala, which is
effected by inserting a narrow strip implant in between the vertically incised
edges of the ala (Isshiki 19775, 19803, 19837 ). A vertical incision is made at the
junction of the anterior and middle one-third of the ala, just as in surgery to
lower the vocal pitch. After separation between the cartilage and the inner
perichondrium for 2-3 mm from the edge, the gap between the edges is widened
mechanically to observe any change in vocal pitch. Usually, a long silastic im-
plant, 2-4 mm wide with a thin flange, is individually made and inserted into the
gap (Fig. 8.6). If medialization of the vocal cord is also necessary, the flange
should be thick and transversely wide at the level of the vocal cord (Fig. 8.7).
Fixation of the silastic implant with the cartilage edges is made by two 4-0
nylon mattress sutures, a shown in Fig. 8.6. If the pitch elevation is insufficient,
the same procedure may also be performed on the contralateral side. I have
performed this type of surgery in three patients. In one, the gap was filled for the
lower two-thirds with a silicone shim and for the upper third with two stacked
pieces of cartilage. The results, advantages, and disadvantages are discussed at
the end of this section, together with those of other surgical techniques to tighten
the vocal cord.
148 Surgery to Elevate Vocal Pitch

Fig. 8.7. Cross section of the anterior-

posterior expansion of the thyroid ala
combined with vocal cord medialization

8.4.2 Inferiorly Based Midline Cartilage Flap: Anterior Commissure

Advancement of Le Jeune

In 1983 Le Jeune et aP9 reported a surgical technique they called springboard

advancement for tightening flaccid vocal ligaments (Fig. 8.8) . The indication for
surgery was mainly a breathy voice due to bowed vocal cords.
A horizontal incision is made in a skin crease near the thyroid prominence.
The anterior portion of the thyroid cartilage is exposed and an inferiorly based
cartilage flap is formed so as to include the anterior commissure, with approx-
imately 3 mm on either side of the midline, and with the inferior pedicle within 3
mm of the inferior border of the thyroid cartilage . The outer perichondrium and
the cartilage are carefully cut through, while preserving the inner perichon-
drium. With the use of a small elevator, the inner perichondrium is elevated
from the ala on the lateral side of the incision for 3-4 mm. No attempts are made
to elevate the perichondrium medial to the incision in order to preserve the
internal attachment of the anterior commissure to the cartilage (Broyle's liga-
ment). The upper end of the flap is lifted approximately 3 mm above the surface
of the thyroid cartilage, and a tantalum shim , approximately 2 mm wide and
fashioned so as to hold the flap in position, is inserted between the flap and the
remaining thyroid cartilage. Laterally, the metal shim is sutured to the perichon-
drium of the thyroid ala.
By this procedure, the anterior commissure is reported to be advanced ap-
proximately 2 mm, which corresponds to about 10% of the vocal cord length.
This surgery was performed on six patients with a breathy voice and bowing of
the vocal cords. All six patients showed improvement in voice quality, though
the two with a previous Teflon injection evidenced the poorest results.
A-P Lengthening of the Thyroid Ala 149

Fig. 8.8. Surgery for elevation of vocal pitch: Le Jeune's springboard advancement. An
inferiorly based cartilage flap is elevated and fixed in an anteriorly displaced position by
inserting a shim

8.4.3 Superiorly Based Cartilage Flap: Anterior Commissure

Laryngoplasty of Tucker

Tucker in 1985 19 modified Le Jeune's technique by reversing the pedicle (Fig.

8.9). The advantage of the superior pedicle, he advocates, is the greater
advancement of the anterior commissure made possible, because the midline
150 Surgery to Elevate Vocal Pitch

superior portion of the thyroid cartilage is much thinner than in the vicinity of
the lower margin. Tucker also used the flap to lower the vocal pitch by displacing
the flap in the dorsal direction. Tightening of the vocal cords was attempted in
seven patients (five male and two female) with flaccid vocal cords and in two
male-to-female sex-change patients with low-pitched voices, while loosening of
the vocal cords was done in a man whose voice had remained high after puberty.
The other surgical details including flap size, position, elevation of the inner
perichondrium from the cartilage, and the use of a tantalum shim are essentially
identical to those of Le Jeune as far as the descriptions in the papers are con-
cerned.

8.4.4 Comparison of the Three Techniques

Comparison of the above three techniques on the basis of the results appears
impossible because of the rather small number of case histories published, lack
of objective data regarding vocal pitch and quality, and the short follow-up
periods, though no significant complications have been reported in any of them.
Moreover, the surgical indications adopted seem to be different from type to
type.
The surgical techniques should theoretically be examined in terms of the
immediate tightening effect, the long-term effect (cartilage tolerance to the
pressure), the degree of surgical intervention, and the potential risk of com-
plications.
The A-P expansion of the thyroid ala by insertion of a silastic implant (Isshiki
19775 , 19803 , 19837 ) requires a longer cartilage incision and wider elevation
of the inner perichondrium, especially when the procedure has to be made
bilaterally. The tightening effect of the vocal cords in my technique depends on
the width of the silicone implant that is introduced. However, the effect may be
less than in the anterior advancement techniques of Le Jeune or Tucker due to
the long distance between the anterior commissure and the site of extension.
The tightening effect can, however, be greater than in the others if due regard is
paid to the limitation of the springboard advancement by the cartilage pedicle.
In my technique, the curvature of the thyroid cartilage and the site of A-P
expansion also affect the tightening effect. The shape of the thyroid cartilage in
women is known to be obtuse anteriorly. If the expansion is made at the anterior
portion, where the cartilage plane may be flat transversely rather than in the A-P
direction, the effect will be lateral expansion of the thyroid cartilage rather than
A-P expansion. For an extremely obtuse thyroid cartilage, the expansion should
be made at the latero-posterior site, where the direction of the ala is more A-P.
As to the long-term effect, it is more critical how well the cartilage tolerates
the long-lasting pressure without erosion or deformity being caused. The force
applied to the cartilage should be dispersed over a sufficiently wide area to
decrease the pressure imposed. No definite information is presently available
about the long-term fate of the interposed materials. A cartilage piece is probably
safer than foreign materials but may be subject to absorption. The possibility
cannot be ruled out that cartilage under constant great pressure from metal or
alloplastic material erodes, leading to deformation, especially when infection is
also involved. A long-term foreign body reaction to the tantalum shim or allo-
A-P Lengthening of the Thyroid Ala 151

Fig. 8.9. Tucker's modification. A superiorly based cartilage flap is made

plastic implant when interposed between the cartilages should be assessed by

follow-up.
The soft tissue structure inside the thyroid ala appears to be closely related to
the risk of surgery. The soft tissue behind the thyroid cartilage is very thin near
the anterior commissure. Therefore, surgical intervention such as lifting the car-
tilage flap there seems to be attended with a potential risk of perforating the
airway mucosa-a higher risk than when it is done more laterally, when abun-
152 Surgery to Elevate Vocal Pitch

dant soft tissue exists between the cartilage and mucosa. The scarcity of soft
tissue may retard obliteration of the tiny midline dead space, which can be pro-
duced behind the metal shim in the anterior commissure advancement tech-
niques. It seems better to place a tiny cartilage piece behind the shim to close
the dead space and give more stabilization to the springboard flap.
The surgical risk of the anterior cartilage flap technique may not actually be so
great as assumed here, since no complications have been reported so far. It
should also be taken into account that the mucosa and the cartilage are firmly
connected to each other by thin but strong ligaments or other connective tissue
near the anterior commissure and its subglottic region. Anterior displacement of
the anterior commissure would be restricted not only by the cartilage pedicle but
also by these fibrous tissues, unless separation between the inner perichondrium
and the cartilage is made over a fairly wide area. This chondro-perichondrial
separation could slightly medialize the vocal cord at the anterior portion. This
medialization effect together with the tightening in Le ]eune's technique would
have brought about the good results in patients with a hoarse voice and bowing
of the vocal cord reported by Le Jeune et al. (1983 19 ). To enhance this
medialization effect, Koufman, utilizing Tucker's modification of Le Jeune's
technique, inserted a silastic implant between the inner perichondrium and the
thyroid cartilage. The details will be described separately in Chap. 9.
To summarize, the anterior commissure advancement techniques, as com-
pared with my A-P expansion technique, seem to have the advantages of less
surgical intervention and perhaps a more direct effect of tightening the vocal
cords. The possible disadvantages are the surgical risk due to the lack of soft
tissue behind the thyroid cartilage there and the restriction of advancement by
the pedicle and ligament fibers.
Experimental and clinical research is needed to determine a safe and effective
surgical procedure.

8.5 Comparison of Cricothyroid Approximation with Anterior

Commissure Advancement Techniques

At present, it is not yet conclusive which is the better technique for elevating the
vocal pitch-cricothyroid approximation or A-P expansion of the thyroid ala,
including the springboard advancement technique.
The apparent advantages of the cricothyroid approximation are that it is a
simple technique and no cartilage incision or compression is required. The dis-
advantages include a relatively great force required to approximate the two car-
tilages, the problem of long-lasting tolerance of the cartilage, the presence of
thin soft tissue behind the cricoid cartilage, a well vascularized and hemorrhagic
region at the site of suture, occasional paresthesia in the region, a postoperative
tendency of the vocal pitch to revert to a lower level, and possible narrowing of
the vocal range after operation. These disadvantages are, however, common to
other techniques, too.
At first sight, it may appear that cricothyroid approximation makes the cri-
cothyroid muscle function more ineffective than the other techniques, because
the cricothyroid approximation produces the condition of maximal contraction
Longitudinal Incisions in the Vocal Cords 153

of the cricothyroid muscle. However, when the tension of the vocal cords is
considered, it is seen to be almost at maximal tightening, whatever methods are
used; there is little room for the cricothyroid muscle to function effectively.
Theoretically, the voice should become monotonous after operation, with a
narrowed vocal pitch range. Practically, there has been no patient in whom
speech sounded more monotonous than before. Probably the vocal cords were
not tightened sufficiently to obtain maximal tension, or some other mechanisms,
such as sub glottal pressure or articulatory effect, may have been involved,
compensating the monotony due to maximal tension of the vocal cord. From
personal experience, it is clear that the original, unnaturally low vocal pitch is
always far more worrisome to the patient than any postoperative monotonous
tendency.

8.6 Longitudinal Incisions in the Vocal Cords

The vocalis muscle is known to be antagonistic to the cricothyroid muscle in
terms of elevating the vocal pitch (Hirano et al. 1969 19 , 197019 , Hirano (1975 19).
Saito (1977 19 ) and Kokawa (1977 19 ) reported an operation in which the vocalis
muscle was partly sectioned by longitudinal incisions in the vocal cords to raise
the vocal pitch. Their results, obtained in patients with androphonia, were
generally satisfactory in elevating the vocal pitch.
Experimental work with dogs was conducted by Tanabe et al. (1985 19 ) to
assess the long-term effect of longitudinal incisions on the vocal pitch. The post-
operative, gradual but marked elevation of the vocal pitch with time indicates
that the rise in pitch probably resulted from the increased stiffness of the vocal
cord due to scarring.
Longitudinal incisions in the vocal cords were performed on three patients
under general anesthesia with a suspension direct laryngoscope. Using laryngo-
microscopy, parallel incisions in the vocal cords, two to four for each side, were
made not too close to the edges. Simultaneous intracordal injection of steroid
(triamcinolone) can also be carried out. The effect of raising the vocal pitch
cannot be assessed until the scarring becomes stable, at shortest 3 months post-
operatively (Isshiki et al. 1983 18). Excessive scarring along the edge of the vocal
cord may deteriorate the voice. The procedure must be performed fairly conser-
vatively at first, and after 6 months' follow-up to confirm no deterioration of the
voice, an additional surgical procedure may be carried out to elevated the pitch
further if necessary.

8.7 Stripping of the Vocal Cord Mucosa

Hirano et al. (1976 19) compared stripping with minor excision and suction as a
treatment for a polypoid vocal cord and concluded that stripping was less suc-
cessful. Fritzell et al. (1982 19) utilized vocal cord stripping in 12 patients (all
women) with edematous vocal cords. In one-third of them, the pitch rise was
remarkable with a mean of 96 Hz, but the others had a moderate rise of pitch
ranging from 17 to 44 Hz, with a mean of 31 Hz.
154 Surgery to Elevate Vocal Pitch

8.8 Intracordal Injection of Corticosteroid

The injection of corticosteroid (triamcinolone) is known to induce atrophy of the

local tissue where the drug is injected. In fact, intradermal injection of triamci-
nolone is one of the most effective treatments for hypertrophic scar or keloid.
In hypertrophic vocal cords with excessively low pitch, this technique can be
applied either under indirect laryngoscopy or using a direct laryngomicrosurgical
technique. Prior to injection, it should be understood by the patient that the
vocal cord swelling due to the injection and consequent severe hoarseness will
last for at least 3-4, usually 7, days.
The effect is unpredictable. Usually it is not so substantially effective, prob-
ably because the amount of triamcinolone injected, 0.5 ml (20 mg), is so small.
However, a gradual, conservative policy of injection is recommended rather
than a drastic effect, as an excessive dose may cause irreversible vocal cord atro-
phy. It occasionally happens that after the first and second inefficacious injec-
tions, the third or fourth one suddenly demonstrates a remarkable effect. The
above procedure was performed on six subjects (androphonia due to anabolic
hormone treatment and transsexuals). With further modifications in frequency,
dose, and site of injection, there would be greater improvement in effectiveness
and wider application.

8.9 Partial Evaporation of the Vocal Cord by Laser

The continuous CO 2 laser was discovered in 1965, and shortly thereafter in-
tensive research was conducted by a group in Boston (Strong and Jako 1972 19 ;
Polanyi et a1. 197019 ; Mihashi et a1. 197619 ). Through animal experiments
(Jako 1972 19 ), it was found that the new type of energy could be
controlled with precision and safety and applied to a preselected area of the
vocal cord. Subsequently, clinical applications were attempted (Strong and Jako
1972 19), and the results were very encouraging and impressive when applied to
small lesions, such as papillomas, polyps, nodules, cysts, hyperkeratosis, and
carcinomas in situ. The advantages of laser surgery include an extraordinary
reduction of bleeding, and prompt healing with minimal edema and scarring.
The results obtained by other investigators (Andrews and Moss 197419 ; Hirano
19753; Mihashi 197619 ) support these findings.
The results indicate that the increased mass of the vocal cord may safely be
reduced with minimal scarring by laser surgery. Based on the above concept and
our own experimental results (Tanabe et a1. 1985 19 ), laser evaporation of the
vocal cord was performed conservatively on two women with excessively high
vocal pitch-one with adrenogenital syndrome and one with congenital low-
pitch voice without specific disease. In both cases, the voice quality was not
affected at all, but the vocal pitch elevation was not so marked, probably be-
cause the evaporation was performed too conservatively. The patient with adre-
nogenital syndrome demonstrated a conversational pitch rise from 175 Hz to 205
Hz as of 3 months postoperatively, while the other patient informed me that she
had become capable of singing higher notes postoperatively.
Conservative Approach to Direct Surgical in the Vocal Cord 155

Again, excessive evaporation of the vocal cord will deteriorate the voice irre-
versibly and almost incurably. However, this therapeutic modality seems most
promising, if adequate doses and site for laser application are established.

S.10 Conservative Approach to Direct Surgical Intervention in

the Vocal Cord
Whatever measures are taken to reduce the mass of the vocal cord, there is an
accompanying risk of hindering the vocal cord vibration as a result of scarring.
Excessive reduction of the vocal cord mass will cause imperfect closure of the
glottis during phonation and a great deal of scarring, thereby deteriorating the
voice seriously. Similarly, excessive scarring in or on the vocal cord caused by
longitudina incisions will increase the stiffness, producing diffculty in phonation.
It should be emphasized that any attempt to increase the stiffness or reduce
the mass by direct cordal intervention always involves some risk of deteriorating
the voice quality. A conservative approach should be taken in performing direct
cordal surgery to elevate the vocal pitch.
The pitch elevation thus far obtained in direct cordal intervention is not as
great as expected, but none of the patients had any difficulty with phonation.
This implies that the surgical intervention can safely be extended a little further
in order to gain more elevation of the vocal pitch. Further accumulation of clinical
data after step-by-step surgical procedures will provide information as to the
most appropriate extent and site of intracordal intervention to be done for a
desired pitch elevation.
9. Combined Technique:
Medialization and Tension Adjustment

The preoperative manual test is capable of predicting to some extent the out-
come of surgery. The intraoperative manual test provides a more reliable guide
to the mechanical changes of the vocal cord possible from surgery. After tenta-
tive medialization of the vocal cord without fixing the window in depression,
noninvasive manual slackening or tightening of the vocal cords should always be
attempted prior to the surgical procedure to observe any change in voice quality.
This test is especially important when the voice is not satisfactory at this stage or
the patient complains of some strain on vocie production.
Noninvasive slackening of the vocal cords is carried out by pressing dorsally
the midpoint of the thyroid cartilage that corresponds to the anterior commis-
sure. Mechanical slackening of the vocal cords not only lowers the vocal pitch
but also often makes phonation easier, with less sub glottal pressure required,
especially when the glottis is completely closed and the vocal cord is rather stiff.
Tightening of the vocal cord is done by pushing up the lower margin of the
cricoid cartilage with an instrument such as an elevator or the handle of a pair of
forceps. The procedure has a dual effect-pitch elevation and slight medializa-
tion of the vocal cords are also produced, particularly when the vocal cord is lax
and paralyzed.
It is preferable and sometimes possible to make a preoperative decision as to
whether surgery to change the vocal cord tension should be performed. More
frequently, however, the final decision is made intraoperatively, based on the
response to this test. If the tensing or loosening substantially improves the voice,
the appropriate surgical procedure to that effect should be added.

