Welcome
to Our
Clinic !
Pediatric Voice Care
A collaborative, modern approach
Lisa Kelchner, Ph.D.
Susan Baker Brehm, Ph.D
Alessandro de Alarcon, M.D., MPH
Barbara Weinrich, Ph.D.
Disclosure Statement
Drs. Kelchner and deAlarcon have
no financial or nonfinancial
interest in any organization
whose products or services are
described, reviewed, evaluated or
compared in the presentation.
Disclosure Statement
Drs. Weinrich and Brehm have a nonfinancial interest
in an organization whose products or services are
described, reviewed, evaluated or compared in the
presentation.
• Name of organization(s):KayPentax
• Description of relationship(s) (not amount) such as
ownership interest, financial interest, employee, own all
or part of a licensed patent or copyright, ongoing
relationship (pediatric aerodynamic norms research
project-coordinators), financial compensation, in-kind
support, scholarship/grant, family member works
there, etc.
Learner Outcomes
• Participants will demonstrate knowledge of:
– The primary etiologic categories of pediatric voice
disorders
– Current advances in medical, instrumental and
behavioral assessments
– Current advances in medical, instrumental and
behavioral interventions
– Use of the Pediatric Voice Handicap to
characterize the effects of having a pediatric voice
disorder
The CCHMC Model: Modern?
• Modern
– Belonging to the present day
– Of the latest kind; using the most advanced
equipment
– Using the latest styles
The CCHMC Model: Collaborative?
• To work with others
– To work with another person or group in order to
achieve something; a common end; synergy
– Learn or accomplish something together
– Work with the enemy: to betray others by working
an enemy
Mission
• Advance clinical services as well as establish and meet
research goals in the area of Pediatric Voice and Airway
Care
• Unique in our design
– Contributions of time and talent from 2 area universities (faculty
and students)
– Commitment from the CCHMC Department of Speech Language
Pathology to fund release time
– Commitment from Department of Pediatric Otolaryngology to
provide medical direction
– Participate in a multi departmental consortium dedicated to
voice at UC and the greater Cincinnati region
– Almost every patient becomes a participant in our voice registry
data base and /or other IRB approved projects
• Cincinnati Conservatory of Music
• Department of Aerospace Engineering
• Departments of Otolaryngology (Adult and
Ped)
• Communication Sciences Research Center
– Imaging
– Audiology
• Community Collaborators
History of the CCHMC Team
• Participants
– 3 PhD level clinical research/academics
– 3 masters level SLP clinicians
– 1 RN
– 1 pediatric otolaryngologist
– Students (masters, doctoral)
• History
– 2004 to present
Why is voice important?
• Communication
– How we interact with the outside world
– How we are interpreted by the outside world
• 6-24% incidence of childhood dysphonia
• Over 1 million children may have voice
disorders
Connor NP Journal of Voice. 2008 (22): 197-209.
Longterm Impact
• Unknown
• Dysphonic children judged more negatively than
their peers1
• Potentially false beliefs
– Dysphonic children have no awareness of disorder
– Not motivated to complete appropriate treatment
1Ruscerllo
DM Folia Phoniatr. 1988; 40: 290-296.
Anatomy
Pediatric Vocal Fold Structure
Is it the same as in adults?
Hirano, 1977
Titze, 1994
• Bilaminar: 2-11 month
• 3 layer structure: 11 months – 6 years
Hartnick CJ. Laryngoscope. 2005 (115) : 4-15.
Voice Disorders
“A child is described as
having a voice problem if the
voice is distracting or
unpleasant to listeners and
is abnormal enough to
interfere with
communication”
(Wilson, 1987)
Common Causes of Dysphonia
• Reflux
• Vocal Fold Trauma
– Nodules/cysts/scar
•
•
•
•
Vocal Fold Paralysis/Immobility
Recurrent Respiratory Papilloma
Functional Voice Disorders
Iatrogenic/Congenital
Larygophargeal Reflux (LPR)
Extraesophageal Reflux
Hard to diagnose
No great diagnostic test
Real cause of inflammation and hoarseness
Esophagus was designed to handle multiple
reflux episodes
• Larynx was not designed to tolerate any!
