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A review of Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

James P. Thomas, MD — Monday, September 28, 2020 - 01:12

Practice guideline articles seem like they should carry a lot of weight given the number of authors and their collective fame and recognition. Yet one of the pitfalls of writing by consensus is publishing something that is effectively the lowest common denominator. Since the article may be frequently quoted, let’s take a closer look at:

Dhillon VK, Randolph GW, Stack BC Jr, et al. Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment. Head & Neck. 2020;1–16. https://doi.org/10.1002/hed.26472

The authors introduce a new term, “immediate VFP” (VFP=vocal fold paralysis). Already we have a problem here because none of these words - immediate vocal fold paralysis - are physiologic descriptions of what actually may go wrong during surgery.

Consider the word immediate. If you are a patient, whether an injury is immediate or delayed it not really relevant, it is still an injury. However, most injuries probably are immediate and occur during surgery. Ok, correct terminology, but helpful? The injured patient primarily cares about why their voice is not functioning like it did before surgery. They want to know what the injury is and will it get better. Ideally (and all too often in retrospect) the patient actually wants to know before surgery what are the potential pitfalls of surgery - what can go wrong with the voice, how often does it occur, how severe can it be and will it recover.
Consider the next term vocal fold. The thyroid surgeon never injures the vocal folds during thyroid surgery. It's possible the anesthesiologist might traumatize the vocal folds during intubation but that is not the essence of this guideline. The surgeon does not get near or injure the vocal folds.
Consider the final term paralysis. Paralysis means complete injury to a nerve, yet this may be the minority condition. At least if you consider paralysis relative to the number of partial nerve injuries (paresis). Paresis is the most common condition after a surgical nerve injury and is not well represented by this definition, “immediate vocal fold paralysis.” The authors add the term, “partial neural dysfunction” but we already have a more succinct word, paresis.

Surgical injury occurs to a nerve which supplies the muscles that move the vocal fold. So already, the semantic foundations of the paper might be built on sand.

Just say, thyroid surgery has a risk of nerve injury. We already have three descriptive terms which well describe how a nerve is injured (Neuropraxia, physiologic block of nerve conduction within an axon; Axonotmesis - anatomical interruption of the axon with no or only partial interruption of the connective tissue framework; Neurotmesis - complete anatomical disruption of the both the axon and all of the surrounding connective tissue (rupture of the nerve)). These nerve injuries lead to reduction or complete cessation of contraction for the supplied muscle(s).

I suspect that surgeons primarily think about neurotmesis when they are discussing the potential for nerve injury with patients before thyroid surgery. And actually severing the nerve is probably reasonably uncommon after all the training most surgeons receive. So a surgeon may feel comfortable saying, "I almost never injury the nerve," meaning they can't really recall ever cutting one of the laryngeal nerves.

However, traumatizing the nerve without cutting it may lead to axonotmesis and this is why many surgeons attempt to rely on intraoperative laryngeal EMG, trying to detect when they are pulling too hard on the recurrent laryngeal nerve and potentially internally injuring nerve conduction.

But I suspect the most common surgical injury is some devascularization of the nerve, leading to immediate or delayed axonotmesis or neuropraxia.

Perhaps as a surgeon you think these “minor” nerve injuries aren’t worth worrying about. I assure you that patients can detect these injuries and many of them seek care elsewhere after you tell them nothing is wrong, leading you to think you hardly ever injure the nerves because you don't cut them, because there is a high rate of recovery and compensation and because patients quit bothering you.

Consensus statements

Let’s consider the statements utilized for the consensus discussion in the paper.

Statement #1 first part:

“Laryngeal dysfunction is complex and involves more than just motion impairment.”

“Laryngeal dysfunction” is complex because there are 4 nerves¹ and 9 muscles² involved, but “nerve injury” is straightforward in the case of motor nerves. Simply, an injured nerve results in reduced or no contraction of the muscle it innervates. So rather than thinking about the larynx as a whole not functioning, the astute examiner will consider what function each muscle of the larynx performs when it contracts. There is much less complexity when each muscle is considered on its own.

For example, a lateral cricoarytenoid muscle only moves one vocal process medially during phonation. So an astute examiner will focus in turn on only one vocal process, during phonation, to determine if it is moving medially. The examiner isolates the function of each muscle in their mind and concentrates on whether it moves at the appropriate time. Then the examiner moves on to another function. This is why performing a video recording of laryngeal function is so important. Various parts of the larynx must be viewed on their own while other parts are ignored. Consequently a neurolaryngeal exam benefits from viewing motion multiple times. That is much easier to do from a recording on a computer then to perform it live during an exam. In fact, I would say an accurate neurolaryngeal exam is nearly impossible to perform with a mirror examination of the larynx.