9.1 Medialization Combined with Slackening of the Vocal Cords

A combined technique is most frequently indicated for vocal cord atrophy, sul-
cus vocalis and scarring. After depression of the window (thyroplasty type I), a
vertical incision is made at the anterior middle one-third line of the thyroid ala,
just as described on Page 135.
The incised edges are first overlapped so that the lateral edge comes under the
medial one, then the vocie and the laryngeal finding are assessed. If the overlap-
ping is judged to cause excessive medialization, a vertical strip excision, 2 mm
wide is done instead of the overlapping.
158 Combined Technique: Medialization and Tension Adjustment

Fig. 9.1. Incisions in the ala for thyroplasty I and III make the lower frame, marked X, of
the window flimsy, and the vertical shim which has to be put under the lower frame of the
window is not suitable for fixing the window

Silicone

Fig. 9.2. A shim should be placed transversely in this case to avoid pressure on the infirm
lower frame of the window
Medialization Combined with Slackening of the Vocal Cords 159

Fig. 9.3. A plug can be used for fixation of the window without much of a pressure
burden on the lower frame

a b
Fig. 9.4. a Relaxation and slight medialization of the vocal cord by overlapping the verti-
cally incised edges. b Relaxation and substantial medialization accomplished by removal
of a vertical strip and transplantation of a cartilage piece
160 Combined Technique: Medialization and Tension Adjustment

A modification that is necessary for the combined technique concerns fixation

of the window. The inferior frame of the window (Fig. 9.1) is now not firm
enough to hold down the silastic implant for fixation of the window. The shim
has to be inserted transversely (Fig. 9.2) or plug type fixation is employed (Fig.
9.3).
Simultaneous medialization and slackening of the vocal cord can be achieved
without making the window (Fig. 9.4). For slight medialization, just an overlap-
ping of the incised edges, with the posterior one inside, may be sufficient. More
medialization can be carried out by transplanting a cartilage piece through the
vertical incision.

9.2 Medialization Combined with Tightening of the Vocal Cords

The indication for this type of surgery is vagus nerve paralysis, especially with a
brain lesion origin.

9.2.1 Thyroplasty Type I and Cricothyroid Approximation

Combination of thyroplasty type I (window medialization) and cricothyroid

approximation is somewhat difficult because the suture sites for the cricothyroid
approximation on the thyroid ala become narrow and insufficient for the strong
force pulling the cricoid cartilage upward. If cricothyroid approximation is an-
ticipated prior to surgery because of the manual test (Fig. 9.5), the window is
made narrow to leave a wide cartilage bar frame along the lower margin of the
cricoid cartilage. An alternative may be to shift the suture sites on the thyroid
cartilage more laterally than in the standard technique for cricothyroid approx-
imation (Fig. 9.6), or Lee's long-suture technique (Fig. 8.5) may be used.

\
,r""\
\ \
! \
\O"J.t \
'.
"

Fig. 9.5. Manual test for medialization

and cricothyroid approximation. The
lower border of the cricoid cartilage is
pushed upward while the thyroid alae
are pressed medially
Medialization Combined with Tightening of the Vocal Cords 161

Hole

C-T distance

Fig. 9.6. Thyroplasty type I combined with cricothyroid approximation. The window
may be made narrower so that a sufficiently wide and firm area is left inferiorly for the
suture to pull up the cricoid. C- T distance distance between the cricoid and thyroid
cartilages at the median line. The slashed area is undermined from below between the
cartilage and the inner perichondrium prior to making holes for threading sutures to pull
up the cricoid

Cartilage
flap

Tantalum
shim

Silastic
implant

Fig. 9.7. Combination of medialization and tightening of the vocal cord by Koufman.
Medialization by silastic implant and tightening by anterior displacement of a cartilage
flap incorporating the anterior commissure
162 Combined Technique: Medialization and Tension Adjustment

9.2.2 Koufman's Technique

A U-shaped, superiorly based cartilage flap is made at the anterior portion of the
thyroid cartilage (Tucker's technique), and the inner perichondrium is elevated
from the cartilage at the level of the vocal cord only on the side lateral to the
incision. The space thus created holds a silastic implant or a piece of cartilage for
vocal cord medialization (Fig. 9.7). The U-shaped flap is fixed by a shim at an
anteriorly displaced position for tightening the vocal cord.
10. Spastic Dysphonia

10.1 Definition and Diagnosis

Spastic dysphonia, first reported by Traube in 1871 2°, has been controversial in
every aspect-definition, etiology, symptoms, diagnostic basis, and treatment.
The diagnosis is usually made auditorily on the basis of a strange strenuous man-
ner of phonation. It has been described as strained, harsh, tight, strangulated,
tremulous, squeezed voice, overpressure, vocal arrest, etc. Tentatively, it may
be defined as dysphonia caused by spasm or excessive contraction of the intrinsic
laryngeal muscle. It is often accompanied by spasm of the other muscles in the
neck and oropharyngeal region.
As spasm is classified into tonic and clonic forms, spastic dysphonia can be
grouped into tonic and clonic types. The former is characterized by tonic spasms
of the adductor muscle, which result in excessively tight closure of the glottis and
a consequent strained and squeezed voice or even aphonia. The contour of the
neck muscles, particularly the strap muscle, is often quite prominent due to spas-
tic contraction of the muscle. The clonic type is characterized by a tremor-like
voice, often attended by synchronous movement of the mandible and perhaps
other articulatory organs. A mixed type of the two occurs, and very rarely a type
of spasm of the abductor muscle on phonation is also seen.
The incidence of the disease seems to vary greatly from country to country,
being probably most frequent in the United States of America. It is rather rare in
Japan. Diagnostic criteria are not yet universally established, and some spastic
dysphonia may be diagnosed as a type of hyperfunctional dysphonia. Using a
neck-contact speech accumulator devised for measuring the time of vocal cord
vibration during a day, Watanabe et al. (198720 ) found that a patient with spastic
dysphonia had an extremely high score in speaking time, indicating hyperactivity
of the larynx. From the patient's common complaints, i.e, reluctance or inability
to speak, this is rather an unexpected finding.
The etiology is mostly unknown, although psychogenic factors have been con-
sidered to precipitate the disease (Berendes 19392°; Segre 19512°; Moses 19542°;
Heaver 19602°; Bloch 19652°; Brodnitz 19762°).
Aronson et al. (1968a20) found that patients with spasmodic dysphonia were
as a group less psychoneurotic than the average clinic population. They propose
a neurological aspect to the disease, suggesting the extrapyramidal tract as the
possible site of the lesion (1968b 20).
164 Spastic Dysphonia

A recent survey on 200 patients matched to 200 controls by Izdebski et al.

(198420 ) rather suggests a nonpsychogenic, nonbehavioral causation. From new
observations with the help of a complex inpatient treatment, however, Krum-
bach (198720) puts forth the view that a psychogenic factor can be one of the
multiple etiologies for spastic dysphonia. Robe et al. (196020) are among those
who believe that spastic dysphonia is of neurological origin at least in some
patients, based on the findings such as a high percentage (90%) with an EEG
abnormality and some neurological signs. Aronson and Hartman (198120 ) found
similarities of spastic dysphonia to essential voice tremor, suggesting a linkage
between them.
According to the early report by Dedo et al. (19772°, 19782°), an abnormal
histological finding, e.g., myelin abnormality, was found in 30% of the recurrent
laryngeal nerve sectioned during surgery. This finding in favor of the organic
theory seems to have been somewhat toned down later. In their later light and
electron microscopic study, Carlsoo et al. (1987 20) stated that there were no
significant differences between the sectioned nerve in spastic dysphonia and con-
trols in terms of myelinated or unmyelinated fibers; the slight morphological
differences which were found between the two were not significant enough to
explain the causation of the disease. While Boccino and Tucker (1978 20) found
pathological signs, De Santo et al. (197920 ) denied any neuropathic abnormality
in the recurrent laryngeal nerve in spastic dysphonia.
What is termed spastic dysphonia may not be a single disease but a symptom
complex of various diseases of different etiological natures. Usually in singing
the spasm does not occur or may be less severe than during speech. The disease
is quite resistant to voice therapy, which is believed to be effective only at a very
early stage. Even when therapy is somewhat effective, recurrence of the symp-
toms is common.

10.2 Surgical Treatment

Berendes (1939 20 , 195620 ) reported a patient with spastic dysphonia in whom a
recurrent laryngeal nerve section during thyroid surgery resulted in temporary
relief from the symptom for a period of 1 month.

10.2.1 Sectioning the Recurrent Laryngeal Nerve (Dedo)

Dedo in 19762° reported surgical section of the unilateral recurrent nerve first as
a treatment for spastic dysphonia with a dramatic, immediate improvement of
the voice. The treatment has been performed by many surgeons such as Levin et
al. (197920) and Biller et al. (19792°, 198320 ) with varying degrees of success.
In order to decide the indication for surgery a routine recurrent laryngeal
nerve block was utilized as a preoperative test (Dedo 19762°; Izdebski et al.
19792°), but it was later discontinued (Dedo and Izdebski 1983a20 ) because it
does not predict long-term surgical results. Without the block procedure, Dedo
and Izdebski (1983 20) state that the postoperative results can be predicted by the
preoperative vocal characteristics and other criteria. The recurrent laryngeal
nerve is always sectioned on the left at the level of the inferior pole of the thyroid
Surgical Treatment 165

gland. They caution that the topographical relation of the recurrent laryngeal
nerve to the tracheoesophageal groove is likely to be changed by surgical retrac-
tion of the surrounding tissue and advise the use of the facial nerve stimulator for
identification in combination with fiberscopic observation of the larynx, so as not
to cut the inferior thyroid artery and Galen's anastomosis by mistake.
The main problems appear, as they state on the basis of over 300 cases (Dedo
and Izdebski 1983b2o , 198420 ), to be related to the occasional occurrence of a
persistent, weak, breathy voice (8%-10%) and later recurrence of vocal spastic-
ity (10%-15% in long-term follow-up studies). They attributed the recurrent
spasticity mostly to reduced glottal space and advised vocal cord thinning or
widening of the glottis by staged applications of the CO 2 laser to the vocal cord
body, together with supportive voice therapy.
A higher rate of recurrent spastic dysphonia was, however, reported by Aron-
son and De Santo (1981 20 , 198320 ): of 33 patients, voice improvement was main-
tained in 82% at 1 year, 58% at 2 year, and 36% at 3 years postoperation, as
assessed on the recorded voice by a speech pathologist. Sapir et al. (198620 )
reported on the over 4 years' follow-up results of recurrent laryngeal nerve sec-
tion for adductor spastic dysphonia; according to patient self-assessment, voice
quality was better in 88% and effort easier in 84%. Clinician's ratings of the
patients' voices they found were highly consistent and reliable but severer than
those by the patients. They discussed this discrepancy between these two assess-
ment methods.
Fritzell et al. (1982 20 ) reported on four patients with spastic dysphonia in
whom the recurrent nerve was sectioned. The immediate effect was dramatic in
all four, but the symptoms recurred in two. Reoperation eliminated the symp-
toms, again in one but had no effect in the other. From the electromyographic
findings, it was assumed that most, if not all, recurrences are due to reinnerva-
tion of the paralyzed laryngeal muscles from the sectioned end and possibly even
from the contralateral side or the superior laryngeal nerve.
Whatever surgical methods may be used for spastic dysphonia, the greatest
problem is the recurrent spasticity, though the reported rates are diverse even
for the same procedure. It seems that the cause of recurrence has not yet been
analyzed fully. As possible causes, Dedo and Izdebski (198420 ) suggested rein-
nervation, repositioning of the paralyzed vocal cord toward the midline, lack of
postoperative voice therapy, and poor patient selection. Limiting the discussion
to the glottal level, the possibilities would be: (a) return or further enhancement
of excessive adduction of the intact cord; (b) gradual change in the position of
the paralyzed cord; (c) reinnervation; or (d) regained mobility of the once
almost paralyzed vocal cord by reinforced contraction of the muscles which are
ordinarily not significant adductors but remained intact even after recurrent
laryngeal nerve section. As to the last factor, Dedo and Izdebski (1983a20 ) men-
tioned that later additional section of the ipsilateral superior laryngeal nerve had
always resulted in failure. However, the function of the interarytenoid muscle,
which is innervated bilaterally, and of the extrinsic laryngeal muscles, though
probably much less significant than the intrinsic muscles, need to be evaluated
thoroughly in connection with the recurrence.
Briefly, mobility and position of the vocal cords under spastic conditions
should be analyzed quantitatively using videorecording, for instance. Resurgent
166 Spastic Dysphonia

overadduction of the intact cord seems the most likely cause though (Aronson
and De Santo 198320 ).
There is no doubt that Dedo's surgery has relieved the majority of patients
treated from a great communication disability, but some problems also remain.
Besides the recurrence rate and occasional breathy voice, respiratory distress
after the nerve section requiring tracheotomy in three patients was also reported
by Salassa et al. (1982 20 ). Although this symptom cannot be fully attributed to
the surgery, it illustrates the need for further development of new treatment.
Biller et al. (1979 20 ) preferred crush of the nerve to sectioning, which resulted
in initial improvement in all patients, but it was maintained only in 13% after 3
years. Dedo and Izdebski (1983a 20 ) reported 100% recurrence of spasticity in six
patients treated with this nerve crush.

10.2.2 Selective Section of Nerve Branch to Adductor Muscles (Iwamura,

Carpenter)

In the sixth symposium of care of the professional voice at the Juilliard School,
New York (van Laurence 19772°), I proposed sectioning the nerve branch to the
lateral cricoarytenoid muscle only, instead of the whole recurrent laryngeal
nerve. It seemed that this selective section would at least solve the problems of
respiratory distress. So far there have been two reports of the selective section
technique.
°,
In 197920 and 19862 Iwamura reported the technique of cutting solely the
branch to the thyroarytenoid muscle through a window 10 x 5 mm made on the
thyroid ala (Fig. 10.1). Before sectioning, the nerve branch to the thyro-
arytenoid muscle is identified by electrical stimulation. After the division, the
cut end of the nerve is electro coagulated in order to prevent spontaneous reanas-
tomosis. From 1979 to 1986, he performed selective section of the thyr-
oarytenoid branch of the recurrent laryngeal nerve in 20 patients, 14 of whom
could be followed. The results were complete cure in 3, marked improvement in
10, moderate change in 1. He emphasized postoperative voice training, recom-
mending high-pitched phonation.
°,
Carpenter et al. (1979 2 1981 20 ) described a technique of sectioning the ad-
ductor branch of the recurrent laryngeal nerve. Under general anesthesia, the
right recurrent laryngeal nerve is first identified at the inferior pole of the
thyroid gland just lateral to the trachea and carefully dissected superiorly until
reaching the division into three branches. The adductor branch, most likely the
middle larger one, is identified by nerve stimulation under direct laryngoscopy,
and a l-cm segment is removed. The phonatory results were similar to those
of complete nerve section, though the details are not described.

10.2.3 Selective Section of the Thyroarytenoid Muscle

As a means of selective sectioning of the thyroarytenoid muscle and its innervat-

ing nerve branch, Takayama et al. (1988 20 ) utilized a longitudinal incision in the
vocal cords in a patient with not so severe spastic dysphonia. The surgery was
performed under general anesthesia with laryngomicrosurgical technique. No
recurrence was noted 2 years postoperatively.
Surgical Treatment 167

Fig. 10.1. Surgery for spastic dysphonia. Iwamura's technique for sectioning of the nerve
branch to the adductor muscles. A window 10 X 5 mm is made on the thyroid ala, through
which the nerve is electrically stimulated for identification before sectioing

10.2.4 Thyroplasty Type II or III (Isshiki)

This type of operation aims at lateralization and relaxation of the vocal cords in
order to release the excessively tight closure of the glottis (Figs. 10.2, 10.3).
Spastic dysphonia of the tonic type is a good indication for this surgery. So far, it
has been successful in four of six patients with the tonic type, though one im-
mediate success case could not be followed up for a sufficiently long period. My
case of the clonic type did not show substantial improvement in voice quality,
though the patient felt somewhat greater ease in voice production after the op-
eration.
Under local anesthesia, the thyroid cartilage is exposed and cut vertically at
the anterior middle one-third line. The incised edges are overlapped, with the
lateral side over the median side, so that the vocal cord, or at least the posterior
portion of it, is slightly displaced laterally. The vocal changes are carefully as-
sessed both in terms of the quality and of the subjective strain for phonation.
According to the degree of voice change, further procedures are selected,
either further overlapping, with or without cartilage interposition between the
168 Spastic Dysphonia

Fig. 10.2. Surgery for spastic dysphonia. The schematic cross section indicates the effects
of surgery-relaxation and slight lateralization of the vocal cord

Fig. 10.3. Schema of the surgery performed on a patient with spastic dysphonia with cure
in the voice still evident after 6 years

edges, or the same procedure on the contralateral side (Fig. 10.2). Selection of
the procedure is made intraoperatively on a trial and error basis. The procedures
so far employed are illustrated in Fig. 10.3.
Tucker (1988 15 ) utilized laryngeal framework surgery for adductor spasmodic
dysphonia. The anterior commissure segment was retrused into the larynx, and
after confirming improvement in voice and spasticity control, the incised carti-
Surgical Treatment 169

lage edges were fixed with nylon sutures. In 9 of the 16 patients, the surgery
yielded virtually spastic-free communication for the follow-up period varying
from 7 months to just over 2 years. It was ineffective in 6, and 3 of them under-
went subsequent recurrent laryngeal nerve lysis. One patient experienced initial
relief of spasm but it returned 1 month thereafter. Three months after the re-
currence, the spasm again disappeared spontaneously and has not returned for 8
months. At least short-term relief of spasm was achieved in 63% of his patients.