•
•
•
•
LPR
• Signs and Symptoms
• Globus sensation
• Chronic cough and throat
clearing
• Stroboscopy
– Edema, erythema, pachy
dermia
– Non-specific findings
LPR Treatment
• Proton Pump Inhibitors (purple pill)
– Taken correctly
– 30 minutes prior to am meal on an empty
stomach
• Lifestyle modification
• GI Referral for recalcitrant cases
Vocal Nodules
•
•
•
•
•
•
•
Laryngeal hyperfunction
Bilateral
Fairly symmetric
Hourglass closure configuration
History of Vocal Overuse
Variable voice
Reactive lesion
Vocal Fold Nodules: Strobe
Vocal Fold Cysts
• Unilateral/bilateral
– Contralateral nodule/reactive
lesion
• Variable strobe findings
depending on depth
• Variable response to voice
therapy
• More likely to undergo
surgery
Vocal Fold Cysts
Vocal Fold Lesions
Management Controversies
• How much therapy is enough?
– 10 therapy sessions (2-3 months)
– Operative exam
– Treat other potential causes
• Eosinophilic esophagitis
• GERD
Vocal Fold Lesions
Management Controversies
• When to operate on children?
– No clear guidelines
– 7 years of age “safe” from anatomical
– Many advocate conservative measures first
– Change the therapy
– Operate on one side first
– Based on the patients/families perceptions
– Can they “perform”
Pediatric Vocal Cord Paralysis
• 2nd most common congenital laryngeal
anomaly (10%)
• Most recognized before 2 years of age
– Usually present between birth and 2 months
• Often a manifestation of multi-system anomaly
– Central nervous system
– Cardiovascular malformations
– Pulmonary malformations
• Association with laryngeal clefts and subglottic stenosis
Unilateral VCP
• More common than
bilateral VCP
• Left > Right
• Symptoms:
– Weak, breathy cry
– Hoarse
– Diplophonia
Unilateral VFP
Management
• Observation
• Medialization
– Injection
• Office based
• Operative
– Permanent
• Gortex
• Silastic
– Ansa-Cervicalis
reinnervation
Bilateral VCP
• Associated with birth
trauma, CNS
abnormalities
• Paramedian position
• Symptoms:
– Stridor
– Aspiration
– Good voice
Interventions for BVCI
•
•
•
•
•
•
Observation
Tracheotomy
Posterior Cordotomy
Arytenoidectomy
Vocal Cord lateralization
Posterior Cricoid expansion
Fine balance between breathing, aspiration and voice
Endoscopic vs. Open VF Lateralization
• Open
–
–
–
–
Permanent
Most of the cord
Laryngofissure approach
Scarring
• Endoscopic
– Reversible
– Posterior third of the cord
– Better voice outcomes?
VF Lateralization
Juvenile Recurrent Respiratory Papillomatosis
• Benign exophytic lesion
• Most common benign
neoplasm in children;
2nd common cause of
hoarseness in children
• HPV 6 and 11
• Presentation
– Airway obstruction >
hoarseness
HOW DO WE TREAT IT?
Surgical Management of RRP
• Laser ablation
– Carbon dioxide (CO2)
– Potassium-titanyl-phosphate (KTP)
– Pulsed-dye
•
•
•
•
•
Microdebrider (powered instrumentation)
Tracheotomy
Sharp resection (Microlaryngeal removal)
Cautery ablation
Tracheal separation
Goal of Surgery
•
•
•
•
•
•
Reduce tumor burden
Decrease spread of disease
Create a safe airway
Improve voice quality
Increase time interval between surgeries
NOT CURATIVE
New Technology for RRP
PHOTOANGIOLYTIC LASERS
Selective Targeting of Blood Vessels
Anderson et al, Science, 1983
OXYHEMOGLOBIN ABSORPTION CURVE
532nm KTP
585nm PDL
TUMOR ANGIOGENESIS
Jako & Kleinsasser: 1966
Folkman: 1971
KTP Laser
• 532 nm laser
• Broader control of pulse
width
• Better control of tissue
damage
• Office based treatment
in adults
• Operative treatment in
children
Airway Reconstruction
Subglottic Stenosis
• Subglottic Stenosis
– Congenital or acquired
– Biphasic stridor
– Dyspnea on
exertion, exercise
intolerance
– Microlaryngoscopy and
bronchoscopy
– Cotton-Myer Grading
System
Grading of SGS
Laryngotracheal Reconstruction
• Primary aim
– Decannulation
– Balance Airway/Voice/Swallowing
– Create a safe situation
• Warning signs
– The “Active Larynx”
• Reflux > allergic esophagitis > idiopathic
– High O2 requirements
– Aspiration
Reconstruction Options
• EXPANSION
– Anterior cartilage graft
– Posterior cartilage graft
– Anterior / posterior cartilage
grafts
• Anterior graft posterior split
• RESECTION
– Cricotracheal resection
– Tracheal resection
– Slide tracheoplasty
Anterior Cartilage Graft
Anterior/Posterior Cartilage Graft
• Indications
–
–
–
–
Subglottic stenosis Grade II or III
Posterior glottic stenosis
Vocal cord paralysis
Laryngotracheal cleft repair (rare)
• 5-6 mm width graft adequate
Cricotracheal Resection
• CONCEPT:
– Remove the “Diseased” or
damaged segment of the
laryngotracheal airway
– Connect the “Healthy”
superior and inferior airway
segments
– Achieve decannulation
Cricotracheal Resection
• Indications
Severe stenosis (Gd III or IV)
Concentric scarring
Salvage procedure
Congenital anomaly of
cricoid or upper trachea
– Structurally inadequate
subglottis
– Inflammatory subglottic
stenosis - Wegener’s
–
–
–
–
•Contraindications
•Stenosis involves cords
•Grade I or II subglottic
stenosis
•Previous low tracheal
surgery
•Previous TEF repair or
laryngeal cleft repair
ALL are relative
contraindications!