Statement #1 second part:

“A comprehensive evaluation in the immediate postoperative setting is important if there is concern for any neural dysfunction.”

This is not sufficient. If a surgeon wants to know if they are injuring the nerves during thyroid surgery, a comprehensive neurolaryngeal evaluation must be performed both before and after surgery. It is the change in the exam which is the primary method for determining when and what nerve injury secondary to surgery. Without a complete preoperative neurolaryngeal examination, who knows what changed during surgery.

Even the word “important” is insufficient here. More than “important,” examination is the only way to determine if a surgeon has caused an injury and what the injury is. If you examine everyone before and after surgery, you will find many more injuries. You may not want to find them, but not noticing an injury does not mean that it has not occurred.

Recommended statement #1:

Laryngeal nerve injury is relatively straightforward. A comprehensive neurolaryngeal examination before and after an intervention (in this case thyroid surgery) will document and reveal the incidence and degree of injury from surgery.

Statement #2:

Early identification of injury leads to improved patient outcomes. This is a huge hurdle to overcome. Given how often the laryngeal nerves spontaneously recover, very large sample sizes are required to determine if interventions alter outcomes. This is very similar to studying facial nerve injuries and very many proposed treatments for improving recovery after facial nerve injuries have failed to stand up to the test of time.

Recommended statement #2:

It is appropriate to perform a neurolaryngeal exam before and after any intervention which might impair the nerve supply of the larynx. If there are positive findings in the immediate postoperative period, neurolaryngeal exams should be repeated for up to a year until the injury resolves or stabilizes. Even a year is a short period of time if a surgeon really wants to know what the long-term rate of injury is for laryngeal nerve function. Recovery with neural dysfunction may continue to evolve for up to 20 years after an injury. I have seen increasing dyskinesis develop 20 years after thyroid surgical nerve injury, Based on the evolution of the patient’s symptoms, laryngospasm (inappropriate timing and degree of lateral cricoarytenoid muscle contraction) worsens over many years.

Statement #3 first part:

Wait for two months before you check out patient complaints. Have an “Index of suspicion.”

Waiting and indexing are poor triggers for evaluation. The surgeon relying on “index of suspicion” before examining laryngeal muscles is an ostrich. By putting patient complaints off, you are making the patient feel that they are pestering you with their complaints. By two months, they quit bothering you, but the problem injury may still be there, whether you look or not.

Recommended statement #3:

Evaluating pre-and post intervention vocal parameters (including maximum phonation time, vocal range and volume) is one of the strongest verifications of nerve injury. If a patient loses vocal volume or vocal range, there has been a nerve injury until proven otherwise on a detailed endoscopic examination.

In addition, after surgery, if you looked at the onset of a patient complaint, you would learn what the injury was and if you looked again later, you would learn which injuries resolve, which injuries evolve and which ones are permanent.

Statement #4:

If you think there is an injury, do an “objective voice evaluation through validated questionnaires.”

Validated questionnaires are not objective voice evaluations. They are measures of patient feelings.

Recommended statement #4:

If a surgeon wants to learn how often they injure a nerve, they will document vocal capabilities (volume, range and duration), both before and after any intervention near the laryngeal nerve. If vocal capabilities are not equivalent at this interval, an injury has occurred.

Go ahead and administer questionnaires if you like them, but they don't really tell you anything about neural function or injury.

Statement #5:

Stroboscopy is important.

Ok. Maybe, though it depends on how stroboscopy is performed and whether it is performed across a range of vocal pitch and vocal volume. The larynx is excellent at compensation for an injury. If stroboscopy is performed at a single pitch and the endoscope is far away from the larynx, most injuries will be missed.

Recommended statement #5:

Endoscopy and stroboscopy, using a neurolaryngeal approach, before and after an intervention can determine which muscles were injured, which recovered appropriately and which ones recovered inappropriately. Want details on a complete neurolaryngeal examination? Download a pdf on Neurolaryngeal examination.

Results

Summary Statement #1: immediate paralysis

There's not much here to support adding the term “immediate” to our description of neural injury that occurs during surgery.