Vicious Circle in Spastic Dysphonia. The change in voice induced by the thyro-
plasty (which lateralizes as well as slackens the vocal cord) usually occurs gra-
dually, unlike the changes in other types of thyroplasty. Under unchanged con-
ditions of overlapping, the voice tends to improve gradually. It seems that with
each act of phonation, the patient gains confidence in producing the voice easily,
with less and less tension, most likely through auditory or proprioceptive feed-
back.
From the above findings, it may be hypothesized that a kind of vicious circle is
involved in the development of spastic dysphonia. The patient cannot phonate
easily and tries harder to do so, thereby closing the glottis tighter and tighter,
which finally makes phonation almost impossible (Fig. 10.4). Thyroplasty, which
enforces a mechanical change of the vocal cord tension and position, is consid-
ered to break this vicious circle, working as pump priming.
This hypothesis seems consistent with other clinical findings. In one patient, a
prominent muscle contour in the anterior neck, which had remained for a while
after the operation, gradually disappeared as the patient gained confidence and
mental stability. It is conceivable that voice therapy is effective only at the very
early stage of this illness since the vicious circle can only be interrupted or re-
versed before it is firmly established. At the very early stage, procedures other
than voice therapy, such as local anesthesia of the cricothyroid muscle, can also
be of some help in breaking the circle.
In two of the four patients with the tonic type of spastic dysphonia, signs of
recurrence, e.g., subjective difficulty in phonation, emerged several months
after operation. In one, a couple of sessions of speech therapy to enhance re-
laxation were sufficient to bring about an apparently permanent cure (at more
than 6 years postoperation). In the other case, additional section of the strap
muscle eliminated the early signs of recurrence.
Voice therapy after surgery is of critical importance in maintaining good voice
production.
Of course, this hypothesis is only one of the multiple etiological or precipitat-
ing factors in spastic dysphonia, which is very diverse in clinical manifestation.
One severe case of adductor spastic dysphonia of tonic type failed to respond
substantially to this type of operation. During operation, the voice sounded less
and less strangulated with ease of phonation but not to a level satisfactory to
both patient and surgeons. Because of past experience with a similar patient who
showed gradual continued improvement, further surgical procedures were post-
poned to observe the outcome for a while with intraoperative consent of the
patient. As of follow-up at 2 months, there is no sign of further improvement of
the voice. Sectioning the adductor muscles is designed for this patient as the final
procedure (Page 172).
170 Spastic Dysphonia

IAphonia I

(
HIgher subitt
· goaI
~n Incr.
for phonal"n,
muscle tonus
. L - - - r - - - - -........
pressure required

Forced relaxation of
the V.F. by operation
Tighter closure
of the glottis

Fig. 10.4. Vicious circle in spastic dysphonia. The patient cannot phonate easily and tries
harder to do so, thereby closing the glottis tighter and tighter, which only worsens the
situation

10.2.5 Injection of Botulinum Toxin

The recent trend is to regard this disease as a disorder of central motor process-
ing. Based on clinical and EMG findings, Blitzer (1985 20) and Blitzer et al.
(198()2°) classify spastic dysphonia as a type of dystonia, a neurological disorder
characterized by abnormal, often action-induced, involuntary movement or un-
controlled spasms. Such laryngeal dystonia may present focally or in association
with other dystonic movements. Furthermore, they later (198820) utilized local
injection of botulinum toxin (Botox) effectively in treating laryngeal dystonia
(spastic dysphonia). The toxin acts presynaptically at nerve terminals to prevent
calcium-dependent release of acetylcholine, thereby producing a chemical de-
nervation effect (Kao et al. 197()2°). It is injected into the vocalis-thyroarytenoid
muscle complex bilaterally through the cricothyroid membrane, with a monopo-
lar, tefton-coated, hollow, EMG recording needle. Fluency of voice induced by
the injection lasted 3-6 months for each injection.
Breathiness and slight aspiration occurred for the initial 3 days, otherwise no
side effects were noted. Although determination of the optimal dose and the
correct frequency awaits further research and clinical experience, this rather
conservative treatment is certainly an important treatment option for patients
with spastic dysphonia.

10.2.6 Electrical Stimulation of the Recurrent Laryngeal Nerve

Friedman et al. (1987 20 ) are trying to develop an entirely new type of treatment.
Five patients with spastic dysphonia were treated with unilateral electrical stim-
ulation given by a needle electrode percutaneously inserted into the region of
the recurrent laryngeal nerve. During the period of electrical stimulation, three
patients demonstrated dramatic improvement of voice, judged to be almost nor-
Surgical Treatment 171

Composite graft

Fig. 10.5. Surgical possibility 1 for spastic dysphonia: widening of the anterior glottis by
transplantation of a mucos-cartilage composite graft

mal. The other two had minimal improvement. During stimulation no obvious
change in the vocal cord position was noted under fiberscopic observation. Ex-
perimental study is in progress to make implantation of a nerve stimulator clini-
cally feasible for those patients who respond well to percutaneous stimulation.

10.2.7 Tissue Evaporation

Dedo and Izdebski (1983a 20 ) recommended partial evaporation of the vocal cord
by laser in patients in whom the nerve section and voice therapy failed.

10.2.8 Other Possibilities

There are a number of operations that may be utilizable for treating spastic
dysphonia. Their aim is mechanical widening of the glottis during phonation.

Expansion of the Anterior Commissure. After laryngofissure, the vertical gap at

the anterior commissure is filled with a mucosa-cartilage composite graft 2-3
mm wide so as to maintain the lateral expansion. The composite graft may be
taken from the nasal septum or produced of oral mucosa and a thyroid cartilage
piece in combination (Fig. 10.5). Probably a two-stage operation is preferred to
a one-stage one for the secured survival of the transplant and for the prevention
of granulation or adhesion at the anterior commissure.
A part of the epiglottis may be utilized to put in the split anterior commissure
as a slide-down flap.

Lateralization of the Vocal Cord Through a Window. A rectangular incision is

made in the thyroid ala just as in thyroplasty type I, and the cartilage piece is
removed to open a window. Through the window, the soft tissues lateral to the
172 Spastic Dysphonia

Fig. 10.6. Surgical possibility 2 for spastic dysphonia: lateralization of the vocal cord
through a window. The soft tissue lateral to the vocal cord including the muscle is pulled
laterally through the window

vocal cord (vocalis-thyroarytenoid muscle complex) are pulled laterally by sever-

al sutures so as to lateralize the vocal cord (Fig. 10.6).
Most likely, a cartilage piece or a silicone plate larger than the window is
needed as a bolster for the sutures. One of the problems in this type of operation
would be the long-term effect: how long the sutures can maintain the vocal cord
in the lateralized position against the force of the adductor muscles without
being torn from the tissue. It may be recommended to add a surgical procedure
to inactivate some of the muscle fibres which are exposed just beneath the
window.

Controlled Deprivation of Adductor Function (Sectioning Adductor Muscles).

Under local anesthesia, an approach is made to the muscle process by applying
the same technique as arytenoid adduction, except for dislocation of the cri-
cothyroid joint. Since the recurrent laryngeal nerve runs just posterior of the
joint, the inferior horn is cut at its root so that retraction of the posterior margin
of the thyroid ala leaves sufficient space for approaching the muscle process. The
arytenoid cartilage can be identified by palpation as a small mobile hard sub-
stance lying on the hard ground (the cricoid cartilage). Without opening the
cricoarytenoid joint, the adductor muscle fibers attaching to the front surface are
sectioned little by little under laryngoscopic control and auditory monitoring of
the voice (Fig. 10.7) .
In view of the possible recurrence of the symptom as previously reported, the
procedure should be performed rather excessively until the voice becomes a bit
Surgical Treatment 173

Fig. 10.7. Surgical possibility 3 for spastic dysphonia . Under local anesthesia the adduc-
tor muscles are sectioned step by step, while being followed by laryngoscopic and voice
monitoring

Fig. 10.8. Surgical possibility 4 for spastic dysphonia: Woodman's operation

174 Spastic Dysphonia

breathy and the glottis remains slightly open during phonation. The muscle
should be separated far enough from the arytenoid facet to prevent reconnec-
tion. If it is possible to determine how much muscle is to be sectioned, surgery is
better performed under general anethesia using an electrocoagulator to cau-
terize the muscles.

Woodman's Operation. A similar technique to arytenoid adduction is utilized to

expose the muscle process region, with care being taken not to injure the recur-
rent nerve. The joint is opened, and one or two 4-0 nylon sutures grasp suf-
ficient tissue around the vocal process. Two holes are drilled near the posterior
edge of the thyroid ala, and the sutures are threaded through the holes. During a
phonatory attempt the sutures are pulled laterally to adjust the extent of later-
alization of the vocal cord (Fig. 10.8). From experience with Woodman's opera-
tion, much greater force is required to lateralize the vocal cord than to medialize
it, and rebound also seems likely to occur in the long run. This technique alone
would probably be insufficient to accomplish long-lasting adequate lateraliza-
tion of the vocal cord. It may be used as an adjunct to the muscle sectioning
technique.
Perhaps this can be used additional to the other procedures when they are
insufficient to accomplish the purpose.
11. Surgical Managment of Scar of the Vocal Cord

11.1 Mucosa Transplantation

In the introductory section of this book, it was mentioned that wide scarring of
the vocal cord, such as after laryngeal trauma, is almost incurable by the ther-
apeutic means currently available.
Okamura et al. (1987 21 ) demonstrated experimentally that after secondary
healing of the vocal cord mucosa, the vibratory pattern was of reduced ampli-
tude, and there was reduced mucosal vibration during phonation. Based on ex-
perimental work with dogs, they recommend that any raw surface of the vocal
cord created by surgery be covered with a mucosa transplant if it cannot be
covered with a local flap. For the purpose of mucosa grafting through a laryngo-
microsurgical approach, they found an activated human fibrinogen concentrate,
a biological tissue adhesive, most useful to obviate complicated suturing for fixa-
tion of the mucosa transplant. The activated human fibrinogen concentrate is
said to consist of lyophilized human fibrinogen and lyophilized bovine thrombin
(Fig. 11.1).
The vocal cord excised for glottic cancer was reconstructed with a posteriorly
pedicled mucosal flap of the false vocal cord in 18 patients by Fujioka et aP1 in
1986. This technique may be utilized to replace the wholly scarred vocal cord.
My recent experience of one patient with a wide and thick glottal web has
demonstrated that mucosa transplantation to the whole vocal cords could be a
solution to the problem. A 26-year-old woman had undergone repeated exci-
sions of laryngeal papillomas since the age of 4 months. The two vocal cords
were in adhesion over a wide area except for the posterior portion, both vertical-
ly and anteroposteriorly. The patient's voice was almost aphonic. Under laryn-
go microsurgical control, the web was totally excised and a silicone stent was
placed at the glottis for 2 months to prevent readhesion. The voice showed no
improvement. Using a laryngofissure technique, skin grafting was done then
without producing much improvement of the voice. The patient complained of a
breathy voice and difficulty of expectoration. The second operation, mucosa
transplanation, was performed as follows.
176 Surgical Management of Scar of the Vocal Cord

iological
adhesive

Fig. 11.1. Okamura's technique of using biological adhesive for mucosa graft to the vocal
cord

Technique. Under general anesthesia by intratracheal intubation through the

tracheostoma, the larynx was opened anteriorly (laryngofissure) to expose fully
the bilateral vocal cords. The scar tissue in the bilateral subglottic and glottic
regions was totally removed, including the previous skin graft. Mucosa was
taken from the deep portion of the lower lip and divided into two to match the
raw surfaces of the two vocal cords (Fig. 11.2).
The mucosa was sutured to the raw surface of the vocal cord with 6-0 nylon.
The donor site was left unclosed. A special compression technique for the mu-
cosa graft was employed.
An elastic silicone block, used as a core, was thickly covered by a soft, com-
pliant silicone called ear putty, and this material was then wrapped in the finger
portion of a surgical rubber glove (Fig. 11.3). This three-layer material was
placed in the glottal region to compress the whole grafted mucosa with an ade-
quate pressure. A mattress suture, 3-0 nylon, which passed through the skin,
silicone core, and skin again, stabilized the soft silicone stent in place. The
reason why a rubber surgical glove was used as a cover was to prevent the soft
silicone from tearing during the compression and fixation of the mucosa. The
stent was removed after 10 days, and the graft as a whole took well.
The rough-surfaced skin graft was totally replaced by the smooth mucosa. At
42 days after the removal of the stent when the epithelialization of the anterior
commissure region had been completed, the laryngofissure was closed; the
Mucosa Transplantation 177

Fig. 11.2. Mucosa taken from the oral mucosa (lower lip) for transplantation to the vocal
cord surface defect

111I'Ilttlll
. I
Fig. 11.3. A soft pliable stent for fixation of mucosa transplant to the vocal cord. An
elastic silicone, used as a core, is thickly covered by a soft compliant silicone called ear
putty, and this material is further wrapped in the finger portion of a surgical rubber glove
(scale is in cm)
178 Surgical Management of Scar of the Vocal Cord

~
Mattress suture
Thyroid
cartilage ~r- for approximating
the incise cartilage
Mucosa ~ edges
transplant
..,.,

~ Thyroid ala
~Silicone block
Fig. 11.4. Surgical procedures performed for a wide scarring of the vocal cords: mucosa
transplantation, closure of the laryngeal fissure, and thyroplasty type I

utmost care was taken to achieve a suitably tight approximation of the anterior
incised edges of the thyroid cartilage. For this fine adjustment, the surgery was
done under local anesthesia with voice monitoring. Later, thyroplasty type I, a
window medialization, was added to improve the glottal closure during phona-
tion. The surgeries performed on the patient are summarized in Fig. 11.4.
The improvement in the voice and vocal efficiency was remarkable; it sur-
passed my expectation and was to the patient's satisfaction (Fig. 11.5)
The three cardinal conditions for a skin or mucosa graft to take are complete
hemostasis, fixation, and adequate compression. The grafting becomes difficult
when the recipient site is uneven, mobile, or liable to contamination. These
three unfavorable conditions all apply to the glottal region. With the use of the
soft silicone, compliant enough to fit any uneven surface, the difficulty in grafting
mucosa in the glottal region seems at least partly to have been overcome.
It may be concluded that mucosa grafting for an extensively scarred vocal cord
is a worthwhile technique to attempt, when other, more conservative means do
not seem to have succeeded.

11.2 Collagen Injection

Recently, injectable collagen is being used to remove glottal insufficiency caused
by paralysis or atrophy (Ford and Bless 1986a,b22 ; Joussen 198622 ; Okamoto et
al. 198622 ; Yumoto et al. 198822 ). Ford and Bless reported the scar-softening
effect of injectable soluble collagen such as that used for vocal cord augmenta-
tion.
Mucosa Transplantation 179

"~ ... ~i6 a

-----------------

IUf'It \.~ !j~ b

Fig. 11.5. Digital sonagrams of the patient's voice before (a) and after (b) mucosa trans-
plantation: narrow band, vowel [a]
12. Remobilization of the Paralyzed Vocal Cord

Remobilization is the goal of treatment for vocal cord paralysis. A number of

experimental as well as clinical attempts have been made to achieve this, mostly,
however, without attaining practical application.

12.1 Nerve Anastomosis (Nerve to Nerve or Nerve to Muscle)

Direct reanastomosis of the sectioned or injured recurrent laryngeal nerve or its
modification has been made by many investigators such as Horsley (1909 23 ),
Frazier (1924 23 ), Lahey (1928 23 ), Shimazaki (1957 23 ), Mielke (1958 23 ), Doyle
et al. (1967, 196823 ), Tomita (1967 23 ), Gordan and McCabe (1968 23 ), Dedo
(19712 3), Murakami and Kirchner (1971 23 ), Shin (19712 3 ), Tashiro (1972 23 ), and
Sato and Ogura (1978 23 ). Despite sporadic successes, it now seems conclusive
that this technique does not bring about effective vocal cord movement, as clear-
ly demonstrated, for example, by Boles and Fritzell (1969 23 ). Failure to restore
the functional mobility even in immediate reanastomosis of the experimentally
sectioned nerve ends would appear to be explicable by misdirection in the pro-
cess of nerve regeneration.
Sunderland and Swaney (1952 23 ) demonstrated that the two antagonistic
fibres, adductive and abductive, in the recurrent laryngeal nerve are randomly
intermingled. On the basis of electromyographics findings, Siribodhi et al.
(1963 23 ) in dogs and Hiroto et al. (1968 23 ) in humans noted a discrepancy be-
tween the active electric potentials of the laryngeal muscles and the vocal cord
immobility. The latter group attributed this to probable misdirection of the re-
generated nerve fibers. Dedo (1971 23 ) criticized some of the previous studies, in
which he thought that adduction of the vocal cord resulting from contraction of
the cricothyroid muscle may have been misinterpreted as restoration of mobility
by nerve anastomosis. In interpreting the laryngoscopic finding, the real adduc-
tion of the vocal cord should be distinguished from the apparent adduction
secondary to rotation of the whole larynx induced by circothyroid muscle con-
traction.
Besides the misdirection, the factors responsible for the failure to restore nor-
mal mobility of the vocal cord include neuroma formation at the site of nerve
anastomosis, failure of the nerve fibers to penetrate the scar tissue, spasmodic
uncoordinated movement of the vocal cord, a time lapse between injury and
182 Remobilization of the Paralyzed Vocal Cord

anastomosis, and the local and general condition of the animal or patient. After
these rather disappointing results, the interest in research has gradually drifted
to restoration of abduction only in the case of bilateral vocal cord paralysis.
Murakami and Kirchner (1971 23 ) demonstrated in dogs that abductive move-
ment could be restored by anastomosis of the sectioned recurrent laryngeal
nerve only when the intralaryngeal adductor nerve branches were cut.
Vagus-recurrent nerve bypass anastomosis was experiementally introduced by
Miehlke et al. (196723 ), Berendes and Miehlke (196823 ), Miehlke (1974 23 ), and
Doyle et al. (1967 23 ). An anastomosis between the recurrent nerve component
of the vagus nerve and the abductor branch of the recurrent nerve at its entry to
the larynx produced excellent results in abductor function in dogs and humans
(Miehlke 197423 ).
Iwamura (197423 ) successfully restored both adduction and abduction by anas-
tomosis of the split vagus to the adductor branch of the recurrent laryngeal nerve
and of the phrenic nerve to the abductor branch in dogs.
The proximal end of the phrenic nerve was implanted by suturing to the pos-
terior cricoarytenoid muscle with some success in restoring abduction (Wigand
et al. 1969; Fex 1970; Taggart 1971; Morledge et al. 1973 23 ). The recurrent
nerve or the split vagus ending was inserted into the posterior cricoarytenoid
muscle with some restoration of abductive capability both experimentally
(Doyle et al. 196723 ) and clinically (Mig lets 197423 ).