Best Candidates for CTR
• Grade IV or Severe
Grade III Subglottic
Stenosis with a Clear
Margin (> 3 mm)
Between the Stenosis
and the Vocal Folds
Airway Reconstruction
• Balance between
airway and voice and
aspiration
– Voice often is the last on
the totem pole
• Procedures
– Some may be more likely
to cause problems
– Up to 50-75% may have
abnormal voice
LTR – CTR AT CCHMC
Teenagers/Young Adults
Post-LTR Voice
Parent/Child Concerns
• 1-5 years – decannulation
• 5-14 years – Social participation/ Sports
• 14-30 – Voice
– Social Interactions
– Occupation
CCHMC Post LTR Voice
How does vibration source influence voice?
Supraglottic Phonation
Supraglottic Phonation
Risk Factors
• High Grade SGS
(III, IV)
• Posterior Grafting
LTR
• More than 3 LTR/CTR
• CA Joint Ankylosis
Post LTP Voice
Glottic Diasthasis
• Glotticstasis
– Glottic incompetence
– Almost always posterior
glottic region
– Medialization techniques
will not address
– Arytenoid techniques
will not address
Post LTR Voice
Concerns
• Loudness
– I can’t be heard in noisy
environments
– I have to repeat myself
• Quality
– Rough sounding
– Why are you sick?
– What is wrong with your
voice?
Post-LTP Voice
•
•
•
•
Most severe dysphonias
Better counseling of families and children
Concentrated patient population
May provide a window to understanding less
severe dysphonias
CCHMC Airway Outcomes
• Treat the whole child
– Decannulation
– Swallowing
– Voice
• Voice Outcomes
– Prediction
– Prevention
– Repair
Update: Assessment
•Medical
•Behavioral
•Acoustic
•Aerodynamic
•pVHI
•Imaging
•Trial Therapy
Typical Visit
Intake
• RN:
• SLP: Background, review of protocol, Forms (pVHI, consent)
• RN sprays for nasal endoscopy
Booth
• Acoustic
• Aerodynamic
• Perceptual
Imaging
• Rigid, flexible
• Interdisciplinary Consultation
Medical Evaluation: Update
Background-Intake
• Typical H&P
• In depth questioning about:
– Birth complications; prolonged intubation
– Need for a trach (time; successes; failures)
– Respiratory status
– Developmental issues
– Feeding and swallowing
• Voice use; fluid intake; vocal hygiene; recent changes
• Airway/dyspnea
Perceptual Assessment
• Use of the CAPE V with children but not the
pediatric version(A. Masaki, 2009).
• Modify the sentences as needed
• 2 raters for each sample
• For all research protocols, we re-rate
independently or as the methods dictate
– All recorded in controlled fashion
Perception
Perceptual Study
• 3 raters independently rated 50 pediatric participants on six vocal
attributes,
• Ps: ages 4-20 years; 32 females; 18 males; Post AR
• Estimates of inter-rater reliability were strongest for perceptual ratings of
breathiness (ICC=71%), roughness (ICC=68%), pitch (ICC=68%), and overall
severity (ICC=67%). Reliability was lower for ratings of loudness (ICC= 57%)
and strain (ICC=35%).
• For each rater, intra-rater reliability on all but one parameter (strain) was
moderate to strong (ICC= 63%-93%).