It is that a big jump in this section to assume that using this new term, immediate, will lead to better patient outcomes after nerve injury if injection augmentation procedures are performed. Certainly that's a topic which should undergo research. But there is a strong possibility of selection bias in some articles.

On the rationale for “Early Identification,” the authors recommend, “a high clinical suspicion for unilateral VFP is important if the patient complains of a weak voice or has an audible breathy quality to the voice.” This triggering approach means that only the most severe injuries even graduate to the point of an examination.

Summary Statement #2: Preoperative laryngeal exams may be helpful.

The word, “may” is a very weak link here. Preoperative exams combined with postoperative exams are the only potential way to find even most of the injuries that occur. Not looking before surgery does not mean there wasn’t an injury during surgery. It is very difficult to go back and time and wish you had an exam that wasn’t performed.

Summary Statement #3: Partial neural dysfunction

It is easy to be concise with this statement. Partial neural dysfunction after thyroid surgery is widely under diagnosed.

Let's figure out how we can improve this. Patients considering thyroid surgery deserve a more accurate understanding of the risk of nerve injury, especially considering the number of thyroid surgeries performed for what are often ultimately benign conditions. Just ask some of the singers I have seen who had thyroid removal for fear of a cancer that in hindsight had only benign tissue removed and their vocal injury never recovered completely. Was the vocal injury worth removal of benign tissue?

My summary

Nerve injury means a muscle does not contract partially (paresis) or at all (paralysis). Appropriate recovery means the muscle contracts at the appropriate time. Inappropriate recovery means the muscle contracts at an inappropriate time. When opposing muscles contract, one at an appropriate time and one at an inappropriate time, some degree of synkinesis results. When an unopposed muscle contracts at an inappropriate time, dyskinesis results.

My concern with these expert practice guidelines is that they will continue to perpetuate the sense that neural injury is uncommon during thyroid surgery. Neural injury is underdiagnosed and will likely remain that way if neurolaryngeal examinations are only performed for an index of suspicion.

1. Nerves: Left and right superior and left and right recurrent laryngeal nerves = 4 nerves.

2. Muscles: paired thyroarytenoid, lateral cricoarytenoid, posterior cricoarytenoid, cricothyroid equals 8 muscle and the interarytenoid may functionally act as a single muscle = 9 muscles.

Phonogram - Identifying a voice disorder with your ear

James P. Thomas, MD — Tuesday, March 24, 2020 - 20:55

In lieu of travelling these next few months, I have placed online one of my favorite lectures about identifying a voice disorder by sound - Phonogram.

You could reasonably ask,

Why should the examiner listen to the voice?

Seeing sound.

I am a visual person you say. I went into a surgical speciality for my talent to see something and remove it, yet, my ear isn’t well trained. I can’t carry a tune, but I specialize in laryngology and my patient is hoarse, a complaint about sound. Sound is created by the movement of air and I can’t see air, how do I visualize sound? This video gives you some ideas.

The larynx looks normal.

Patients often seem more accurate about their perception that something is not clear in their voice than physicians are at recognizing what is impaired. While the task of identifying the impairment is more difficult than just hearing it, diagnosticians all too often hide (perhaps unconsciously) their knowledge deficit. A “normal” appearing larynx ends up being “treated” by prescribing a pill or speech therapy rather than admiting the need for a more directed examination.

Audio Patterns.

Training your ear a little bit, we can begin to recognize regular and irregular air flow. Listening to a range of pitch and volume patterns of hoarseness appear. We can convert these findings into a phonogram, a graphic profile representing a vocal signature.

Seeing a vocal signature improves understanding of vibration disorders and laryngeal compensation, leading an ear-trained diagnostician to an accurate perception of the vocal cord vibratory impairment before looking with an endoscope and stroboscope.

Ultimately, this phonogram identifying hoarseness translates visually into pathology using endoscopy and stroboscopy. Gradually it can become possible, even easy, to identify voice disorders by ear alone.

Summary of Vocal Capabilities

James P. Thomas, MD — Friday, June 7, 2019 - 19:15

Vocal capabilities pattern matching

Reviewing the four Vocal Capabilities Pattern examples, we can begin to visually see that combining loudness and pitch reveal patterns.

Clear sound is coded in green. Roughness is encoded Red and Breathiness is encoded in Blue.

Vocal cord margin swellings

With impairments at low volume and high pitch we see a graph with audible pathology on the lower right side and that points toward vocal swellings.