12.2 Nerve-Muscle Pedicle

The nerve-muscle pedicle technique was described as a method of functional

restoration of the implanted larynx by Takenouchi and Sato (1968 23 ) and Ogura
et al. (1970 23 ). It was thought suitable for treating vocal cord paralysis by Tucker
et al. (197023 ) and Tucker and Ogura (1971 23 ). Since then, the technique seems
to have gained increasing interest among surgeons.
The sternohyoid muscle with its intact motor branch from the ansa hypoglossi
or the cricothyroid muscle with its motor nerve branch was utilized for the pur-
pose of abduction or adduction, respectively. General success in obtaining
abduction was reported by Hengerer and Tucker (1973 23 ), Lyons and Tucker
(1974 23 ), Matsui (197623 ), Takenouchi (1977 23 ), and Sato and Ogura (1978 23 ).
For restoring adduction in the unilaterally paralyzed cord, Tucker (1977 23 )
utilized the nerve-muscle pedicle from the omohyoid muscle, which was inserted
into the throarytenoid muscle (Fig. 12.1). Some degree of return of adduction
was reported in all nine patients.
May and Beery (198623 ) utilized this Tucker technique, in combination with
intrachordal Gelfoam injection, for 20 patients with unilateral vocal cord paral-
ysis, and long-term improvement in voice was noted in 19, although return of
vocal cord mobility was observed in only one patient. Possible factors contribut-
ing to the voice improvement are, they cite, postopeative edema, addition of
bulk to the paralyzed vocal cord, change in the fixed position of the cord due to
muscle fibrosis, increase in tone, and/or a slight change in the level of the vocal
cord. Crumley and Izdebski (1986 23 ) also reported excellent human voice quality
following laryngeal reinnervation by ansa hypoglossi transfer in two cases, de-
Nerve-Muscle Pedicle 183

'- Lateral thyroarytenoid M.

b
Fig. 12.1a,b. Tucker's nerve-muscle pedicle. a Nerve-muscle pedicle is produced from
the ansa hypoglossi and the anterior belly of the omohyoid muscle . Stay sutures are
placed immediately adjacent to the point of entry into the muscle. b After elevation of the
unipedicled perichondrial flap, rectangular excision of the thyroid cartilage, and incision
of the inner perichondrium, the lateral thyroarytenoid muscle is exposed , to which the
nerve-muscle pedicle graft is sutured
184 Remobilization of the Paralyzed Vocal Cord

spite obtaining no improvements in the vocal cord mobility.

Anyway, the effect of the surgery on voice seems to result from the change in
rheology, mass, or position of the vocal cord, not from return of the mobility.
Recently, Rice et al. (1983 23 ) demonstrated histochemically failure of reinnerva-
tion after the nerve-muscle pedicle technique.

12.3 Switching of Intact Muscle

Remobilization of the paralyzed vocal cord was also attempted with the use of
intact muscle. To accomplish abduction, King (193923 ) connected the omohyoid
muscle to the muscle process of the arytenoid cartilage; however, this did not
work due to joint ankylosis. Evoy (1968 23 ) experimentally used the sternothyroid
muscle for the purpose of abduction, the results of which were improved by the
use of a polyethylene envelope of prevent adhesion. For the purpose of regain-
ing adduction in unilateral paralysis, Isshiki (19775 ) and Issiki et al. (19783 )
switched the cartilage-muscle flap of the cricothyroid muscle to the muscle pro-
cess (Fig. 12.2). In acute experiments with dogs, some mobility (about one-third
of normal) was noted. In one clinical case, the procedure was performed, but no
adductive movement was observed postoperatively, though the voice was much
improved by the vocal cord adduction and medialization concurrently accom-
plished by the surgical procedure. Failure to remobilize in patients was attri-
buted to mechanical friction caused by the sheer of the contacted pieces of cartil-
age upon contraction of the cricothyroid muscle, insufficient muscle force, and
perhaps most importantly postoperative adhesion. Intensive experimental stu-
dies were recently carried out by Shiba (1987 23 ), in which restoration of both
adduction and abduction was attempted by transferring the cricothyroid and
sternothyroid muscles, respectively, to the muscle process. The success rate was
75% for adduction and 50% for abduction.

12.4 Artificial Muscle

Basic research into the potential use of an artificial muscle for vocal cord mobi-
lization was made by Baken and Isshiki (1977 23 ). The items studied included the
force of each intrinsic laryngeal muscle and resultant vocal cord movement.
However, a contractile material similar to muscle that can be controlled by elec-
trical potentials as low as physiological nerve excitation voltage has not yet been
found.

12.5 Conclusion
None of the above-mentioned procedures has yet reached the stage of universal
acceptance for clinical application.
It should be stressed that the larynx of animals differs greatly from that in
humans in the extent of spontaneous recovery of vocal cord movement after
section of the recurrent laryngeal nerve. Therefore, whether the regained mobil-
Artificial Muscle 185

Fig. 12.2a-d. Switching of the cricothyroid muscle to the muscle process. a A muscle
cartilage flap is produced by reverse- U incision in the inferior portion of the thyroid ala.
b, c 3-0 nylon suture connects the muscle-cartilage flap end to the muscle process. d
Opening for the flap to go inside the thyroid ala is slightly widened by cartilage excision,
and fat tissue is packed between the thyroid ala and the flap to prevent adhesion
186 Remobilization of the Paralyzed Vocal Cord

ity is really caused by the experimental surgical procedure, such as nerve anasto-
mosis, or is simply due to any increased compensation by the muscles that are
still intact requires thorough examination, preferably by sectioning again the
anastomosed nerve to observe any change in mobility.
Any vocal cord mobility restored after nerve-muscle pedicle transplantation
should be very carefully assessed to see whether it really resulted from rein-
nervation or not. In the case of bilateral vocal cord paralysis, Woodman's opera-
tion can sometimes bring about substantial mobility of the vocal cord equal to or
a little more than that after n-m pedicle transplantation. This regained mobility
is only explained by the hypothesis that surgical procedure in the arytenoid re-
gion, such as Woodman's operation, has led to an imbalance in the contraction
force between the misdirected antagonistic muscles (see 6.6.14, p. 128). The
regained mobility after the transplantation may also be a mere result of im-
balanced misdirection of the laryngeal muscles.
13. Potentials for Research

13.1 Problems
Laryngeal framework surgery is capable of changing the position, shape, and
tension of the vocal cord to some extent to obtain a good voice. More specifical-
ly, it is quite effective in eliminating imperfect closure of the glottis, which re-
sults from vocal cord paralysis or atrophy. This type of surgery, however, cannot
alter the structural and rheological features of the vocal cord, e.g., a stiff cord
due to scarring is incurable. It is still technically difficult to increase the stiffness
of the vocal cord or to elevate vocal pitch. It is beyond the scope of this type of
surgery to change the mass of the vocal cord, alter the mobility of the vocal cord
mucosa, or remobilize the paralyzed vocal cord.
The diagnostic means presently available for assessing the stiffness of the vocal
cord are mostly still at the experimental stage. There are no definitive means for
permitting accurate preoperative planning as to what should be done with the
laryngeal framework. As a result, surgery currently has to be performed usually
on a trial and error basis. However, these repeated intraoperative trial and error
processes under simultaneous auditory and visual monitoring have provided an
enormous amount of data on the pathophysiology of voice production and a
great deal of information on how best to cope with a particular problem of dys-
phonia. Most of this, however, requires further experimental corroboration.
Some of the problems encountered in the intraoperative adjustments are de-
scribed below.

13.2 Diagnosis
13.2.1 Manual Test

The prime indication for laryngeal framework surgery is the glottal chink during
phonation, which is usually easily identifiable on laryngoscopy. If the vocal cord
is stiff, the prognosis is not as good as otherwise, and the surgical indication has
to be decided with other findings or factors taken into consideration. As pre-
viously mentioned, the manual test (6.3.1) seems to be the most practical among
the other tests. The drawbacks of the test include: In the calcified larynx, its
188 Potentials for Research

application is limited. It is too crude a procedure to make assessment from a

single trial, and phonation may be distorted by pain caused by compression of
the cartilage.
A patient with a sensitive gag reflex often responds to the manual compression
test with a reflexive strenuous manner of phonation, which makes correct assess-
ment of the test difficult. Superficial anesthesia of the pharyngo-Iaryngeal mu-
cosa may be necessary. The introduction of noninvasive, simple, reliable proce-
dures to displace, tense, or relax the vocal cord temporarily during phonation
would greatly improve the results of surgery by improving the patient selection.

13.2.2 Assessment of Vocal Cord Stiffness

There are two types of imperfect closure of the glottis: One is found in vocal
cord paralysis, atrophy, or tumor, in which the glottis does not close even with
no subglottal air flow; the other is encountered in a vocal cord with severe scar
edging, in which the glottis, even momentarily closed at the initiation of phona-
tion, is forced apart without vibration as the subglottal air passes through.
This second condition, which may be difficult to understand from clinical ex-
perience alone, can be illustrated by a simple experiment with an excised larynx.
With a repeated subglottic influx of dry air, the dessicated vocal cords set at the
midline are blown apart and remain in this state without vibrating. This experi-
ment clearly demonstrates how critical the rheology of the vocal cord, especially
its most superficial layer , is in vibration.
Medialization of the vocal cord is effective in the first type of imperfect closure
of the glottis. The second type is incurable even by medialization of the vocal
cord, because the problem is not the position but the stiffness of the cord. In-
creased stiffness of the superficial layer of the vocal cord, of course, vitually
reduces the mobility of the vocal cord mucosa, whch is essential for the Bernoulli
effect in contributing to the vibration of the vocal cord.
Some indications which may be useful in differentiating between the two types
of imperfect closure have previously been mentioned (Pages 36, 52). Some ex-
perimental work for the purpose of the differentiation is currently underway in
our laboratory. The clinical application must await the further long-term accu-
mulation of data. One approach would be the direct measurement of the stiff-
ness, mucoelasticity, viscosity, etc. of the excised vocal cord, and the next step
would be to study the larynx of living human subjects under static anesthetized
conditions, using an instrument like an oculotonometer. The second approach,
which is clinically more significant, would be made by aerodynamic analysis of
the vocal cord vibration in normal or dysphonic subjects supplied by data from
high speed photography, air flow and pressure measurements, and acoustic sig-
nals. Undoubtedly, analysis of the vibratory pattern of the vocal cords would
yield clinically very useful information on the stiffness of the vocal cord, espe-
cially if the data were matched to those obtained by the computer simulation
model of, for instance, Ishizaka and Flanagan, or Titze.
The first step toward the goal, that is, accurate assessment of the stiffness of
the vocal cord, would be to devise a practical instrument, probably a modified
stroboscope or high speed camera together with a graphic analyzer, capable of
Planned Surgery 189

providing the essential data for the computer simulation. In future, only the
voice signal of the patient may be sufficient for a rough estimate of the stiffness
of the vocal cord by computer analysis. Again, a computer simulation model for
voice production seems to be the shortest and surest way to the goal.

13.2.3 Mechanical Conditions for Vocal Cord Vibration

In the process of intraoperative adjustment of voice, the voice often approaches

a satisfactory level. The glottis appears to be adequately closed. The next trial is
usually to determine the effect of changing the tension of the vocal cord on the
voice. The intraoperative manual test is employed prior to the surgical pro-
cedure to lower or raise the tension. The problem is that the manual test is
not exactly equivalent to the surgical procedure. Even when the response to
the manual test is not so significant, the surgical procedure, without unneces-
sary pressure on the laryngeal cartilage, can often improve the voice. At the mo-
ment, it is, unfortunately, not possible to judge with confidence whether the
tension should be decreased or increased just by hearing the voice. Manual tests
are far from satisfactory, and more knowledge is needed on the mechanism of
phonation.
At present, there is almost no knowing under what mechanical conditions the
vocal cords will vibrate or not. Similarly, the threshold value of stiffness of the
vocal cord mucosa at which it ceases vibrating is not known. The threshold value
naturally varies with the initial glottal size (Ago), morphological features of the
vocal cords, and sub glottal pressure.
Three- or four-dimensional display of the conditions required for vibration of
the vocal folds is necessary to permit greater precision in surgical planning.

13.3 Planned Surgery

The trial and error tactics now employed in surgery seem to be acceptable since
constantly satisfactory results with no complications have been obtained. Such a
procedure has provided the surgeon with valuable information. Undoubtedly,
however, planning is perferable to the situation in which intraoperative decision
making is required: the latter often proves very difficult. Specifically, when per-
forming thyroplasty type III for lowering pitch, judgment is extremely difficult as
to how wide a vertical strip of cartilage should be excised or overlapped and
whether it should be performed unilaterally or bilaterally. Most surgical proce-
dures are reversible, but with some it is difficult to reestablish the original condi-
tion as in, e.g., making a narrow vertical strip excision.
After thyroplasty type I for medialization of the vocal cord, the surgeon often
examines whether tension or relaxation of the vocal cord further improves the
voice. If it is seen to be expedient to change the vocal cord tension, the first
procedure, thyroplasty type I, frequently makes a second operation difficult or
forces some, usually disadvantageous, modification. After thyroplasty type I,
(window formation), the standard cricothyroid approximation seems almost
impossible, because the cartilage portion below the window is too narrow to
tolerate the tension of the sutures which approximate the cricoid and thyroid
190 Potentials for Research

cartilages. If the combination is preoperatively planned, the design for each

procedure, e.g., the size and shape of the window, can be modified so as to
match the combination. Planned surgery will be carried out more and more with
the advent of three-dimensional (3-D) CT. The plug, wedge, interpositioning
material, or whatever is required for reconstruction of the laryngeal framework
is better prefabricated on the basis of 3-D CT calculation. Many developments
would have to be made before this prefabrication system can be realized, be-
cause at present instrumentation such as 3-D CT is of limited value due to the
dynamic nature of the larynx. Dynamic 3-D reconstruction of each individual
larynx is the first step toward achieving a simulated operation with the use of a
computer. Essential information required by the computer includes not only
specific static data but also dynamic variation of the glottal chink during phona-
tion and rheological features of the vocal cords.

13.4 Voice Therapy and Phonosurgery

13.4.1 Functional or Organic?

Discrete differentiation between functional and organic voice disorders is im-

practical in many instances, as has been emphasized by Brodnitz (1965)1 and
many others. A vocal nodule has frequently been cited as an example of dyspho-
nia which, though originally functional, becomes organic. For such functional-
organic dysphonia, voice therapy is ideally indicated; this can heal the organic
lesions gradually by eliminating causative factors, e.g., vocal abuse. Much less
frequently though, after surgical excision of the lesion, voice therapy is essential
to prevent recurrence.
The reverse aspect, i.e., organic-functional dysphonia, does not seem to have
been given much attention in the available literature. Several surgical cases of
vocal cord atrophy illustrate this type. Bilateral vocal cord atrophy was cor-
rected under fiberoptic confirmation by thyroplasty type I, but the medialization
seemed slightly insufficient. On attempted phonation, the false vocal cords
sometimes approximated to the midline, almost in contact with each other, more
medially than before the operation. This may suggest that once the patient felt
capable of phonation, he or she made a greater effort, resulting in overcom-
pensation, or excessive adduction including the false vocal cords. The vocal
quality in those cases fluctuated, being sometimes quite normal and sometimes
strained especially for speech production.
A similar phenomenon was also noted in some cases of vocal cord paralysis.
After the paralyzed cord was brought to the midline by the arytenoid adduction
technique, the intact false vocal cord adducted across the midline and produced
a bulging, resulting in a very rough strident voice. Since no surgical intervention
was made on the intact side, this sudden change in the laryngeal finding is re-
garded as functional in that surgical reduction of the glottal chink temporarily
elicited or further enhanced the preexistent overcompensation of the intact cord
including the false cord.
Intraoperatively, there is neither reason nor the surgical means to change the
manner of adduction of the intact cord, and the patient is treated by postopera-
Voice Therapy and Phonosurgery 191

tive voice therapy. Usually, after 2-3 months of relaxation and reassurance ther-
apy, the overcompensatory adduction of the false vocal cord gradually subsides,
and a normal voice is gained.
Although the incidence of such an organic-functional problem is not so high in
voice disorders, this type of functional disorder is quite conceivable when faulty
articulations such as the glottal stop in cleft palate speech are considered: These
develop as a result of organic deficiency, i. e., velopharyngeal incompetence.

13.4.2 Performing Voice Therapy First

In deciding the indication for laryngeal framework surgery, functional dysphonia

that can be cured by voice therapy alone must be excluded. If functional factors
are suspected to be involved in dysphonia, consultation with the voice therapist
and trial voice therapy for a while are recommended. These dysphonias include
excessively high male vocal pitch, spastic dysphonia, and false vocal cord phona-
tion.
A detailed discussion has been made with regard to deciding the surgical in-
dication for excessively high vocal pitch in men. In spastic dysphonia, probably
the most inveterate dysphonia, the patient is first sent to the voice therapist for
treatment, and this is followed by a joint discussion with both the therapist and
surgeon. How best to attain relaxation of the muscles involved in spastic phona-
tion seems to be the key issue in both spastic dysphonia and false vocal cord
phonation. The relaxation methods are described separately.
The other type of voice therapy-reinforced contraction of the adductor mus-
cles for phonation, e.g., pushing exercise-is frequently employed for dysphonia
with a slight glottal chink on phonation. The most common indication for this
exercise is vocal cord paralysis with slight imperfect closure of the glottis during
phonation. It is quite effective in improving the voice, especially at the early
stage of paralysis.

13.4.3 Performing Surgery First

The indication for each therapeutic modality should be individually decided.

When it is uncertain which of the two, voice therapy or surgery, should be
selected, or both appear to work, voice therapy should be carried out first as a
trial. This is certainly a safe rule to observe. If voice therapy for several months
does not bring about any significant sign of recovery, surgery may be considered.
Functional distortion of the voice based on organic or morphological problems
of the vocal cord or laryngeal framework can be more efficiently corrected by
surgery first, followed by voice therapy. This therapeutic policy is similar to that
for velopharyngeal incompetence. Continuation of unpromising futile speech
therapy for severe velopharyngeal insufficiency may create faulty articulation such
as glottal stop. The commonly accepted therapeutic policy for velopharyngeal
incompetence is, therefore, pharyngeal flap first, followed by speech therapy if
necessary.
Likewise, surgical correction of severe atrophic or bowed vocal cord should
usually be carried out prior to voice therapy. Functional training can be more
effectively performed after surgical correction of such a vocal cord deformity. In
192 Potentials for Research

my experience, the pushing exercise to reduce the glottal chink due to vocal cord
atrophy is usually ineffective and only imposes a great burden on the patient. To
make matters worse, the false vocal cords may be approximated to compensate
the glottal chink, resulting in false vocal cord phonation, in which a strident,
rough, or sometimes breathy voice is produced.
When trial voice therapy is instituted for some time without any significant
improvement, it is advisable to consider whether or not a short-cut therapy, e.g.,
surgery is indicated. A search should be made for any organic predisposition
which may lead to the functional disorder. The organic-functional problem is
very complicated; it is extremely important not to be overinfluenced by the stan-
dard types and images of particular diseases which have been firmly and long ago
created by textbooks and not to assign a patient to a disease category to which he
or she does not belong.
Even when a functional disorder is not based on any organic lesion such as a
framework deformity, the structural change accomplished by surgery may facili-
tate functional restoration, just as thyroplasty can work as a pump priming,
breaking the vicious cricle of spastic dysphonia.

