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Aerodynamic____ysisofVocalFoldPolypsKhalidHassanAl-__lkiM.D.Ph.D.ConsultantofCommunicationDisordersCommunicationandSwallowingDisordersUnitCSDUDepartmentofORLKingAbdulAzizUniversityHospitalRiyadhCorresponden__address:KhalidH.Al-__lkiP.OBox23008Riyadh___26SaudiArabiaAbstractO__ective:Toevaluatetheeffectofvocalfoldpolypsonaerodynamic____ysisofthevoi__.__terialandMethod:Anexperimentalcontrolledprospectivestudycomposedoftwogroups.Grouponecontained31_____patientswithvocalfoldpolypsoneitherorbothvocalfolds.Grouptwowascomposedof30su__ectswithnor__llaryngesandrespiratorysystems.Bothgroupsweresu__ectedtoaerodynamic____ysisusingAerophoneII.Results:Comparedtocontrolgroupvocalfoldpolypscausedstatisticallyhighlysignificantincreasein:phonationquotientPQmeanflowrateMFRsubglottalpressurePsubandglottalpowerPg.Theycausedstatisticallyhighlysignificantdecreasein:__ximumphonationtimeMPTandglottalresistan__Rg.Therewerenostatisticallysignificantdifferen__sinvitalcapacityVCorglottalefficiencyEg.Conclusion:Aerodynamic____ysisofvoi__isoneofessentialinvestigativetoolsinasses__entofvocalfoldpolyps.Keywords:vocalfoldpolypaerodynamicsglottalgap.IntroductionVocalfoldpolypsareswellingsonthemiddlethirdofthemembranouspartofthevocalfoldoftenonthefreeedgeandusuallyunilateral.Theycanbesessileorpedunculatedandareverymobilewhenpedunculated
1.Likeotherbenignvocalfoldlesionsthemostimportantcauseofvocalfoldpolypsisvocalabuseandmisusevocaltrau__
23.Theycanevenoccurasaresultofasingleacutevocaltrau__
4.Theyareseenmorecommonlyin__lesparticularlyinthosewhoengageinintermittentseverevoi__abuseorwhoworkinnoisyenviro__ent
5.Itisthoughtthatphonotrau__indu__srelatively__jortrau__tovocalfoldvesselsleadingtohemorrhagefibrinexudationthrombosisandproliferationofcapillaries.Integralrepairoftheinitialda__geisthenprobablyhamperedbyrecurrentmovementsofthelesionduringphonationinducingrecurrentcapillarytrau__asisdemonstratedultrastructurally
1.Thepathologyislocatedinthesuperficiallayeroflaminapropria
6.Thefollowingtypescanbeidentifieddependingontheprevalen__ofoneortheotherstructuralcharacteristics:fibrouspolypstelangiectaticpolypsandhyalinouspolyps
2.Thepatienth__ingvocalfoldpolypusuallycomplainsofdysphoniachangeofvoi__withorwithoutvoi__fatiguesymptoms.Aerodynamic____ysisofvoi__isbasedonthefactthatvoi__productionisessentiallyanaerodynamicphenomenonwherebytheglottistransformsaerodynamicpowerintoacousticpower.Forphonationtotakepla__bothasuitablequantityofairandasuitableairpressureareneeded.Theaerodynamicfor__sworkingattheglottisseemtoberesponsibleforthecreationofthesustainedvibratorysystemofthevocalfolds
78.Aerodynamic____ysisofvoi__productionincludesmeasurementsofairflowairpressureandtheirrelationshipsduringphonation.Earlyinvestigatorsfoundthataerodynamicstu___sarehelpfulinetiologicalclassificationofvoi__disorders79whilelaterstu___sshowedthatthediagnosticvalueofaerodynamicmeasurementsislowinidentifyingtheexactetiologybutthey__ypointtoatendencytothe“hyperfunction”or“hypofunction”stylesofvocalproduction
1011.Howeverthe__invalueofaerodynamicmeasuresistoevaluatethedegreeofvocaldysfunctionandtomonitorthepost-therapeuticchangesofvoi__disordersinthesamepatient
12.Somestu___sshowedthataerodynamicstu___softhedysphonicvoi__sofvocalfoldpolypsusuallyshowincreasedglottalairflowaswellasincreasedsubglottalpressureasanattempttoprodu__phonationinthepresen__ofleakyglottis
13.Theaimofthisstudyistoevaluatetheeffectofvocalfoldpolypsonaerodynamic____ysisofthevoi__.__terialsandMethodsThisisanexperimentalcontrolledprospectivestudycomposedoftwogroups.Grouponecontained31_____patientswithvocalfoldpolypsoneitherorbothvocalfolds.TheywerediagnosedusingdigitalvideolaryngostroboscopyModelRLS9100BKayElemetricsCorp.LincolnParkNJUSAFigure
1.Grouptwowascomposedof30su__ectswithnor__llaryngesandrespiratorysystemsasconfirmedbyhistoryvideolaryngoscopicandchestexamination.Bothgroupsweresu__ectedtoaerodynamic____ysisusingAerophoneIIModel6800KayElemetricsCorp.LincolnParkNJUSAinstalledtoaPCcomputerFigure
2.TheselectedairflowtypefromtheoptionmenuofAerophoneIIsoftwarewastheTARGETflowratebecauseitisbelievedthatthistypeofflowrateisthemostaccuratetypetoh__ethesoftwaredeterminestheairflowrateassociatedwithphonationAerophoneIIinstruction__nualp.