Recurrent laryngeal nerve paresis

With vocal paresis of the anterior branch of the recurrent laryngeal nerve, findings will be most audible at low pitch and low volume, so in the lower left corner.

Vocal cord bowing

With vocal bowing, the pattern is of impairment at low volume, where there is not enough air to drive the vocal cords through a wide gap.

External compression of vocal cords

With external compression of the vocal cords, the pattern is of impairment at all volumes and both volume and range can be restricted.

These patterns orient us to predict what we will find on laryngoscopy. At a minimum, they will direct the examiner where to look and what task to ask the patient to perform while recording with an endoscope or a stroboscope. When the same person performing endoscopy performs these vocal elicitations, the process of differential diagnosis formulation that began during the history progresses during vocal capabilities testing. The examiner is beginning a visual thinking process about where to look for the sound impairment while listening to the vocal capabilities. The examiner is an audio engineer, seeking any impairment of the vocal signal, seeking any inappropriate introduction of noise into the voice. In my experience, these tests are sufficient to elucidate almost all vocal disorders.

Every type of vocal impairment will have a characteristic pattern, not only in which quadrant the impairment is present, but the pattern of red (roughness) and blue (breathiness) will add to the character of the pattern. We can think of them as a Vocal Signature specific to a disorder. There are also very specific findings, such as onset delays, pitch breaks and flutter that further aid in the identification of a disorder. Many of these patterns are so distinct that the examiner can make a relatively accurate prediction of what will be found on laryngoscopy before looking.

I have been performing these tests often enough and long enough that I can often hear and identify voice problems just walking through a crowd. One of my hobbies is traveling and meeting new people. I hear the person’s accent and their vocal character, and then I can start to hear a vocal impairment if one is present. At some point into our conversation, I can make some predictions about where they are from based on the accent and what they are like socially based on whether I hear the attributes of vocal swellings. The accent of speech and the character of voice tell a lot about an individual, particularly if they are a member of the vocal overdoers or vocal underdoers of the world.

Secrets of listening for hoarseness – Vocal capabilities handout

Download the Laryngology – Secrets of Listening pdf file: Secrets of listening - 2020-01.pdf

I utilize this handout at lectures. It is a pdf file covering the same ground as the Vocal Capabilities section of this website, compiled into a 24 page, full-color booklet.

Learning

These examples are not enough to cover all the audible patterns that can be created by laryngeal disorders that cause hoarseness and, by definition, impair harmonic voice production. However, whatever pattern one hears, the vocal pattern should be explainable by the subsequent visual examination. In fact, this technique is self-teaching in that, when a new vocal impairment pattern is heard, the examiner who views the vocal cords endoscopically using the same vocal maneuvers that elicit an impaired voice on vocal capabilities testing, will often discover the reason for the vibratory impairment, even if it is new to the examiner. The examiner who records audio of vocal capabilities pattern matching will also have feedback to discover and learn when the phonatory system is altered during surgery on the vocal cords or in the vicinity of the motor nerve supply of the larynx, whether intentionally or unintentionally.

Conclusion

All vocal impairments can be described in terms of roughness and breathiness, the “R” and “B” of the GRBAS system. Roughness is typically diplophonia, although other quantities of multiple simultaneous pitches can be produced, all creating the perceived quality of roughness. Breathiness is unwanted air leak or air escape between vocal cords that do not completely approximate or are stiff. We can be more precise than simple grading of the amount of roughness and breathiness. A more accurate descriptive method is noting the onset of roughness and/or breathiness as present at high pitch, low pitch or at both. We can be even more precise and note the specific pitch at which diplophonia begins to be produced or breathiness become significantly noticeable, and then whether or not this condition is present from this onset pitch upward or this onset pitch downward. The most accurate record is to have dated audio and video recordings maintained for future review and comparison.

Utilizing the following parameters for vocal capabilities pattern matching; comfortable speaking pitch, maximum phonation time at comfortable speaking pitch, vocal range (lowest pitch, highest pitch), loudness capability, vegetative sound capability and vocal swelling test we can then define or describe the vocal signature of each patient with a complaint of hoarseness. This vocal signature orients the examiner to the where (vocal cord margins), when (pitch and volume) and what to observe for (gap or diplophonia) during recording of laryngoscopy and stroboscopy.