13.4.4 Driver and Navigator (Pilot)

The intraoperative assessment as to whether or not to perform a further proce-

dure is made on the basis of the patient's voice and the laryngeal findings. In the
process, any change in the laryngeal findings in response to deformations of the
laryngeal framework produced by the surgeon should be accurately and scrupu-
lously assessed one by one. The surgeon can simultaneously observe the vocal
cord on a video screen, but specialization of the tasks-production and eval-
uation-seems perferable. The fiberscopist, preferably a voice scientist well
versed in voice production mechanisms, can also advise on the next surgical step
to take, just as a navigator who makes the driving easier and safer under compli-
cated circumstances (Fig. 13.1). The most difficult tasks for the fiberscopist are
related to assessing on: the degree and location of the glottal gap during phona-
tion; excessive adduction of the vocal cord, if any, especially in the case of the
arytenoid adduction technique; and the pathological laryngeal finding responsi-
ble for a particular distorted voice. The relation between the glottal condition
and the voice produced is best learnt through repeated experiments on artificial
voice with an excised larynx.

13.5 Relaxation as Postoperative Voice Training

Relaxation of the muscles of the whole body facilitates harmonious coordination
of the laryngeal muscles for phonation. A patient aged 61 years who underwent
thyroplasty type I for vocal cord atrophy illustrates how important relaxation is
for postoperative voice training. After the operation he wrote many letters in
which he complained of still having a breathy voice intermittently: this occurred
especially in the afternoon or evening. The voice sample tape he sent for evalua-
tion indicated fluctation of the voice quality during the course of a day, with
always an almost normal voice in the morning. Regardless of the patient's COffi-
False Vocal Cord Phonation 193

plaints, the voice and laryngeal findings were practically normal whenever he
was examined at the hospital (every 3 months). He said his voice was always
exceptionally good on the day of his visit to the clinic. This phenomenon often
occurs in cases of psychogenic aphonia. An interpretation may be that visiting
the university hospital provides the patient with relief from anxiety and relaxa-
tion, probably by exerting some kind of hypnotic effect.
Various positive means for relaxation such as auto-training according to the
method of Schultz, self-hypnosis, and deep breathing are taught as a means for
self-training for relaxation at home. Most of the patients at our clinic are from
remote parts of the country, and postoperative voice training is not always possi-
ble, even though its necessity is realized. Various types of home voice training
are also advised-humming, the chewing method as recommended by Brodnitz,
trial phonation with the neck twisted in various ways to find the optimal neck
position, and manual compression of the thyroid ala. In particular, relaxed
phonation in the bath-sustained vowel production or singing-is recom-
mended. The bath is an ideal place for phonation, with the relaxing effect of the
hot water, the laryngeal lubrication effect of the humidity in the room, and the
resonance effect of the, usually, small tiled room. One of the most important
keys in postoperative voice training is to help the patient to gain confidence for
voice production.

13.6 False Vocal Cord Phonation

This type of dysphonia, characterized by a breathy and strident quality of the
voice, presents a number of issues to be solved. Organic as well as functional
involvement is possible, and the two must be differentiated from each other. The
false vocal cord can protrude unilaterally or bilaterally as a result of deformity or
hypertrophy of the thyroid ala cartilage. A bilaterally protruding false vocal cord
can be a clinical manifestation of amyloidosis. Differentiation from an under-
lying tumor is the essential first step to be made by radiographic and, perhaps,
histological examination.
False vocal cord phonation can also be a sign of a hyperfunctional voice dis-
order. It can simply be a result of excessive adduction of the true and false vocal
cords in an effort to close the glottal chink due to vocal cord atrophy. This type
of false vocal cord phonation, compensating for vocal cord atrophy, is often
difficult to diagnose. Atrophic or bowed vocal cords may not be visible or may be
overlooked, because the excessively adducted false vocal cords actually cover, or
may divert the examiner's attention from, the underlying true vocal cords. False
vocal cord phonation, generally regarded as a type of hyperfunctional dyspho-
nia, can occur of course without vocal cord atrophy, as has been evidenced by
many clinical cases.
Another differentiation seems necessary between the severe type of false vocal
cord phonation and spastic dysphonia mainly for the reason that discussion can
be made on the basis of common terminology. In this book, the severe type of
false vocal cord phonation or more precisely sustained tight closure of the glottis
on attempted phonation, to the extent resulting in quasi-aphonia, is regarded as
a synonym for tonic type spastic dysphonia, because tonic contracture of the
194 Potentials for Research

adductor muscles is thought to be responsible for the dysphonia. The related

problems are discussed separately in Chap. 10.
False vocal cord phonation, if it is a purely hyperfunctional dysphonia, is an
indication for voice therapy which aims at relaxation of the muscles (Feinstein et
al. 198724 ). Depending on the result of voice therapy after several months, sur-
gical indication may be reconsidered. Feinstein et al. successfully used a carbon
dioxide laser in the excision of the hypertrophied false vocal cords.
Much remains unknown about the mechanism of false vocal cord phonation.
While Rethi (1969 24 ) explained the dysphonia with the stylopharyngeal muscle
system and recommended local injection of anesthetics (5 ml, 0.5-1 % Xylo-
caine) at the junction point from plica pharyngo-epiglottica to plica palatosty-
loidea to anesthetize the muscle, Kruse (1981 24 ) ascribed that to the dysfunction
of the "ventricular fold muscle' .

13.7 Outcome of Surgery to Elevate Vocal Pitch

Surgery to elevate vocal pitch, which was described in the previous chapter, can
hardly be said to be satisfactory or established on the basis of objective data.
There is a limit to the extent vocal pitch can be raised by applying tension to the
vocal cords. More effective means of elevating the vocal pitch seem to lie in
reduction of the vibrating mass of the vocal cord. Conservative laser evaporation
of the vocal cord seems to have a great potential here.

13.8 Lubrication of the Vocal Cord

In experimental voice production with the use of an excised larynx, it is always
noted that slight drying of the vocal cord mucosa beyond a threshold value sud-
denly causes vibration to cease. It seems that the significance of the smooth,
moist mucosa covering the vocal cord has hitherto not been fully appreciated. In
normal subjects, lubrication of the vocal cord mucosa is thought to be carried
out by the mucous glands most numerously found in the laryngeal ventricle and
saccules (Freedman 193825 ). It is controlled by the autonomic nervous system
(Hisa et al. 198225 ). Shaikh et al. (1986 25 ) found that the vibratory pattern of the
vocal cords and the voice changed as a result of atropine injection. It was also
noted that all subjects perceived an increase in vocal fatigue concomitant with
the perception of increase in dryness. The lubricatory function seems to decrease
with age. Together with the atrophic tendency of the vocal cord in senescence,
this deficient lubrication may be partly responsible for the breathy, weak, high-
pitched voice in old people, especially in men. In the excised larynx, just a few
drops of water on the vocal cord are sufficient to produce again the vibration that
had ceased due to desiccation.
Clinically, no effective lubricant is available at present. Although a nebulizer
has been employed with some drugs, the effect is questionable and temporary. A
good deal of further investigation on the role of lubrication in vocal cord vibra-
tion and its related treatment is required.
Laryngeal Pacing 195

13.9 Laryngeal Pacing

Clinical success in the cardiac and diaphragmatic pacing has led to the research
endeavor to develop practical laryngeal pacing for relieving respiratory distress
in bilateral vocal cord paralysis. The problems currently confronting the re-
searchers include a long-lasting source of electrical power, trigger source for
synchronization with inhalation, optimal mode of electrical stimulation, long-
implantable electrode and its placement, and possible biological change of the
muscle induced by long-term electrical stimulation (Bergman et al. 198426 ;
Obert et al. 198426 , 198726 ; Broniatowski et al. 1985 26 , 198726 ; Otto and Davis
198726 ).
Although laryngeal pacing has so far aimed only at abductory remobilization
for inhalation, adductory remobilization of the unilaterally paralyzed vocal cord
during phonation can also be an urgent subject of research which may find wide
clinical application in the future.
"Laryngeal pacing" may not be the right phrase for remobilization of the
paralyzed laryngeal muscles by electrical stimulation.

Fig. 13.1. Driver and navigator. Navigator (fiberoptist) leads the car (operation) onto the
right track. Laryngeal findings and voice during operation are equally important in decid-
ing which further surgical procedure to make
14. Conclusion

In summing up, three points are reemphasized for the success of this type of
surgery.

Surgical Skill. The results of cleft lip repair depends more upon how it is per-
formed than the method used, either Millard's or triangular method. This holds
true in the laryngeal framework surgery too. Taking the case of thyroplasty type
I, the procedures requiring particular scrupulousness are the design and incision
of the cartilage window so as not to damage the soft tissue inside the window.
How to perform this has a critical effect on the outcome of surgery.

Surgical Judgment. Intraoperative judgments have to be made as to the surgical

procedure to make in response to the voice produced and the laryngeal finding.
These decision-makings should be based upon the knowledge on voice produc-
tion.

Long-Term Results. The conditions that may influence on a long-term results

of surgery, such as intraoperative edema or progressive atrophy of the muscle,
should also be taken into account in deciding the procedure to make. Slight
overcorrection is usually recommended in medialization procedure for the para-
lyzed vocal cord.

The laryngeal framework surgery is a safe and effective surgery to improve the
voice. However, much remains to be further studied to develop more effective
surgeries to elevate the vocal pitch, to manage the scarred vocal cord, and to
remobilize the paralyzed vocal cord.
Selected Bibliography
Superscript numbers appended to in text reference dates indicate the corresponding
bibliographic section.

l. Textbooks 200
2. Physiology of Voice Production 200
3. Pathophysiology of Voice Production 203
Assessment of Vocal Function
4. Perceptive Assessment 204
5. Hoarseness 204
6. Aerodynamic Examination 207
7. Vocal Efficiency 209
8. Pitch Measurement 209
9. Stroboscopy 209
10. Radiographic Examination 210
11. EMG 211
12. Fiberscopy 212
13. Ultrasonic Wave 212
14. Anatomy for Laryngeal Framework Surgery 214
15. Medial Displacement of the Vocal Cord 214
16. Chordal Injection 216
17. Vocal Cord Atrophy and Sulcus Vocalis 217
18. Surgery to Lower Vocal Pitch 217
19. Surgery to Elevate Vocal Pitch, Laryngeal Asymmetry 218
20. Spastic Dysphonia 219
Surgical Management of Scar of the Vocal Cord
21. Mucosa Transplantation 223
22. Collagen Injection 223
23. Remobilization of the Paralyzed Vocal Cord 224
Potentials for Research
24. False Vocal Cord Phonation 226
25. Lubrication 227
26. Laryngeal Pacing 227
200 Selected Bibliography

1. Textbooks
Aronson AE (1980) Clinical voice disorders. Thieme-Stratton, New York
Baken RJ (1987) Clinical measurement of speech and voice. Taylor and Francis, London
Beranek LL (1954) Acoustics. McGraw-Hill, New York Tornoto London
Borden GJ, Harris KS (1984) Speech science primer, 2nd edn. Williams & Wilkins, Balti-
more London
Brodnitz FS (1965) Vocal rehabilitation, 3rd edn. Custom Printing, Rochester
Campbell E (1968) The respiratory muscles. Ann NY Acad Sci
Daniloff R, Schuckers G, Feth L (1980) The physiology of speech and hearing. Prentice-
Hall, Englewood Cliffs, NJ
Fant G (1970) Acoustic theory of speech production. Mouton 'S-Gravenhage
Flanagan JL (1972) Analysis, synthesis and perception of speech, 2nd edn. Springer,
Berlin
Gould WJ, van Lawrence L (1984) Surgical care of voice disorders. In: Arnold GE,
Winkel F, Wyke BD (eds) Disorder of human communication. Springer, Wien New
York
Gundermann H (1970) Die Berufsdysphonie. VEB Georg Thieme, Leipzig
Hirano M (1981) Clinical examination of voice. In: Arnold GE, Winkel F, Wyke BD
(eds) Disorder of human communication, 5. Springer, Wien New York
Johnson W, Darley FL, Spriestersbach DC (1963) Diagnostic methods in speech
pathology. Harper & Row, New York Evanston London
Kirchner JA (1986) Physiology of the larynx (orig. Pressman JJ, Kelemen G) Am Acad
Ophth Otol, Custom Printing, Rochester
Luchsinger R, Arnold GE (1970) Handbuch der Stimm- und Sprachheilkunde, 3 Auf!.
Springer, Wien New York
Malmberg B (1968) Manual of phonetics. North-Holland, Amsterdam
Martin JAM (1981) Voice, speech and language in child: development and disorder. In:
Arnold GE, Winckel F, Wyke BD (eds) Disorder of human communication. Springer,
Wien New York
Pressman JJ, Kelemen G (1955) Physiology of the larynx. Physiol Rev 35: 506-553
Proctor DF (1980) Breathing, speech, and song. Springer, Wien New York
Tosi 0 (1979) Voice identification: theory and legal applications. University Park Press,
Baltimore
Travis LE (1971) Handbook of speech pathology and audiology. Appleton-Century.
Croft, New York
Tucker H (1981) Surgery for phonatory disorders. Churchill Livingstone, Edinburgh
London New York
Schonharl E (1960) Stroboskopie in der praktischen Laryngologie. Thieme, Stuttgart
Van Riper C, Irwin JV (1958) Voice and articulation. Prentice-Hall, Englewood Cliffs,
NJ
Wendler J, Seidner W (1987) Lehrbuch der Phoniatrie. VEB Georg Thieme, Leipzig
Wilson DK (1979) Voice problems of children, 2nd edn. Williams & Wilkins, Baltimore

2. Physiology of Voice Production

Arnold GE (1964) Clinical application of recent advances in laryngeal physiology. Ann

Otol Rhinol Laryngol 73: 426-444
Bouhuys AE (1968) Sound production in man. Ann NY Acad Sci 155: 1-381
Dunkel E (1969) Neue Ergebnisse der Kehlkopfphysiologie. Folia Phoniatr 21: 161-178
Fairbanks G (1950) A physiological correlative of vowel intensity. Speech Monogr 17:
390-395
Fant G (1960) Acoustic theory of voice production. Mouton 'S-Gravenhage, pp 265-272
Selected Bibliography 201

Farquharson 1M, Anthony JKF (1970) Research techniques in voice pathology. J Laryn-
gol Oto184: 809-817
Fink BR (1962) Tensor mechanism of the vocal folds. Ann Otol Rhinol Laryngol 71:
591-600
Flanagan JL (1958) Some properties of the glottal sound source. J Speech Hear Res 1:
99-116
Flanagan JL, Ishizaka K, Shipley KL (1975) Synthesis of speech from a dynamic model of
the vocal cords and vocal tract. Bell Syst Tech J 54: 485-506
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cord vocal tract speech synthesizer. IEEE Transactions on Acoustics, Speech and Sig-
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Ph.D. Thesis, Northwestern University
Floyd WF, Negus VE, Neil E (1957) Observations on the mechanism of phonation. Acta
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Griesman BL (1943) Mechanism of phonation demonstrated by planigraphy of the
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Haji T, Isshiki N, Taira T, Ohmori K, Honjo I (in press) Folia Phoniatr
Hast MH (1966) Physiological mechanism of phonation: tension of the vocal fold muscle.
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Hirano M, Koike Y, Joyner J (1969a) Style of phonation. An electromyographic inves-
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Hirano M, Ohala J, Vennard M (1969b) The function of laryngeal muscles in regulating
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13: 669-672
Kaneko T, Asano H, Miura H, Ishizaka K (1971) Biomechanics of the vocal cords-on
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Koyama T, Kawasaki M, Ogura JH, Louis SM (1969) Mechanics of voice production.