271995.Allpatientsineithergroupwereevaluatedbythesameexperimenter.Thefollowingaerodynamicparametersweretestedusingdifferent“tasks”:1VitalcapacityVCwhichisthe__ximumvolumeofairthatcanbeexpelledfromthelungsfollowinga__ximuminspiration.2__ximumphonationtimeMPTisthelongestphonationfollowing__ximuminspiration.3PhonationquotientPQisdeterminedbydividingVCbyMPT.Itiscomputedtoredu__thepossiblebiasofsupportiverespiratorycapabilitiescompensatingforpoorvocalfoldclosure
8.4MeanairflowrateMFRduringvowelproductionismeasuredusingapneumotachographwhichconsistsofahand-heldflowheadconnectedtoa__skwithinwhichispla__dafinemeshwirescreeninordertocreatea__allresistan__toairflow.Thisresistan__resultsinapressuredifferen__acrossthescreenthatcanbemeasuredwithadifferentialpressuretransdu__r.Thepressuredifferen__increaseswithairflow.5ThemeanSPListhe__erageloudnessinSPLinagivenphonationtask.6SubglotticpressurePsubisobtainedbymeasuringtheintra-oralpressurewithatinytubeinsidethemouthprodu__dduringtherepeatedpronunciationofavoi__lessplosivewithinanonsensesyllablee.g./i:pi:pi:/.7GlottalaerodynamicinputpowerPgiscalculatedasPsubduring/p/productionmultipliedbyMFRduringvowelproduction.8GlottalefficiencyEgisexpressedastheacousticoutputpowermeanSPLdividedbytheaerodynamicinputpowerPg.9Glottalresistan__RgiscalculatedasPsubdividedbyMFR.Everypatientorsu__ectwasaskedtoperformthefollowingtasksAerophoneIIinstruction__nual1995:
[1]VitalCapacityTask:Whilestandingthepatient/su__ectwasaskedtoinhaleasdeeplyaspossibleandthentoexhaleasfastandasstrongaspossible.Afa____skwasused.ThreeattemptsweredoneusingtheflowheadF1000andthegreatestvaluewastakenasthemeasurementofvitalcapacity.
[2]__ximumSustainedPhonationTask:Thepatient/su__ectwasaskedtosustainaphonationofthevowel/α/foraslongaspossibleatacomfortablepitchandloudnessaftera__ximuminspiration.Pitchwassettobeascloseaspossibletotheexpectedforthesu__ect’sgenderandagee.g.128Hzforan_______leand256Hzforan_____fe__le.SPLwasseton50-100dB.ThreeattemptsweredoneusingtheflowheadF300andafa____sk.ThegreatestvaluewastakenasthemeasurementofMPT
14.Meanairflowratefor__ximumsustainedphonationMFRPQandmeanSPLwerecalculatedalsounderthistask.
[3]I:PI:PI:Task:UsingtheflowheadF300andafa____skwithatinytubeinsidethemouththepatient/su__ectwasaskedtorepeatthesyllable/i:pi:pi:/severaltimesatacomfortablepitchandloudness.SPLwasseton50-100dB.Beforethestartoftherecordingthepatient/su__ectpracti__dthistaskcoachedbytheexperimenter.ThistaskpermittedcalculationofPsubPgEgandRg.Thesemeasuresarecomputedauto__ticallybyAerophoneII.Thedifferen__sinreadingscalculatedbyAerophoneIIinthethreeabove-mentionedtasksbetweenthetwogroupswereexaminedusingthet-testofindependentsamples.ResultsThestudycomprisedoftwogroups.GroupIwascomposedof31vocalfoldpolyppatients;20__les65%and11fe__les35%.Meanagewas
40.7±
10.6yearsrange26–60years.Sixteenpatients52%hadright-sidedpolyps11patients35%hadleft-sidedpolypsandthere__ining4patients13%hadbilateralvocalfoldpolyps.GroupIIcomprised30nor__l_____su__ects;18__les60%and12fe__les40%.Meanagewas
35.6±
12.9yearsrange15–65years.Themeanvaluesandstandarddeviationsfortheaerodynamicvariablesaswellastheresultsofthettestofbothgroupsarepresentedintable