If each physician were to record the vocal capabilities of every patient before and after interventions to the vocal cords, and before and after interventions in the region of the recurrent laryngeal nerve, we would learn more about vocal injuries. We would more precisely learn when we are successful in altering the voice, since harmonic sound production is a successful outcome, not vocal cord appearance. Vocal capabilities pattern matching essentially tests the status of the laryngeal muscles, the status of the closure of the margins of the vocal cords, the flexibility of the vocal cord mucosa, as well as the status of the symmetry of the vocal cords.

Bibliography

1. Cohen SM, Pitman MJ, Noordzij JP, Courey M (2012) Evaluation of dysphonic patients by general otolaryngologists. Journal of voice : official journal of the Voice Foundation 26 (6):772-778. doi:10.1016/j.jvoice.2011.11.009

2. Thomas JP, Zubiaur FM (2013) Over-diagnosis of laryngopharyngeal reflux as the cause of hoarseness. Eur Arch Otorhinolaryngol 270 (3):995-999. doi:10.1007/s00405-012-2244-8

3. Isshiki N, Okamura H, Tanabe M, Morimoto M (1969) Differential diagnosis of hoarseness. Folia Phoniat 21:9-19

4. Hirano M (1981) Clinical Examination of Voice. Springer-Verlag, Vienna

5. Dejonckere PH, Lebacq J (1996) Acoustic, perceptual, aerodynamic and anatomical correlations in voice pathology. ORL; journal for oto-rhino-laryngology and its related specialties 58 (6):326-332

6. Sulica L (2014) Hoarseness misattributed to reflux: sources and patterns of error. Ann Otol Rhinol Laryngol 123 (6):442-445. doi:10.1177/0003489414527225

7.. Cohen SM, Garrett CG (2008) Hoarseness: is it really laryngopharyngeal reflux? The Laryngoscope 118 (2):363-366. doi:10.1097/MLG.0b013e318158f72d

8. Belafsky PC, Postma GN, Koufman JA (2002) Validity and reliability of the reflux symptom index (RSI). Journal of voice : official journal of the Voice Foundation 16 (2):274-277

9. Hopkins C, Yousaf U, Pedersen M (2006) Acid reflux treatment for hoarseness. The Cochrane database of systematic reviews (1):CD005054. doi:10.1002/14651858.CD005054.pub2

10. Koufman JA, Aviv JE, Casiano RR, Shaw GY (2002) Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 127 (1):32-35

11. Turley R, Cohen S (2010) Primary care approach to dysphonia. Otolaryngology -- Head and Neck Surgery 142 (3):310-314. doi:10.1016/j.otohns.2009.12.022

12. Chandrasekhar SS, Randolph GW, Seidman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J, Benninger MS, Blumin JH, Dennis G, Hanks J, Haymart MR, Kloos RT, Seals B, Schreibstein JM, Thomas MA, Waddington C, Warren B, Robertson PJ, American Academy of O-H, Neck S (2013) Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg 148 (6 Suppl):S1-37. doi:10.1177/0194599813487301

13. Rosen CA, Murry T (2000) Voice handicap index in singers. Journal of voice : official journal of the Voice Foundation 14 (3):370-377

14. Hogikyan ND, Sethuraman G (1999) Validation of an instrument to measure voice-related quality of life (V-RQOL). Journal of voice : official journal of the Voice Foundation 13 (4):557-569

15. Takahashi H, Koike Y (1976) Some perceptual dimensions and acoustical correlates of pathologic voices. Acta oto-laryngologica Supplementum 338:1-24

16. Dejonckere PH, Obbens C, de Moor GM, Wieneke GH (1993) Perceptual evaluation of dysphonia: reliability and relevance. Folia phoniatrica 45 (2):76-83

17. Kempster GB, Gerratt BR, Verdolini Abbott K, Barkmeier-Kraemer J, Hillman RE (2009) Consensus auditory-perceptual evaluation of voice: development of a standardized clinical protocol. American journal of speech-language pathology / American Speech-Language-Hearing Association 18 (2):124-132. doi:10.1044/1058-0360(2008/08-0017)

18. Thomas JP (2014) Assessment of the Professional Voice: The Three-Part Examination. In: Bhattacharyya AK, Nerurkar NK (eds) Laryngology. Otolaryngology - Head and Neck Surgery Series. Thieme Medical and Scientific Publishers Private Limited, a-12, Second Floor, Sector-2, Noida, Uttar Pradesh - 201 301, India, pp 315-323