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Yanagihara N, Koike Y, von Leden H (1966b) Phonation and respiration: functional

study in normal subjects. Folia Phoniatr 18: 323-340
Yanagihara N, Koike Y (1967) The regulation of sustained phonation. Folia Phoniatr 19:
1-18

3. Pathophysiology of Voice Production

Dunker E, Schlosshauer B (1964) Irregularities of the laryngeal vibratory pattern in

healthy and hoarse persons. In: Brewer DW (ed) Research potentials in voice
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Hirano M (1975) Phonosurgery. Basic and clinical investigations. Otologia (Fukuoka) 21
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Hiroto I (1966) Patho-physiology of the larynx from the standpoint of vocal mechanism.
Pract Otol (Kyoto) 59: 229-294 (in Japanese)
Ishizaka K, Isshiki N (1976) Computer simulation of pathological vocal cord vibration. J
Acoust Soc Am 60: 1193-1198
Isshiki N, von Leden H (1964) Hoarseness: aerodynamic studies. Arch Otolaryngol 80:
206-213
Isshiki N, Yanagihara N, Morimoto M (1966) Approach to the objective diagnosis of
hoarseness. Folia Phoniatr 18: 393-400
Isshiki N, Tanabe M, Ishizaka K, Broad D (1977) Clinical significance of asymmetrical
vocal cord tension. Ann Otol Rhinol Laryngol 86: 58-66
Isshiki N, Kitajima K, Kojima H, Harita Y (1978) Turbulent noise in dysphonia. Folia
Phoniatr 30: 214-224
Isshiki N (1980) Recent advances in phonosurgery. Folia Phoniatr 32: 119-154
Klingholz F, Martin F (1983) Speech wave aperiodicities at sustained phonation in func-
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Matsushita H (1969) Vocal cord vibration of excised larynges-a study with ultra-high-
speed cinematography. Otologia (Fukuoka) 15: 127-142 (in Japanese)
Moore P, Thompson CL (1965) Comments on physiology of hoarseness. Arch Otolaryngl
(Chicago) 81: 97-102
Moore P (1976) Observation on laryngeal disease, laryngeal behavior and voice. Ann
Otol Rhinol Laryngol85: 553-564
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196-212
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66:500-516
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Sonninen A (1970) Phoniatric viewpoints on hoarseness. Acta Otolaryngol 263: 68-81
Tanabe M, Isshiki N, Kitajima K (1972) Vibratory pattern of the vocal cord in unilateral
paralysis of the cricothyroid muscle. Acta Otolaryngol 74: 339-345
Tanabe M, Isshiki N, Sawada M (1979) Damping ratio of the vocal cord. Folia Phoniatr
31: 27-34
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Rhino Lar 21: 425-450
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Lancet 78: 50-53
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wave, part III. Pathologic larynx. Arch Otolaryngol 71: 16-35
von Leden H, Moore P (1961) Vibratory pattern of vocal cords in unilateral laryngeal
paralysis. Acta Otolaryngol (Stockholm) 53: 493-506
Yanagihara N (1967a) Hoarseness: investigation of the physiological mechanisms. Ann
Oto Rhinol Laryngol 76: 472-488
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Yanagihara N (1967b) Significance of harmonic changes and noise components in hoarse-

ness. J Speech Hear Res 10: 53F541
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Assessment of Vocal Function

4. Perceptive Assessment
Abe H, Yonekawa H, Ohta F, Imaizumi S (1986) Reproducibility of hoarse voice:
psychoacoustic evaluation. Jpn J Logoped Phoniatr 27: 168-177 (in Japanese)
Isshiki N (1966) C1.assification of hoarseness. Jpn J Logoped Phoniatr 7: 15-21 (in
Japanese)
Isshiki N, Okamura H, Tanabe M, Morimoto M (1969) Differential diagnosis of hoarse-
ness. Folia Phoniatr 21: 9-19
Isshiki N, Takeuchi Y (1970) Factor analysis of hoarseness. Studia Phonol (Kyoto) 5:
37-44
Pahn J (1979) Wesentliche terminologisch-diagnostische Aspekte der Heiserkeit fur die
routinemassige phoniatrische Praxis. Hauptref u Vortrage VIII Kongr, Union Europ
Phoniat, Koszeg
Takahashi H (1974) Significance of perceptual study of pathological voices. Pract Otol
(Kyoto) 67: 949-953 (in Japanese)
Takahashi H, Yoshida M, Oshima T, Sakamoto K, Tsumura S, Yamazaki T (1974) On
the differential diagnosis of laryngeal pathologies through the perceptual impression of
the voices. Pract Otol (Kyoto) 67: 1377-1385
Takahashi H, Koike Y (1976) Some perceptual dimensions and acoustical correlates of
pathologic voices. Acta Otolaryngol [Suppl] 338: 1-24
Wendler J, Anders LC (1986) Hoarse voice-on the reliability of acoustic and auditory-
classifications. In: Proceedings of 20th Congress of IALP. Tokyo, pp 438-439
Wendler J, Seidner W (1987) Lehrbuch der Phoniatrie. VEB Georg Thieme, Leipzig,
pp 133-135

5. Hoarseness (Acoucstic Analysis)

Coleman RF, Wendahl RW (1967) Vocal roughness and stimulus duration. Speech
Monogr34: 85-92
Coleman RF (1971) Effect of waveform changes upon roughness perception. Folia Pho-
niatr 23: 314-322
Cooper M (1974) Spectrographic analysis of fundamental frequency and hoarseness be-
fore and after vocal rehabilitation. J Speech Hear Dis 39: 286-297
Crystal TH, Jackson CL (1970) Extracting and processing vocal pitch for laryngeal dis-
order detection. J Acoust Soc Am 48: 118
Davis SB (1976) Computer evaluation of laryngeal pathology based on inverse filtering of
speech. SCRL Monograph 13. Speech Communications Research Laboratory, Santa
Barbara
Deal RE, Emanuel FW (1978) Some waveform and spectral features of vowel roughness.
J Speech Hear Res 21: 250-264
Emanuel FW, Sansone FE (1969) Some spectral features of normal and simulated 'rough'
vowels. Folia Phoniatr 21: 401-415
Emanuel FW, Lively MA, McCoy JF (1973) Spectral noise levels and roughness ratings
for vowels produced by males and females. Folia Phoniatr 25: 110-120
Emanuel FW, Whitehead RL (1979) Harmonic levels and vowel roughness. J Speech
Hear Res 22: 829-840
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Emanuel FW, Austin D (1981) Identification of normal and abnormally rough vowels by
spectral noise level measurements. J Commun Disord 14: 75-85
Fukazawa T, EI-Assuooty A, Honjo I (1988) A new index for evaluation of the turbulent
noise in pathological voice. J Acoust Soc Am 83: 1189-1193
Hanson W, Emanuel FW (1979) Spectral noise and vocal roughness relationships in
adults with laryngeal pathology. J Commun Disord 12: 113-124
Hecker MHL, Kreul EJ (1971) Descriptions of the speech of patients with cancer of the
vocal folds, part 1: measures of fundamental frequency. J Acoust Soc Am 49: 1275-
1282
Hiki S, Matsuoka K, Kakita Y, Imaizumi S, Hirano M, Matsushita H (1975) A study on
acoustical analysis of hoarseness. J Acoust Soc Jpn 31: 504-506
Hirano M, Kakita Y, Matsushita H, Hiki S, Imaizumi S (1977) Correlation between
parameters related to vocal vibration and acoustical parameters in voice disorders.
Pract Otol (Kyoto) 70: 393-403 (in Japanese)
Hiraoka N, Kitazoe Y, Ueta H, Tanaka S, Tanabe M (1984) Harmonic-intensity analysis
of normal and hoarse voices. J Acoust Soc Am 76: 1648-1651
Hiroto I (1967) Hoarseness-viewpoints of voice physiology. Jpn J Logoped Phoniatr 8:
1-9 (in Japanese)
Hollien H, Michel J, Doherty ET (1973) A method for analysing vocal jitter in sustained
phonation. J Phonetics 1: 85-91
Honjo I, Isshiki N (1980) Laryngoscopic and voice characteristics of aged persons. Arch
Otolaryngol106: 149-150
Horii Y (1979) Fundamental frequency perturbation observed in sustained phonation. J
Speech Hear Res 22: 5-19
Horii Y (1980) Vocal shimmer in sustained phonation. J Speech Hear Res 23: 202-209
Imaizumi S, Hiki S, Hirano M, Matsushita H (1980) Analysis of pathological voices with
a sound spectropraph. J Acoust Soc Jpn 36: 9-16
Isshiki N, Yanagihara N, and Morimoto M (1966) Approach to the objective diagnosis of
hoarseness. Folia Phoniatr 18: 393-400
Isshiki N (1977) Functional surgery of the larynx. Special Report, Jpn Soc Otorhiolaryn-
gol. ENT Alumni Association, Kyoto University, Kyoto (in Japanese)
Iwata S, von Leden H (1970a) Pitch perturbations in normal and pathologic voices. Folia
Phoniatr 22: 413-424
Iwata S, von Leden H (1970b) Voice prints in laryngeal diseases. Arch Otolaryngol 91:
346-351
Iwata S (1972) Periodicities of pitch perturbations in normal and pathological larynges.
Laryngoscope 82: 87-96
Kasuya H, Ogawa S, Mashima K, Ebihara S (1986) Normalized noise energy as an acous-
tic measure to evaluate pathologic voice. J Acoust Soc Am 80: 1329-1334
Kim KM, Kakita Y, Hirano M (1982) Soundspectrographic analysis of the voice of pa-
tients with recurrent nerve paralysis. Folia Phoniatr 34: 124-133
Kitajima K (1973) An analysis of pitch perturbation in normal and pathologic voices.
Pract Otol (Kyoto) 66: 1195-1213 (in Japanese)
Kitajima K, Tanabe M, Isshiki N (1975) Pitch perturbation in normal and pathologic
voice. Studia Phonol (Kyoto) 9: 25-32
Kitajima K, Gould WJ (1976) Vocal shimmer in sustained phonation of normal and
pathologic voices. Ann Otol Rhinol Laryngol 85: 377-381
Kitajima K (1981) Quantitative evaluation of the noise level in the pathologic voice. Folia
Phoniatr 33: 115-124
Klingholz F (1978) Die Bewertung der Heiserkeit. Folia Phoniatr 30: 257-265
Klingholz F, Martin F (1983) Speech wave aperiodicities at sustained phonation in func-
tional dysphonia. Folia Phoniatr 35: 322-327
Klingholz F, Martin F (1985) Quantitative spectral evaluation of shimmer and jitter. J
Speech Hear Res 28: 169-174
Koike Y (1969) Vowel amplitude modulations in patients with laryngeal diseases. J
Acoust Soc Am 45: 839-844
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Koike Y, Takahashi H (1971) Glottal parameters and some acoustic measures in patients
with laryngeal pathology. Studia Phonol6: 45-50
Koike Y (1973) Application of some measures for the evaluation of laryngeal dysfunc-
tion. Studia Phonol 7: 17-23
Koike Y, Markel JD (1975) Application of inverse filtering for detecting laryngeal pathol-
ogy, Ann Otol Rhinol Laryngol 84: 117-124
Koike Y, Takahashi H, Calcaterra TC (1977) Acoustic measures for detecting laryngeal
pathology. Acta Otolaryngol (Stockholm) 84: 105-117
Kojima H, Gould WJ, Lambiase A, Isshiki N (1980) Computer analysis of hoarseness.
Arch Otolaryngol89: 547-554
LaBelle JL (1973) Judgment of vocal roughness related to rate and extent of vibrato. Folia
Phoniatr 25: 196-202
Lieberman P (1961) Perturbations in vocal pitch. J Acoust Soc Am 33: 597-603
Lieberman P (1963) Some acoustic measures of the fundamental periodicity of normal
and pathologic larynges. J Acoust Soc Am 35: 344-353
Lively MA, Emanuel FW (1970) Spectral noise level and roughness severity rating for
normal and simulated rough vowels produced by adult females. J Speech Hear Res 13:
503-517
Mathews MV, Miller JE, David EE Jr (1961) An accurate estimate of the glottal
waveshape. J Acoust Soc Am 33: 843
Mori K, Fukazawa T, Haji T, Honjo I (1987) Objective evaluation of hoarse voice. J Jpn
Bronchoesophagol Soc 38: 352-355 (in Japanese)
Nessel E (1960) Uber das Tonfrequenzspektrum der pathologisch veranderten Stimme.
Acta Otolaryngol (Stockh) 157: 1-45
Passy V (1982) Hoarseness; Evaluation and treatment. Primary Care 9: 337-354
Prytz S, Frfkjaer-Jensen B (1976) Long-term average spectra analyses of nbrmal and
pathological voices. Folia Phoniatr 28: 280
Rees M (1958) Some variables affecting perceived harshness. J Speech Hear Res 1: 155-
168
Rontal E, Rontal M, Rolnick MI (1975) Objective evaluation of vocal pathology using
voice spectrography. Ann Otol Rhinol Laryngol 84: 662-671
Rontal E, Rontal M, Jacob HJ, Rolnick MI (1983) Quantitative and objective evaluation
of vocal cord function. Ann Otol Rhinol Laryngol92: 421-423
Rothenberg M (1973) A new inverse-filtering technique for deriving the glottal air flow
waveform during voicing. J Acoust Soc Am 53: 1632-1645
Sansone FE Jr, Emanuel FW (1970) Spectral noise level and roughness severity ratings
for normal and simulated rough vowels produced by adult males. J Speech Hear Res
13: 489-502
Schonharl E (1963) Beitrag zur qualitativen Stimmanalyse. Z Laryng Rhinol 42: 130-138
Shipp T, Huntington DA (1965) Some acoustic and perceptual factors in acute-laryngitic
hoarseness. J Speech Hear Dis 30: 350-359
Smith WR, Lieberman P (1969) Computer diagnosis of laryngeal lesion. Comput Biomed
Res 2: 291-303
Takahashi H, Koike Y (1976) Some perceptual dimensions and acoustical correlates of
pathologic voices. Acta Otolaryngol [Suppl] 338: 1-24
Tanabe M, Isshiki N, Kitajima K (1978) Application of refiectionless acoustic tube for
extraction of the glottal waveform. Studia phonol12: 31-38
von Leden H, Koike Y (1970) Detection of laryngeal disease by computer technique.
Arch Otolaryngol 91: 3-10
Wendahl RW (1963) Laryngeal analog synthesis of harsh voice quality Folia Phoniatr 15:
241-250
Wendahl RW (1966a) Some parameters of auditory roughness. Folia Phoniatr 18: 26-32
Wendahl RW (1966b) Laryngeal analog synthesis of jitter and shimmer; Auditory
parameters of harshness. Folia Phoniatr 18: 98-108
Wendler J, Doherty ET, Hollien H (1980) Voice classification by means of long-term
speech spectra. Folia Phoniatr 32: 51-60
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Yanagihara N (1967a) Hoarseness: investigation of the physiological mechanism. Ann

Otol Rhinol Laryngol 76: 472-489
Yanagihara N (1967b) Significance of harmonic changes and nosie components in hoarse-
ness. J Speech Hear Res 10: 531-541
Yoon KM, Kakita Y, Hirano M (1984) Sound spectrographic analysis of the voice of
patients with glottic carcinoma. Folia Phoniatr 36: 24-30
Yumoto E, Gould WJ, Baer T (1982) Harmonics-to-noise ratio as an index of the degree
of hoarseness. J Acoust Soc Am 71: 1544-1550.
Yumoto E (1983) The quantitative evaluation of hoarseness. Arch Otolaryngol 109: 48-
52
Yumoto E, Sasaki Y, Okamura H (1984) Harmonics-to-noise ratio and psychophysical
measurement of the degree of hoarseness. J Speech Hear Res 27: 2-6

6. Aerodynamic Examination
Bastian HJ, Unger E, Sasama R (1981) Pneumotachographische Objektivierung von Be-
handlungsverliiufen und-ergebnissen. Folia Phoniatr 33: 216-226
Beckett RL (1971) The respirometer as a diagnostic and clinical tool in the speech clinic. J
Speech Hear Dis 36: 235-240
Campbell CJ, Murtagh JA, Raber CF (1963) Laryngeal resistance to air flow. Ann Otol
Rhinol Laryngol 72: 5-30
Cavagna GA, Margaria R (1965) An analysis of the mechanics of phonation. J Appl
Physiol20: 301-307
Draper MH, Ladefoged P, Whitteridge D (1960) Expiratory pressure and air flow during
speech. Br Med J 1: 1837-1843
Faaborg-Andersen K, Yanagihara N, von Leden H (1967) Vocal pitch and intensity reg-
ulation. Arch Otolaryng 85: 448-454
Gordon MT, Morton FM, Simpson IC (1978) Air flow measurements in diagnosis, assess-
ment and treatment of mechanical dysphonia. Folia Phoniatr 30: 161-174
Hirano M, Koike Y, von Leden H (1968) Maximum phonation time and air usage during
phonation. Folia Phoniatr 20: 185-201
Hixon TJ (1972) Some new techniques for measuring the biomechanical events of speech
production: one laboratory's experiences. ASHA 7: 68-103
Isshiki N, von Leden H (1964) Hoarseness: aerodynamic studies. Arch Otolaryngol 80:
206-213
Isshiki N, Okamura H, Morimoto M (1967) Maximum phonation time and air flow rate
during phonation: Simple clinical tests for vocal function. Ann Otol Rhinol Laryngol
76: 998-1008
Kelman A W, Gordon MT, Simpson IC, Morton FM (1975) Assessment of vocal function
by air flow measurements. Folia Phoniatr 27: 250-262
Kelman AW, Gordon MT, Morton FM, Simpson IC (1981) Comparison of methods for
assessing vocal function. Folia Phoniatr 33: 51-65
Kitajima K, Isshiki N, Tanabe M (1978) Use of hot-wire flow meter in the study of
laryngeal function. Studia Phonol 12: 25-30
Koike Y, Hirano M, von Leden H (1967) Vocal initiation; acoustic and aerodynamic
investigation on normal subjects. Folia Phoniatr 19: 173-182
Koike Y, Hirano M (1968) Significance of vocal velocity index. Folia Phoniatr 20: 285-
296
Koike Y, Perkins WH (1968) Application of miniaturized pressure transducer for ex-
perimental speech research. Folia Phoniatr 20: 360-368
Koike Y, von Leden H (1969) Pathologic vocal initiation Ann Otol Rhinol Laryngol 78:
138-148
Kunze LE (1964) Evaluation of methods of estimating subglottal air pressure. J Speech
Hear Res 7: 151-164
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Komiyama S, Watabnabe H, Ryu S (1984) Phonographic relationship between pitch and