• Conclusions: There was strong inter-rater reliability for four of six vocal
parameters rated using the CAPE-V in a population of children with
marked dysphonia. The parameter of strain, when rated by auditory
sample alone and apart from the clinical context, was difficult to rate.
•
Kelchner, L.N., Brehm, S.B., Weinrich, B, Middendorf, J., deAlarcon, A., Levin, L., Elluru, R. (2009).
Perceptual evaluation of severe pediatric voice disorders: Rater reliability using the Consensus Auditory
Perceptual Evaluation of Voice. Journal of Voice.
Perceptual Rating and other Internal
Calibration Issues
• Few projects have focused on inter and intrarater reliability using the CAPE V
• Periodic cross check of methods, trends etc.
– Data crunching and entry
– Visual perceptual ratings
• Clinic calibration
pVHI
• Developed in 2006 (Zur et al.)
• Adaptation of the VHI; parent proxy
• 45 parents of non-voice disorderd children;
(21m/24f; 3-12 years old); 33 parents of
children with dysphonia due to AR
•
•
•
•
Functional
Physical
Emotional
Total
Control
1.47
0.20
0.18
1.84
Airway
13.94
15.48
12.15
41.58
• What is it telling us?
– Summarized current data (N =20)
– Male/female patients; age 9 years
– AR (n = 10)
– VFN (n=10)
pVHI: Airway Reconstruction and
Nodule Patients
60
50
40
30
20
10
0
AR
VFN
Control
F
P
E
T
OS
pVHI: AR-Females/Males
70
60
50
40
30
20
10
0
Females
Males
F
P
E
T
OS
POS
pVHI: VFN-Females/Males
60
50
40
30
20
10
0
Females
Males
F
P
E
T
OS
POS
Part III
Update on Instrumental Evaluation
Usefulness of Instrumental Values:
Acoustic/Aerodynamic
• Normative values not available for children for all parameters
• Some parameters have a large range of acceptable values
• Changes in aerodynamic values are not a “one size fits all” –
very dependent on laryngeal function changes following
surgery. For example, a child who has undergone
reconstruction may have glottal incompetence resulting in
poor mobility of vocal folds for adduction
– Some children may not compensate – so an increase in
airflow and a decrease in pressure
– Some children may excessively compensate with
supraglottic structures – so decrease in airflow and an
increase in pressure
Usefulness of Instrumental Values:
Acoustic/Aerodynamic
• Effect sizes for the clinical significance of a change in
many of the instrumental parameters is still not
known
• Bottom line…. We still have a lot to learn about the
place and usefulness of this measures….
• HOWEVER, quantitative measures can be very
helpful in documenting clinical outcomes for other
health professionals and insurance reimbursement
Our Current Acoustic Protocol
• Average Fundamental Frequency
– Sustained vowel /a/
– Connected speech (CAPE-V sentences)
• Harmonic-to-Noise*
• Maximum Phonatory Frequency Range
• Intensity
– Comfortable sustained vowel
– Loud sustained vowel (maximum)
• Use texts with data tables for data comparison
– Baken & Orlikoff, 2000
– Kent, 1994
– Variety of voice textbooks
Problems encountered with obtaining
acoustic measures
• Limited laryngeal function
• Poor respiratory support
• Cognition/cooperation
• Limited periodicity of signals
Signal Typing
• National Center for Voice and Speech Workshop on
acoustic voice analysis (Titze, 1995)
– Titze proposed classification of voices into 3 types
• Type 1 – nearly periodic
• Type 2 – contain strong modulations and subharmonics
• Type 3 – irregular/aperiodic
– It is suggested that only Type 1 signals are suitable for
perturbation measures (e.g., shimmer, jitter) and
consistent fundamental frequency.
– Fundamental frequency can be inconsistent in Type 2 and
above.
Signal Classification
Type 1
Type 3
Type 2
Newer approaches in acoustic analysis
• Suggestion of a Type 4 signal
(Sprecher, Olszewski, & Jiang, 2010)
• Other measures to describe more chaotic
voices
– Spectral and cepstral analysis
– Nonlinear dynamic analysis
(e.g., Awan, Roy,& Jiang, 2010).