19. Bastian RW, Keidar A, Verdolini-Marston K (1990) Simple vocal tasks for detecting vocal fold swelling. Journal of voice : official journal of the Voice Foundation 4:172

Combined findings

James P. Thomas, MD — Sunday, November 4, 2018 - 11:39

Specifying pitch and volume when looking at vocal cords is essential. If we take the example of vocal swellings, voice may be clear at some pitch and volume combinations. Yet with the same pathology at other pitch/volume combinations, vocal swellings often have combined sonic elements of air leak and polyphonia. Let's consider why and when harmonic and non-harmonic sounds are present and when both types of non-harmonic sound may be present in combination.

At low pitch, the vocal cords are loose and a swelling(s) tends not to interfere directly with vibration (indirectly a mass on the vocal cord margin affects pitch since the additional mass tends to lower the pitch). At low tension, the swelling on the margin of the vocal cord will also easily compress into the body of the vocal cord during each oscillation. The swelling(s) will tend to separate during the open phase because of the low tension.

At low air flow the vocal cords may not completely close and there will be continous air leak, so huskiness will be apparent. At high airflow (loud) at the same pitch, the vocal cords will come completely together on each cycle and there will not be air leak, but rather regular entrainment of the air pulses and so sound will be clear. So volume will affect clarity in vocal swellings at low pitch.

At low pitch and low airflow, the vocal cords oscillate freely but tend not to come completely together, so huskiness is present.

As we increase pitch and the cricothyroid muscle tightens, the vocal cord margins are brought closer together. At some pitch the vocal cord swellings touch and do not come apart. If airflow is high (loud), then two separate segments are created. There will typically be a jump in pitch because of the sudden cutting in half of the vibratory length - a pitch break. They may vibrate at the same pitch and so sound will be clear. If they are different lengths, then diplophonia will occur. If the swelling is large enough, the vocal cord margins will not approximate during the closed phase and there will be continous air leak - huskiness. So at high pitch and high volume we hear both huskiness and roughness.

If subglottic pressure is low (quiet), then at the pitch where the vocal cords touch, they will stop vibrating and air will leak out - phonatory stop. Or if the sudden leak of air triggers the individual to increae subglottic pressure as compensation, then there will be an onset delay.

At high pitch and high volume, the same vocal cord swelling in the photo above with initiate diplphonia.

So vocal findings of onset delays, phonatory stops, pitch breaks, roughness and breathiness may all be present in the same person, sometimes simultaneously, but dependant on the pitch and volume combination present.

Huskiness - White noise

James P. Thomas, MD — Saturday, November 3, 2018 - 14:30

Case study

History

Gabriella is a performer with nightly shows for another 4 weeks. She is having difficulty with her voice giving out by the end of each performance. Even while I listen to her tell me her history, I can hear a husky quality to her voice.

Vocal Capabilities

This continues as she performs the reading task, although it can be difficult to distinguish the white noise at times with all the words and her robust volume. When she performs a maximum phonation time at her comfortable pitch, the air leak is fairly obvious. She runs out of air after 7 seconds, a very short time for anyone, much less a performer trained in vocal technique. From spontaneous speech, reading speech and maximum phonation time tests, I can begin to graph her voice.

The dark circle represents a typical female speaking pitch. Her comfortable speaking pitch is G3, in the range of a typical female’s speaking pitch, so I have added a yellow circle to signify that her comfortable speaking pitch is normal. Then I painted a light blue area over this, representing audible air leak at this pitch.

I ask her to make sounds at several pitches, working up toward her highest pitch and again I hear air leak.

Wherever I hear air leak, I paint a blue area. At a soft reading volume she is leaking air at a number of pitches. As she goes up in pitch, her volume increases. This is a common and unintentional compensation that has developed over time.

Laryngoscopy

Even before I get out an endoscope to look at her vocal cords, I know that the cords are not closing together completely. There is a continuous flow of air throughout much of her vocal range. If I were to take a look at her vocal cords after this much of a vocal evaluation, I would see that the vocal cords never close on stroboscopy, even during the most closed phase portion of vocal cord oscillation.

Stroboscopic exam at pitch G3 (maximum closed phase). The dark areas are where the vocal cords never close at this pitch and represent air leak and likely turbulent airflow. The dark areas are the reason she is husky at her comfortable speaking pitch.