intensity of the human voice. Folia Phoniatr 36: 1-7
Ladefoged P (1964) Comment on evaluation of methods of estimating subglottal air
pressur. J Speech Hear Res 7: 291-292
Luchsinger R (1951) Schalldruck und Geschwindigkeitsregistrierung der Stimmluft beim
Singen. Folia Phoniatr 3: 25-51
McGlone RE (1966) An investigation of air flow and subglottal air pressure related to
fundamental frequency of phonation. Folia Phoniatr 18: 312-322
McGlone RE (1967) Air flow during vocal fry phonation. J Speech Hear Res 10: 299-304
Miisebeck K, Rosenberg H (1983) Phonatorische Stromungsvorgange im supraglottis-
chen Kehlkofbereich. Laryngol Rhinol Otol 62: 226-231
Murry T, Brown WS Jr (1971a) Subglottal pressure and airflow measures during vocal fry
phonation. J Speech Hear Res 14: 544-551
Murry T, Brown WS Jr (1971b) Sub glottal air pressure during two types of vocal activity:
vocal fry and modal phonation. Folia Phoniatr 23: 440-449
Nishida Y (1967) Aerodynamic studies on voice regulation. Otologia (Fukuoka) [Suppl1]
13: 44-66
Perello J, Tosi 0 (1974) Phonogram. Folia Phoniatr 26: 289-290
Ptacek PH, Sander EK (1963a) Maximum duration of phonation. J Speech Hear Dis 28:
171-182
Ptacek PH, Sander EK (1963b) Breathiness and phonation length. J Speech Hear Dis 28:
267-272
Rau D, Beckett RL (1984) Aerodynamic assessment of vocal function using hand-held
spirometers. J Speech Hear Dis 49: 183-188
Rothenberg M (1973) A new inverse-filtering technique for deriving the glottal waveform
during voicing. J Acoust Soc Am 53: 1632-1645
Rothenberg M (1977) Measurement of airflow in speech. J Speech Hear Res 20: 155-176
Rubin HJ, LeCover M, Vennard W (1967) Vocal intensity, subglottic pressure, and air
flow relationships in singers. Folia Phoniatr 19: 393-413
Sawashima M, Honda K (1987) An airway interruption method for estimating expiratory
air pressure during phonation. In: Baer T, Sasaki C, Harris K (eds) Laryngeal function
in phonation and respiration. College-Hill Press, Boston, pp 439-447
Schutte HK, Seidner W (1983) Recommendation by the Union of European Phoniatri-
cian (UEP): standardizing voice area measurement/phonetography. Folia Phoniatr 35:
286-288
Shigemori Y (1977) Some tests related to the air usage during phonation: Clinical inves-
tigations. Otologia (Fukuoka) 23: 138-166
Strenger F (1960) Methods for direct and indirect measurement of the subglottic air pres-
sure in phonation. Stud Linguist 14: 98-112
Terasawa R, Hibi SR, Hirano M (1987) Mean airflow rates during phonation over a
comfortable duration and maximum sustained phonation. Folia Phoniatr 39: 87-89
van den Berg Jw (1956) Direct and indirect determination of the mean subglottic pres-
sure. Folia Phoniatr 8: 1-24
van den Berg Jw (1962) Modern research in experimental phonetics. Folia Phoniatr 14:
81-149
Vogelsanger GT (1954) Experimentelle Priifung der Stimmleistung beim Singen. Folia
Phoniatr 6: 193-227
Yanagihara N, von Leden H (1966) Phonation and respiration: Function study in normal
subjects. Folia Phoniatr 18: 323-340
Yanagihara N, von Leden H (1967) Respiration and phonation: The functional examina-
tion of laryngeal disease. Folia Phoniatr 19: 153-166
Yoshioka H, Sawashima M, Hirose H, Ushijima T, Honda K (1977) Clinical evaluation
of air usage during phonation. Jpn J Logoped Phoniat 18: 87-93
Yoshiya I, Nakajima T, Nagai I, Jitsukawa S (1975) A bidirectional respiratory flow
meter using the hot-wire principle. J Appl Physiol 38: 360-365
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7. Vocal Efficiency
American Standard Acoustical Terminology (1960) J Acoust Soc Am
Fink BR (1978) Energy and the larynx. Ann Otol Rhinol Laryngol87: 595-605
Isshiki N (1964) Regulatory mechanism of voice intensity variation. J Speech Hear Res 7:
17-29
Isshiki N (1981) Vocal efficiency index. In: Stevens KN, Hirano M (eds) Vocal fold
physiology. University of Tokyo Press, Tokyo, pp 193-207
Isshiki N (1983) Clinical significance of a vocal efficiency index. In: Titze IR, Scherer RC
(eds) Vocal fold physiology: Biomechanics, acoustics and phonatory control. Denver
Center for performing Arts, Denver, pp 230-238
Isshiki N, Ohkawa M (1983) Vocal efficiency index. In: Proceedings of 19th Congress of
IALP. Edinburgh, pp 855-860
Kakita Y (1987) Measures and displays representing phonatory ability. In: Baer T, Sasaki
C, Harris K (eds) Laryngeal function in phonation and respiration. pp 448-462
Kitajima K (1985) Airflow study of pathologic larynges using a hot wire flowmeter. Ann
Otol Rhinol Laryngol 94: 195-197
Rothenberg M (1987) Cosi Fan Tutte and what it means or nonlinear source-tract acous-
tic implications for the definition of vocal efficiency. In: Bear T, Sasaki C, Harris K
(eds) Laryngeal function in phonation and respiration. College-Hill Press, Boston,
pp 255-269
Schutte HK (1980) The efficiency of voice production. Druk Kemper, Groningen
Tanaka S, Gould WJ (1985) Vocal efficiency and aerodynamic aspects in voice disorders.
Ann Otol Rhinol Laryngol 94: 29-33
Titze IR (1978) Vocal efficiency in phonation. In: van Laurence L (ed) Transcript of the
seventh symposium, care of the professional voice. Voice Foundation, New York,
pp 19-23
Titze JR, Talkin DT (1979) A theoretical study of the effects of various laryngeal con-
figurations on the acoustics of phonation. J Acoust Soc Am 66: 60-74
van den Berg Jw (1956) Direct and indirect determination of the mean subglottic pres-
sure. Folia Phoniatr 8: 1-24
Wilson FB, Starr CD (1985) Use of the phonation analyzer as a clinical tool. J Speech
Hear Dis 50: 351-356

8. Pitch Measurement
Askenfelt A, Gauffin J, Sundberg J, Kitzing P (1980) A comparison of contact mic-
rophone and electroglottograph for the measuring of vocal fundamental frequency. J
Speech Hear Res 23: 258-273
Fourcin AJ (1981) Laryngographic assessment of phonatory function. ASHA reports 11:
116-127
Kitzing P (1977) Methode zur kombinierten photo- und electroglottographischen Reg-
istrierung von Stimmlippenschwingungen. Folia Phoniatr 29: 249-260
Kitzing P (1982) Photo- and electroglottographical recording of the laryngeal vibratory
pattern during different registers. Folia Phoniatr 34: 234-241

9. Stroboscopy
Beck J, Schonharl E (1954) Ein neues mikrophongesteuertes Lichtblitz-stroboskop.
HNO 4: 212-214
Buch NH (1970) Phoniatric examination technique. Acta Otolaryngol 263: 52-55
210 Selected Bibliography

Fex S (1970) Judging the movements of vocal cords in laryngeal paralysis. Acta Otolary-
ngol [Suppl] 263: 82-83
Gould WJ, Kojima H, Lambiase A (1979) A technique for stroboscopic examination of
the vocal folds using fiberoptics. Arch Otolaryngol 105: 285
Hirano M (1981) Clinical examination of voice. Springer, Wien New York
Kallen IA (1932) Laryngostroboscopy in the practice of otolaryngoloy. Arch Otolaryngol
16: 791-807
Padovan IF, Christman MT, Hamilton LH (1973) Indirect microlaryngostroboscopy.
Laryngoscope 83: 2035-2041
Pedersen MF (1977) Electroglottography compared with synchronized stroboscopy in
normal persons. Folia Phoniatr 29: 191-199
Saito S, Fukuda H, Kitahara S (1975) Stroboscopic microsurgery of the larynx. Arch
Otolaryngol101: 196-201
Saito S, Fukuda H, Kitahara S, Kokawa N (1978) Stroboscopic observation of vocal fold
vibration with fiberoptics. Folia Phoniatr 30: 241-244
Seidner W, Wendler J, Halbedl G (1972) Mikostroboskopie. Folia Phoniatr 24: 81-85
Sch6nhari E (1960) Die Stroboskopie in der praktischen Laryngologie. Georg Thieme,
Stuttgart
Timcke R (1956) Die Synchron-Stroboskopie von mensch lichen "Stimmlippen bzw
ahnlichen Schallquellen und Messung der Offnungszeit". Z Laryngol Rhinol Otol 35:
331-335
von Leden H (1961) The electric synchron-stroboscope: Its value for the practising laryn-
gologist. Ann Otol Rhinol Laryngol 70: 881-893
Wendler J, Halbedl G, Schaaf G, Seidner W (1973) Tele-Mikrostroboskopie. Folia
Phoniatr 25: 281-287
Yoshida Y (1977) An improved model of laryngo-stroboscope Otolaryngology (Tokyo)
49: 663-669 (in Japanese)
Yoshida Y (1979) A video-tape recording system for laryngostroboscopy. J Jpn Bron-
choesophagol Soc 30: 1-5 (in Japanese)

10. Radiographic Examination

Vocal Cord Length

Damste PH, Hollien H, Moore P, Murry TH (1968) An X-ray study of vocal fold length.
Folia Phoniatr 20: 349-359
Hollien H (1960) Some laryngeal correlates of vocal pitch. J Speech Hear Res 3: 52-58
Hollien H, Curtis JF (1960) A laminagraphic study of vocal pitch. J Speech Hear Res 3:
361-370
Hollien H, Moore GP (1960) Measurements of the vocal folds during changes in pitch. J
Speech Hear Res 3: 157-165
Hollien H (1962) Vocal fold thickness and fundamental frequency of phonation. J Speech
Hear Res 5: 237-243
Hollien H, Colton RH (1969) Four laminagraphic studies of vocal fold thickness. Folia
Phoniatr 21: 179-198
Run WN, Chung YS (1983) Roentgenological measurement of physiological vocal cord
length. An analysis of 59 opera singers. Folia Phoniatr 35: 289-293
Sonninen A (1954) Is the length of the vocal cords the same at all different levels of
singing? Acta Otolaryngol [Suppl] 118: 219-231
Sonninen A (1956) The role of the external laryngeal muscles in length adjustment of the
vocal cords in singing. Acta Otolaryngol [Suppl] 130: 1-102
Wendler J (1964) Zur Messung der Stimmlippenlange. Z Laryng Rhinol44: 162-173
Selected Bibliography 211

Zenker W, Zenker A (1960) Uber die Regelung der Stimmlippenspannung durch von
aussen eingreifende Mechanismen. Folia Phoniatr 12: 1-36

Vocal Cord Paralysis

Calderon R, Ceballos J, McGraw JP (1954) Tomographic aspect of paralysis of the vocal

cords. Radiology 63: 407-410
Isshiki N, Ishikawa T (1976) Diagnostic value of tomography in unilateral vocal cord
paralysis. Laryngoscope 86: 1573-1578
Pozmogov A (1962) Larynx paralysis in tomographic images. Vestn Rentgenol Radiology
(Mosk) 37: 74-75 (Cited from Zentralblatt)
Unger SM, Roswit B, Stein J (1960) Vocal cord paralysis: a Roentgen diagnostic study.
Radiology 75: 741-747

11. EMG
Dedo HH, Hall WN (1969) Electrode in laryngeal electromyography: reliability compari-
son. Ann Otol Rhinol Laryngol78: 172-180
Faaborg-Andersen KL (1957) Electromyographic investigation of intrinsic laryngeal mus-
cles in humans. Acta Physiol Scand [Suppl 140]41: 1-148
Gay T, Harris KS (1971) Some recent developments in the use of electromyography in
speech research. J Speech Hear Res 14: 241-246
Gay T, Hirose H, Strome M, Sawashima M (1972) Electromyography of the intrinsic
laryngeal muscles during phonation. Ann Otol Rhinol Laryngol81: 401-409
Greiner GF, Isch F, Isch-Treussard C, Ebtinger-Jouffroy, Klotz G, Champy M (1960)
L'electromyographie appliquee a la pathologie du larynx. Acta Otolaryngol (Stock-
holm) 51: 319-331
Haglund S (1973) The normal electromyogram in human cricothyroid muscle. Acta Oto-
laryngol 75: 448-453
Hirano M (1969) Recent advance in laryngeal electromyography in human. Kurume Med
J 16: 119-126
Hirano M, Ohala J (1969) Use of hooked-wire electrodes for electromyography of the
intrinsic laryngeal muscles. J Speech Hear Res 12: 362-373
Hirano M, Ohala J, Vennard W (1969) The function of the laryngeal muscles in regulat-
ing fundamental frequency and intensity of phonation. J Speech Hear Res 12: 616-628
Hirano M, Vennard W, Ohala J (1970) Regulation of register, pitch and intensity of
voice, an electromyographic investigation of intrinsic laryngeal muscles. Folia Pho-
niatr 22: 1-20
Hirose H, Gay T, Strome M (1971) Electrode insertion technique for laryngeal elec-
tromyography. J Acoust Soc Am 50: 1449-1450
Hirose H, Gay T (1972) The activity of the intrinsic laryngeal muscles in voicing control.
Phonetica 25: 140-164
Hiroto I, Hirano M, Tomita H (1968a) Electromyographic investigation of human vocal
cord paralysis. Ann Otol Rhinol Laryngol 77: 296-304
Hiroto I, Hirano M, Toyozumi Y, Shin T (1968b) Electromyographic investigation of the
intrinsic laryngeal muscles related to speech sounds. Ann Otol Rhinol Laryngol 76:
861-872
Knutsson E, Martensson A, Martensson B (1969) The normal electromyogram in human
vocal muscle. Acta Otolaryngol68: 526-536
Kotby MN, Haugen LK (1970a) Critical evaluation of the action of the posterior crico-
arytenoid muscle, utilizing direct EMG-study. Acta Otolaryngol 70: 260-268
Kotby MN, Haugen LK (1970b) Clinical application of electromyography in vocal fold
mobility disorders. Acta Otolaryngol 70: 428-437
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Seiffert A (1919) Perkutane Paraffininjektion zur Beseitigung der Folgen einseitiger

StimmbandHihmung. Z Laryng Usw 8: 233-235
Shipp T, Fishman BV, Morrissey P, McGlone RE (1970) Method and control of laryngeal
EMG electrode placement in man. J Acoust Soc Am 48: 429-430

12. Fiberscopy
Blaugrund SM, Gould WJ, Tanaka S, Kitajima K (1983) The fiberscope: analysis and
function of laryngeal reconstruction. In: Titze IR, Scherer RC (eds) Vocal fold
physiology: biomechanics, acoustics and phonatory control. Denver Center for Per-
forming Arts, Denver, pp 252-255
Davidson TM, Bone RC, Nahum LM (1974) Flexible fiberoptic laryngobronchoscopy.
Laryngoscope 84: 1876-1882
Fujimura 0 (1977) Stereo-fiberscope. In: Sawashima M, Cooper FS (eds) Dynamic
aspects of speech production. University of Tokyo Press, Tokyo, pp 133-137
Gould WJ (1973) The Gould laryngoscope. Trans Am Opthalmol Soc 77: 139-141
Gould WJ, Jako GJ, Tanabe M (1974) Advances in high-speed motion picture photogra-
phy of the larynx. Trans Am Orthalmol Soc 78: 276-278
Gould WJ (1977) Newer aspects of high-speed photography of the vocal folds. In:
Sawashima M, Cooper FS (eds) Dynamic aspect of speech production. University of
Tokyo Press, Tokyo, pp 139-144
Gould WJ (1983) The fiberscope: flexible and rigid for laryngeal function evaluation. In:
Titze IR, Scherer RC (eds) Vocal fold physiology: biomechanics, acoustics, and
phonatory control. Denver Center for Performing Arts, Denver, pp 249-251
Kakita Y, Hirano M, Kawasaki H, Matsuo K (1983) Stereolaryngoscopy: a new method
to extract vertical movement of the vocal fold during vibration. In: Titze IR, Scherer
RC (eds) Vocal fold physiology: biomechanics, acoustics, and phonatory control.
Denver Center for Performing Arts, Denver, pp 191-201
Saito S, Isogai Y, Fukuda H, Kitahara S, Ono H, Makino K, Tsuzuki T, Murakami Y,
Suzuki M (1981) A newly developed curved laryngotelescope. J Jpn Bronchoesophag
Soc 32: 328-331
Sawashima M, Hirose H, Fujimura 0 (1967) Observation of the larynx by a fiberscope
inserted through the nose. J Acoust Soc Am 42: 1208
Sawashima M, Hirose H (1968) A new laryngoscopic technique by use of fiberoptics. J
Acoust Soc Am 43: 168-169
Sawashima M, Hirose H, Honda K, Yoshioka H, Hibi SR, Kawase N, Yamada M (1983)
Stereoscopic measurement of the laryngeal structure. In Bless DM, Abbs JH (eds)
Vocal fold physiology: contemporary research and clinical issues. College Hill, San
Diego, pp 265-276
Yanagisawa E (1982) Office telescopic photography of the larynx. Ann Otol Rhinol
Laryngo191: 354-3358
Yanagisawa E, Owens TW, Strothers G, Honda K (1983) Videolaryngoscopy: a compari-
son of fiberscopic and telescopic documentation. Ann Otol Rhinol Laryngol 92: 430-
436
Yanagisawa E (1987) Fiberscopic and telescopic videolaryngoscopy-a comparative
study. In: Baer T, Sasaki C, Harris K (eds) Laryngeal function in phonation and
respiration. Little Brown, Boston, pp 475-484