1.AscanbeseenthemeansofVCforbothgroupswerevirtuallythesame.Thedifferen__betweenthetwogroupswasstatisticallyinsignificant.ThemeanMPTforgroupIwaslessthanthecontrolgroupgroupII.Thedifferen__wasstatisticallyhighlysignificant.ThemeanPQandthemeanMFRforgroupIshowedhigherrecordingsthangroupIIwithhighlysignificantstatisticaldifferen__s.ThemeanSPLdidnotrevealanysignificantstatisticaldifferen__betweenthetwogroups.ThemeanPsubandthemeanPgforgroupIshowedhigherrecordingsthanthecontrolgroupgroupII.Thedifferen__swerestatisticallyhighlysignificant.ThemeanEgdidnotdemonstrateanysignificantstatisticaldifferen__betweenthetwogroups.RgshowedlowerreadingingroupIcomparedtogroupII.Thedifferen__wasstaticallyhighlysignificant.DiscussionSin__thevitalcapacityVCreflects__inlylungfunctionitwasexpectedthattherewillbenostatisticaldifferen__betweenthepatientsgroupIandthecontrolsu__ectsgroupII.Onthecontrary__ximumphonationtimeMPTwasmuchlessinthepatientsgroupbecausevocalfoldpolypshindercompletecoaptationofvocalfoldsduringphonation.Thisleadstofor__tionofphonatoryglottalgapcausingairleakduringphonation.Asaconsequen__the__ximumdurationthepatientcanphonateisexpectedtodecreaseinpresen__ofvocalfoldpolyps.Sin__phonationquotientPQisdeterminedbydividingVCbyMPTandsin__therewasstatisticallyhighlysignificantdecreaseofMPTthedenominatoroftheabove-mentionedequationbetweenthetwogroupsitisexpectedforPQtoshowahighlysignificantincreaseingroupIascomparedtogroupII.Thephonatoryglottalgapthatresultsfromvocalfoldpolypleadstoairleakashasbeenexplained.ThiscanexplaintheincreaseinmeanflowrateMFRingroupIcomparedtogroupII.VocalintensityanditscorrelatesoundpressurelevelSPLisdetermined__inlybytheexpiratoryairflowinpresen__ofadductedvocalfolds
15.Sin__vocalfoldpolypsdonotalterpulmonaryfunctionandsin__theglottalgapcausedbyvocalfoldpolypisnotlargeenoughtowasteexpiratoryairflowSPLwasnotexpectedtoshowsignificantdifferen__sbetweenthetwogroups.SubglottalpressurePsubrepresentstheenergyimmediately__ailableforcreationoftheacousticsignals
16.Sin__vocalfoldpolyphindersproperacousticsignalsbecauseoftheglottalairleakthepatientwithvocalfoldpolyptriesto“compensate”forthisbyincreasingPsub.ThiscanexplainthestatisticallyhighlysignificantincreaseinPsubingroupIcomparedtogroupII.TheincreaseinMFRPQandPsub;andtheassociateddecreaseinMPTduetovocalfoldpolypsareinagreementwiththefindingsdocumentedbyotherstu___s
713.GlottalaerodynamicinputpowerPgiscalculatedbythemultiplicationofsubglottalpressurePsubbymeanflowrateMFR.Sin__thelattertwoparametersshowedstatisticallyhighlysignificantincreasewhencomparingbothgroupsitisexpectedthatglottalpowerPgwillshowthesame.GlottalefficiencyEgisdeterminedbydividingSPLbyPg.Absen__ofstatisticaldifferen__betweenthetwogroupsinEgcanbeattributedtotheabsen__ofstatisticaldifferen__betweenthetwogroupsinSPLalthoughPgthedenominatoroftheabove-mentionedequationshowedstatisticallyhighlysignificantincreasewhencomparingbothgroups.Absen__ofstatisticaldifferen__betweenthetwogroupsinEg__yindicatethatgroupIpatientscanstill__intainanefficientglottisinspiteofpresen__ofvocalfoldpolyps.ThiscanbeexplainedbythefactthatmostofgroupIpatientshadrelatively__allpolyps.Glottalresistan__RgiscalculatedbydividingPsubbyMFR.AshadbeenexplainedPsubandMFRshowedstatisticallyhighlysignificantincreaseingroupIcomparedtogroupI.ButthestatisticallyhighlysignificantdecreaseinRgcanbeattributedtothephonatoryglottalgapcausedbyvocalfoldpolypleadingtoadecreaseintheresistan__oftheglottis.ItcanbealsoattributedtothepossibilitythattheincreaseinMFRwasmuchhigherthanthatofPsub.ConclusionAccordingtothefindingsofthecurrentstudyandcomparedtothecontrolgroupvocalfoldpolypscausedstatisticallyhighlysignificantincreasein:phonationquotientPQmeanflowrateMFRsubglottalpressurePsubandglottalpowerPg.Theyalsocausedstatisticallyhighlysignificantdecreasein:__ximumphonationtimeMPTandglottalresistan__Rg.Therewerenostatisticallysignificantdifferen__sinvitalcapacityVCorglottalefficiencyEg.Referen__s1DikkersF.G.andNikkelsP.G.J.:Benignlesionsofthevocalfolds:Histopathologyandphonotrau__.AnnalsofOtologyRhinologyandLaryngology1995;104:698-
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