On the same exam her vocal cords are recorded during stroboscopy at a higher pitch – C5, and this still photo is extracted from the most closed phase at C5. Again, there are large dark areas representing continuous air leak and likely turbulent airflow generating white noise or huskiness.

Summary

Air leak or huskiness is one of the two major types of hoarseness. We diagramed air leak on a pitch vs. volume plot and the blue areas representing air leak on our vocal diagram will correspond to continuous dark areas during stroboscopy.

We have:

used a few vocal capabilities (reading, maximum phonation time, low and high pitch) to hear a specific vocal impairment – air leak.
diagrammed the impairment on a pitch vs volume plot which gave us a pattern.
correlated the audible finding huskiness with the endoscopic finding of incomplete closure of the vocal cords.

This particular pattern of air leak at low pitch and low volume along with air leak at high pitch and high volume is typical of large vocal swellings. The same pattern may also be typical of muscle tension, where the vocal cords are held apart by a competitive tension between the lateral cricoarytenoid muscles and the posterior cricoarytenoid muscles.

We can (and should) test further vocal capabilities to maximally refine our differential diagnosis. I test all the capabilites mentioned in chapter 18 on each patient. Complete testing increases my ability to recognize patterns and not to miss an important finding.

We can (and should) perform endoscopy and stroboscopy to correlate our suspected audible findings with visual findings.

Gender Affirmation Voice Surgery

James P. Thomas, MD — Friday, January 6, 2017 - 18:04

Thieme published a chapter on Voice modification in "Gender Affirmation Medical and Surgical Perspectives",

edited by Christopher Salgado, Stan Monstrey and Miroslav Djordjevic. This chapter, from pages 31-50, covers several different approaches to modifying the male to female voice surgically.

It has a complete set of photographs of Feminization Larynoplasty along with details about the surgical technique.

The textbook is available from the publisher and on Amazon.com.

Feminization Laryngoplasty

James P. Thomas, MD — Sunday, July 24, 2016 - 15:55

I presented a short description of some of the work I am doing to modify the comfortable speaking pitch and pitch range of transgender individuals wishing to sound more feminine at the 23rd WPATH Symposium in Amsterdam, The Netherlands on July 20, 2016. It included thoughts on the five procedures currently utilized to alter pitch:

Cricothyroid approximation (aka Thyroplasty Type I)
Vocal cord webbing (aka " Vocal Fold Shortening with Anterior Commissure Advancement" or VFSAAC, Wendler Glottoplasty)
Laser reduction of vocal cords (aka "Laser Assisted Voice Adjustment" or LAVA, Laser Glottoplasty) - typically CO2 laser
Laser vocal cord tuning (typically KTP laser)
Feminization Laryngoplasty

European Laryngologic Society Meeting 2016 in Genoa, Italy

James P. Thomas, MD — Tuesday, June 14, 2016 - 15:07

An outstanding meeting just finished in Genoa, Italy for the 11th European Laryngological Society meeting hosted by president Giorgio Peretti on June 8-11.

I found a bit of time to recap the meeting in photos. with the full set available for download on Flickr.

There were many great presentations.

It was extremely educational, particularly the discussions between and after the meetings.

Some members found time for recreation in the form of eating, swimming, singing and dancing. In particular, the evening spent up on the hill at the Villa Lo Zerbino was spectacular.

See you in 2018.

Vocal Signature or Vocal Capabilities - presented ELS meeting 2016

James P. Thomas, MD — Tuesday, June 14, 2016 - 11:56

This short video was produced for the European Laryngology Society's meeting in Genoa, Italy. It was limited to 10 minutes and briefly covers the rationale behind listening to the voice in order to make a diagnosis.The premise is that it is necessary to alter pitch and volume while listening to the voice in order to establish the pattern which is characteristic and different for each type of voice disorder.

High Definition Laryngology 2016

James P. Thomas, MD — Tuesday, June 14, 2016 - 08:36

Lecture given at the 2016 European Laryngologic Society meeting on the topic of High-Definition Laryngology.Essentially I describe the way that a combination of technique and equipment lead to the most pixels on the pathology. The more pixels there are on the problem, the better the resolution and understanding of the person performing the diagnostic examination. The video equipment tends to be expensive. Indeed, at this conference Olympus has been showing their Ultrahigh definition 4K video, the setup which cost about $80,000. However, with a bit of lidocaine, good technique, an understanding of video technicalities and outstanding images of laryngeal problems and pathology can be obtained.