13. Ultrasonic Wave

Asano H (1968) Application of the ultrasonic pulse-method on the larynx. J Otolaryngol
Jpn 71: 895-916
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Beach JL, Kelsey CA (1969) Ultrasonic doppler monitoring of vocal fold velocity and
displacement. J Acoust Soc Am 46: 1045-1047
Chubachi N (1983) Scanning acoustic microscope in interference mode using frequency
modulation method. Proceeding of IEEE Ultrasonic Symposium, pp 611-615
Hamlet SL (1972) Interpretation of ultrasonic signals in terms of phase difference of vocal
fold vibration. J Acoust Soc Am 51: 90-91
Hamlet SL, Reid JM (1972) Transmission of ultrasound through the larynx as a means of
determining vocal fold activity. IEEE Trans Biomed Eng 19: 34-37
Hamlet SL (1973) Vocal compensation: an ultrasonic study of vocal fold vibration in
normal and nasal vowels. Cleft Palate J 10: 367-385
Hamlet SL, Palmer JM (1974) An investigation of laryngeal trills using the transmission
of ultrasound through the larynx. Folia Phoniatr 26: 362-378
Hamlet SL (1980) Ultrasonic measurement of larynx height and vocal fold vibratory pat-
tern. J Acoust Soc Am 68: 121-126
Hertz CH, Lindstrom K, Sonnesson B (1970) Ultrasonic recording of vibrating vocal
folds. Acta Otolaryngol 69: 223-230
Holmer NG, Kitzing P, Lindstrom K (1973) Echo glottography. Acta Otolaryngol 75:
454-463
Kakita Y, Inoue Y, Hirano M (1984) An acoustic microscope designed for observing the
vocal fold tissue. J Otolaryngol Jpn 87: 1702-1706 (in Japanese)
Kaneko T, Kobayashi N, Tachibana M, Naito J, Hayawaki K, Uchida K, Yoshioka T,
Suzuki H (1976) L'ultrasonoglottographie; l'aire neutre glottique et la vibration de la
corde vocale. Rev Laryngol Oto Rhinol 97: 363-369
Kaneko T, Uchida K, Suzuki H, Komatsu K, Kanesaka T, Kobayashi N, Naito J (1981)
Ultrasonic observations of vocal fold vibration. In: Stevens KN, Hirano M (eds) Vocal
fold physiol. University of Tokyo Press, Tokyo, pp 107-117
Kaneko T, Komatsu K, Suzuki H, Kanesaka T, Masuda T, Numata T, Naito J (1983)
Mechanical properties of the human vocal fold-resonance characteristics in living
humans and in excised larynxes. In: Titze IR, Scherer RC (eds) Vocal fold physiology,
Biomechanics, acoustics, and phonatory control. Denver Center for Performing Arts,
Denver, pp 304-317
Kaneko T, Masuda T, Shimada A, Suzuki H, Hayasaki K, Komatsu K (1987) Resonance
characteristics of the human vocal fold in vivo and in vitro by an impulse excitation. In:
Baer T, Sasaki C, Harris K (eds) Laryngeal function in phonation and respiration.
College-Hill Press, Boston, pp 349-365
Kaneko T, Uchida I, Suzuki H, Komatsu K, Kanesaka T, Kobayashi N, Naito J (1981)
Mechanical properties of the vocal fold: measurement in vivo. In: Stevens K, Hirano
M (eds) Vocal fold physiology. University of Tokyo Press. Tokyo, pp 365-376
Kaneko T, Uchida K, Komatsu K (1983) The movement of the inner layers of the vocal
fold during phonation. Observation by ultrasonic method. In: Bless DM, Abbs J (eds)
Vocal fold physiology. College-Hill Press, San Diego, pp 223-228
Kitamura T, Kaneko T, Asano H, Miura T (1967) Ultrasonography. A preliminary re-
port. Jpn Med Ultrasonic 5: 40-41
Kitamura T, Kaneko T, Asano H, Miura T (1969) L'ultrasonoglottographie. Rev Laryn-
golol Otol Rhinol 3-4: 190-195
Munhall KG, Ostry DJ (1983) Ultrasonic measurement of Laryngeal Kinematics In: Titze
IR, Scherer RC (eds) Vocal fold physiology. Denver Center for Performing Arts,
Denver, pp 145-162
Ouate CF (1979) Acoustic microscopy with mechanical scanning-A review. IEEE Trans
Biomed Eng 67: 1092-1114
Zagzebski JA, Bless DM (1983) Correspondence of ultrasonic and stroboscopic visualiza-
tion of vocal folds In: Titze IR, Scherer RC (Eds) Vocal fold physiology. Denver
Center for Performing Arts, Denver, pp 163-168
Zagzebski JA, Bless DM, Ewanowski SJ, (1983) Pulse echo imaging of the larynx using
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14. Anatomy for Laryngeal Framework Surgery

Dickson DR, Maue-Dickson W (1982) Anatomical and physiological bases of speech.

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15. Medial Displacement of the Vocal Cord

Arnold GE (1962) Vocal rehabilitation of paralytic dysphonia. Arch Otolaryngol 76:

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16. Chordal Injection

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17. Vocal Cord Atrophy and Sulcus Vocalis

Arnold GE (1958) Dysplastic dysphonia. Laryngoscope 68: 142-158

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18. Surgery to Lower Vocal Pitch

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19. Surgery to Elevate Vocal Pitch, Laryngeal Asymmetry

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20. Spastic Dysphonia

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oarytenoid muscle. J Jpn Bronchoesophagol Soc 39: 275-278
Traube L (1871) Spastische From der nervosen Heiserkeit. In: GesammeIte Beitrage zur
Pathologie und Physiologie, vol 2 part 2. Hirschwald, Berlin, p 677
van Lawrence L (ed) (1977) Transcript of the sixth symposium, care of the professional
voice, the Julliard school, Voice Foundation, New York, p. 167
van Lawrence L (ed) (1979) Spastic dysphonia: state of the art. Voice Foundation, New
York
Watanabe H, Komiyama S, Ryu S, Kannae D, Matsubara H (1982) Biofeedback therapy
for spastic dysphonia. Auris Nasus Larynx 9: 183-190
Watanabe H, Shin T, Oda M, Fukaura J, Komiyama S (1987) Measurement of total
actual speaking time in a patient with spastic dysphonia. Folia Phoniatr 39: 65-70
Wendler W, Seidner W (1977) Lehrbuch der Phoniatrie. VEB Georg Thieme, Leipzig
White JF, Knight RE (1981) Recurrent laryngeal nerve section in the treatment of spastic
dysphonia. South Med J 74: 1053-1055
Wieser M (1981) Periodendaueranalyse bei spastischen Dysphonien. Folia Phoniatr 33:
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Wolfe VI, Bacon M (1976) Spectrographic comparison of two types of spastic dysphonia.
J Speech Hear Dis 41: 315-324
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chronic and incipient spastic dysphonia. Laryngoscope 89: 1478-1486

Surgical Management of Scar of the Vocal Cord

21. Mucosa Transplantation
Draf W (1980) Erfahrungen mit der Technique der Fibrinklebung in der Hals-Nasen-
Ohren-Chirurgie. Laryngol Rhinol Otol (Stuttgurt) 59: 99-107
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Martin F, Spitzer H, Gastpar H (1981) Endolaryngeale Eingriffe unter Verwendung
Hochkonzentrierten Humane Fibrinogens mit dem Fibrinkleber. Laryngol Rhinol
Otol (Stuttgurt) 60: 369-372
Okamura H, Yumoto E, Okamoto K (1987) Wound healing of canine vocal folds after
phonosurgery. Ann Otol Rhinol Laryngol 96: 425-428

22. Collagen Injection

Ford CN, Bless DM (1986a) A preliminary study of injectable collagen in human vocal
fold augmentation. Otolaryngol Head Neck Surg 94: 104-112
Ford CN, Bless DM (1986b) Clinical experience with injectable collagen for vocal fold
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augmentation. Laryngoscope 96: 863-869

Ford CN (1986) Histologic study of injectable collagen in the canine larynx. Laryngo-
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collagen in vocal rehabilitation. In: Proceedings of 20th Congress of IALP. Tokyo, pp
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Spiegel JR, Sataloff RT, Gould WJ (1987) The treatment of vocal fold paralysis with
injectable collagen: clinical concerns. J Voice 1: 119-121
Yumoto E, Okamoto K, Kawamura Y, Okamura H (1988) Injection of atelocollagen to
augment the paralyzed vocal fold. J Jpn Bronchoesophagol Soc 39: 271-274 (in
Japanese)

23. Remobilization of the Paralyzed Vocal Cord

Baken RJ, Isshiki N (1977) Arytenoid displacement by simulated intrinsic muscle con-
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anastomosis in dogs. Ann Otol Rhinol Laryngol 80: 664-668
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jury. Arch Surg (Chicago) 96: 517-520
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155-161
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and return of laryngeal function. Laryngoscope 78: 236-250
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cord. Arch Otolaryngol 97: 247-250
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cord paralysis. Ann Otol Rhinol Laryngol 77: 296-304
Horseley JS (1909) Suture of the recurrent laryngeal nerve, with report of a case. Trans
Sth Surg Ass 22: 161-170
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laryngol. ENT Alumni Association, Kyoto University, Kyoto (in Japanese)
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paralysis. Arch Otolaryngol104: 555-558
Iwamura S (1974) Functioning remobilization of the paralyzed vocal cord in dogs. Arch
Otolaryngol 100: 122-129
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Lahey FH (1928) Successful suture of recurrent laryngeal nerve for bilateral abductor
paralysis, with restoration of function. Ann Surg 87: 481-484
Lyons RM, Tucker HM (1974) Delayed restoration of abduction in the paralyzed canine
larynx. Arch Otolaryngol 100: 176-179
Matsui T (1976) Pedicle nerve muscle graft for laryngeal nerve paralysis Pract Otol
(Kyoto) 69: 1007-1047 (in Japanese)
May M, Beery Q (1986) Muscle-nerve pedicle laryngeal reinnervation. Laryngoscope 96:
1196-1200
Miehlke A (1958) Zur Indikation und Technik der Recurrensneurolyse. Z Lar Rhinol
Otol 37: 44-54
Miehlke A, Schatzie W, Haubrich J (1967) Tierexperimentelle Untersuchungen liber das
Problem einer Reinnervation des Kehlkopfes durch Vagus-Recurrens-Plastik Arch
Klin Exp Ohr Nas Kehl-heilk 188: 654-667
Miehlke A (1974) Rehabilitation of vocal cord paralysis: studies using the vagus, recur-
rent bypass anastomosis, type ramus posterior shunt. Arch Otoiaryngol100 431-441
Miglets A W (1974) Functional laryngeal abduction following reimplantation of the recur-
rent laryngeal nerves. Laryngoscope 84: 1996-2005
Morledge DR, Lauvstad WA, Calcaterra TC (1973) Delayed reinnervation of the para-
lyzed larynx: experimental study in dog. Arch Otolaryngol 97: 291-293
Murakami Y, Kirchner JA (1971) Vocal cord abduction by regenerated recurrent
laryngeal nerve. Arch Otolaryngol 94: 64-68
Ogura JH, Harvey JE, Mogi G, Ueda N, Ohyama M, Tucker HM (1970) Further ex-
perimental observations of transplantation of canine larynx. Laryngoscope 80: 1231-
1243
Rich DH, Owens 0, Burnstein F, Verity A (1983) The nerve-muscle pedicle: a visual
electromyographic and histochemical study. Arch Otolaryngol109: 233-234
Sahgal V, Hast MH (1986) Effect of de nervation on primate laryngeal muscles: a mor-
phologic and morphometric study. J Laryngol Oto1100: 553-560
Sato F, Ogura JH (1978a) Functional restoration for recurrent laryngeal nerve paralysis:
an experimental study. Laryngoscope 88: 855-871
Sato F, Ogura JH (1978b) Neurorrhaphy of the recurrent laryngeal nerve. Laryngoscope
88: 1034-1041
Shiba K (1987) An experimental study on re-mobilization of paralyzed vocal cord via
muscle transfer method Pract Otol (Kyoto) 80: 1287-1305 (in Japanese)
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paralysis. Pract Otol (Kyoto) 50: 562-581 (in Japanese)
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17: 117-121 (in Japanese)
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laryngeal paralysis and regeneration of laryngeal motor nerves in dogs. Laryngoscope
73: 148-164
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man. Anat Record 114: 411-426
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induced after esophagus reconstruction. In: Proceeding of 2nd Joint Congress of Asian
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neurography. Laryngoscope 82: 225-236
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Tucker HM, Ogura JH (1971) Vocal cord remobilization in the canine larynx: an histo-
logic evaluation. Laryngoscope 81: 1602-1606
Tucker HM (1977) Reinnervation of the unilaterally paralyzed larynx. Ann Otol Rhinol
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Tucker HM (1982) Nerve-muscle pedicle reinnervation of the larynx: avoiding pitfalls
and complications. Ann Otol Rhinol Laryngol 91: 440-444
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abductor muscle after recurrent paralysis by implantation of free nerve transplants to
the phrenic nerve. Arch Otorhinolaryngol194: 372-377

Potentials for Research

24. False Vocal Cord Phonation
Arnold GE (1939) Ein Fall von nicht hysterischer Taschenfaltenstimme. Mscht
Ohrenheik Lar -Rhinol 73: 296-297
Arnold GE, Pinto S (1960) Ventricular dysphonia: new interpretation of an old observa-
tion. Laryngoscope 70: 1608-1627
Beckmann G (1953) Zur Behandlung der unerwiinschten Taschenbandstimme. Arch Ohr
Nas Kehl-heilk 163: 488-490
Berendes J (1956) Neuere Ergebnisse tiber Bewegungsstorungen des Kehlkopfes. Arch
Ohr Nas Kehl-heilk 169: 1-172
Feinstein I, Szachowicz E, Hilger P, Stimson B (1987) Laser therapy of dysphonia plica
ventricularis. Ann Otol Rhinol Laryngol 96: 56-57
Flatau TS (1928) Zur Klinik der Taschenbandstimme. Mschr Ohrenheilk Lar -Rhino I 62:
791-796
Freud ED (1962) Functions and dysfunctions of the ventricular folds. J Speech Hear Dis
27: 340-344
Heymann D (1931) Taschenfaltenstimme auf organischer Grundlage. Z Lar Rhinol Otol
21: 500-506
Jackson C, Jackson CL (1935) Dysphonia plicae ventricularis. Arch Otolaryngol21: 157-
167
Kruse E, Kleinsasser 0, Schonharl E (1975) Muskelfasern in den Taschenfalten des
menschlichen Kehlkopfes. Arch Oto Rhino Laryngol21O: 248-250
Kruse E (1981) Der mechanismus der Taschenfaltenstimme. Folia Phoniatr 33: 294-313
Nemai J (1933) Bemerkungen zum Artikel Aurel Rethis "Taschenbandstimme usw".
Mschr Ohrenheilk 67: 848-851
Pressman 11 (1954) Sphincters of the larynx. Arch Otolaryngol59: 221-236
Pressman 11, Kelemen G (1955) Physiology of the larynx. Physiol Rev 35: 506-553.
Rethi A (1933) Taschenbandstimme. Dysphonia spastica und Rachenmuskulatur. Mshr
Ohrenheilk 67: 572-596
Rethi A (1934a) Anatomisches Spiegelbild des Mechanismus der Taschenbandstimme
und die Rekurrensfrage (I. Mitteilung). Mschr Ohrenheilk 68: 586-594
Rethi A (1934b) Anatomisches Spiegelbild des Mechanismus der Taschenbandstimme
und die Rekurrensfrage (II. Mitteilung). Mschr Ohrenheilk 68: 1151-1156
Rethi A (1935a) Anatomisches Spiegelbild des Mechanismus der Taschenbandstimme
und die Rekurrensfrage (III. Mitteilung). Mschr Ohrenheilk 68: 129-140
Rethi A (1935b) Anatomisches Spiegelbild des Mechanismus der Taschenbandstimme
und die Rekurrensfrage (IV. Mitteilung). Mschr Ohrenheilk 69: 414-428
Rethi A (1935c) Anatomisches Spiegelbild des Mechanismus der Taschenbandstimme
und die Rekurrensfrage (V. Mitteilung). Mschr Ohrenheilk 69: 912-926
Rethi A (1952) Rolle des stylopharyngealen Muskelsystems im Krankheisbild der Tas-
chenbandstimme und der Dysphonia spastica. Folia Phonitar 4: 201-216
Rethi A (1969) Chirurgie der Verengerungen der oberen Luftwege. Thieme, Stuttgart
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Saunders WH (1956) Dysphonia plica ventricularis. Ann Otol Rhinol Laryngol 65: 665-
673

25. Lubrication
Freedman AO (1938) Diseases of the ventricle of Morgagni. Arch Otolaryngol 28: 328-
343
Hisa Y, Matsui T, Fukui K (1982) Ultrastructural and fluorescence histochemical studies
on the sympathetic innervation of the laryngeal glands. Acta Otolaryngol 93: 119-122
Kawaida M, Fukuda H, Fujioka T, Kano S, Takayama E, Oki K, Saito Sh (1986) Dyna-
mic studies on the lubrication of the larynx during phonation. In: Proceedings of 20th
Congress of IALP. Tokyo, pp 336-337
Martin FG (1984) Drugs and the voice, part 2. In: van Laurence L (ed) Transcript of the
thirteenth symposium, care of the professional voice. Voice Foundation, New York,
pp 191-201
Punt NA (1974) Lubrication of the vocal mechanism. Folia Phoniatr 26: 287-288
Shaikh A, Bless D, Ford C (1986) Effect of atropine on vocal fold vibration. In: Proceed-
ings of 20th Congress of IALP. Tokyo, pp 488-489

26. Laryngeal Pacing

Bergman K, Warzel H, Eckhardt HU, Gerhardt HJ (1984) Respiratory rhythmically reg-
ulated electrical stimulation of paralyzed laryngeal muscles. Laryngoscope 94: 1376-
1380
Broniatowski M, Kaneko S, Jacobs G, Nose Y, Tucker HM (1985) Laryngeal pacemaker
II: electronic pacing of reinnervated posterior cricoarytenoid muscles in the canine.
Laryngoscope 95: 1194-1198
Broniatowski M, Kaneko S, Jacobs G, Nose Y, Tucker HM (1987) Laryngeal pacing:
theoretical and practical considerations. In: Baer T, Sasaki C, Harris K (eds)
Laryngeal function in phonation and respiration, vocal fold physiology series. College
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Glenn WL, Holcomb WG, Shawn R, Hogan JF, Holschuh KR (1976) Long term ventila-
tory support by diaphragm pacing in quadriplegia. Ann Surg 183: 566-577
Liberson WT, Holmquest HJ, Scot D, Dow M (1961) Functional electrotherapy: stimula-
tion of peroneal nerve synchronized with the swing phase of the gait of hemiplegic
patients. Arch Phys Med Rehabil 42: 101-105
Obert PM, Young KA, Tobey DN (1984) Use of direct posterior cricoarytenoid stimula-
tion in laryngeal paralysis. Arch Otolaryngol 110: 88-92
Obert PM, Young KA, Tobey DN (1987) Investigation into direct posterior cri-
coarytenoid stimulation in laryngeal paralysis. In: Baer T, Sasaki C, Harris K (eds)
Laryngeal function in phonation and respiration. Vocal fold physiology series. College
Hill Press, Boston, pp 111-119
Otto RA, Davis WE (1987) Continued investigations into electro physiologic pacing of
paralyzed vocal cord abductors. In: Baer T, Sasaki C, Harris K (eds) Laryngeal func-
tion in phonation and respiration. Vocal fold physiology series. College Hill Press,
Boston, pp 131-136
Tobey DN, Sutton D (1978) Contra laterally elicited electrical stimulation of paralyzed
facial muscles. Otolaryngol 89: 812-818
Zealear DL, Dedo HH (1977) Control of paralyzed axial muscles by electrical stimula-
tion. Acta Otolaryngol 83: 514-527
Zealer DL, Herzon GD (1988) Progress toward the development of a chronically im-
plantable laryngeal pacemaker. In: Fujimura 0 (ed) Vocal physiology: Voice produc-
tion, mechanisms and function. Raven Press, New York, pp 443-448