Our Current Aerodynamic
Protocol
•Maximum Sustained Phonation
– 6-22 seconds (Baken & Orlikoff, 2000)
•Average Airflow
– 72 – 223 mL/s (Baken & Orlikoff, 2000)
•Estimated Subglottal Pressure
– 5 – 10 cmH20 (higher values in children)
•Laryngeal Resistance
– 116 cmH20/LPS = preschoolers
– 94 cmH20/LPS = schoolagers
– 69 cmH20/LPS = preadolescents
(Netsell et al., 1994)
Phonatory Aerodynamic System Protocols
• Air Pressure Screening – can patient maintain 5
cmH20 for 5 seconds? (Netsell & Hixon, 1982)
• Vital Capacity
• Maximum Sustained Phonation
• Variation in Sound Pressure Level
• Comfortable Sustained Phonation – used to obtain
average airflow
• Voicing Efficiency – used to obtained estimated
subglottal pressure, laryngeal resistance
(pressure/airflow)
Normative Data for PAS Protocols
• Adults normative values now available in PAS
software (Zraick)
• Current study on pediatric normative values
for PAS protocols
– Ages 6.0 – 17.11 years
– 60 children
Imaging in Pediatrics
• Rigid endoscopy/stroboscopy
– High speed
• Flexible endoscopy/stroboscopy
• Both exams
– MD
– SLP
Collaborative Exams
Prepping the Patient
• Voice activity book
• Verbal explanation and rehearsal
– Patient and parent
• Nasal spray (Afrin and Ponticaine)
• Instructions for seating
Endscopic Exams
• Digital rigid stroboscopy
– Document gross laryngeal function; condition of
the larynx; vocal and vibratory parameters as
possible; magnification
• Eligibility considerations
– Maturity, behavioral, anatomic, parental, signal
tracking
• Flexible endoscopy
– Document VP function; laryngeal; vocal and
vibratory parameters as possible; connected
speech; scope size
Parameters Assessed
Traditional Stroboscopy
• Glottic closure
• Vertical level
• Vocal fold mobility
• Vocal fold edge
• Mucosal wave
• Amplitude of vibration
• Phase symmetry
• Phase closure
Other ratings
• Laryngeal closure
• *Supraglottic
compression/degree
• Vibration Source
Use of High Speed
• High speed permits visualization of vibratory
behavior recorded in real time
– Not dependent on acoustic signal
– Lighting is constant
– Able to study aperiodic vibration; quick
movements; voice onset/offset; phonatory breaks
• Recorded at 2k and greater FPS; depends on
the Fo
• As you increase the FPS, you decrease the size
and resolution of the image
High Speed
• Color vs B&W issues
• Use of either rigid or flexible scopes
• Maximum recording on the KayPentax system
is 4 seconds
• Playback rate~ 30 FPS
• Follows standard strobe
• Warm-hot scope
High Speed
• Intended to add information regarding the
vibratory characteristics of the TVFs
– Other laryngeal structures (ventricular folds, AE
folds etc.)
• Overcomes the issues related to aperiodicity
• Traditional visual perceptual ratings
• Automatic and semi-automatic derived
measures
• Selectively applied in the clinic
Images
Traditional Stroboscopy
High Speed
Update on Treatment
Part IV
Current media as a therapy tool
• Interesting Facts
– 8-18 year-olds devote an average of 7 hours and 38 minutes to using
entertainment media across a typical day (more than 53 hours a
week).
– half (50%) have a console video game player in their room.
(Kaiser Family Foundation, 2010)
– Thirty-five percent of American parents say they play computer and
video games. Further, 80 percent of gamer parents say they play video
games with their kids. Sixty-six percent feel that playing games has
brought their families closer together.
(Entertainment Software Association, 2007)
Games from KayPENTAX
Current Research in Gaming for the
Treatment of Voice Disorders
Inspiratory Muscle Strength Training
• Successfully used to decrease dyspnea in patients
with
– Lower airway disease
– Paradoxical vocal fold dysfunction
– Upper airway obstruction (vocal fold immobility/subglottic stenosis)
• Respiratory trainers are widely available now and many peerreviewed papers exist (e.g., give a number of citations)
• Benefits: Training is relatively simple, results are
quantifiable, patient has a device to take home
Inspiratory Muscle Strength Training
• Examining a 4-week training program in children and
young adults with upper airway obstruction
• Pre/Post measures include
–
–
–
–
–
Dyspnea during speech and exercise
Maximum inspiratory pressure
Peak inspiratory flow
Speech phrasing characteristics
Respiratory parameters during exercise
• NIH/NIDCD 1R03-DC009057
Inspiratory Muscle Strength Training
• Training Program
– 4-week in home program
– Pressure-threshold trainer (POWERbreathe)
– Trainer set at 75% of MIP
www.powerbreathe.com
Current Study Outcomes
Maximum Inspiratory Pressure
Dyspnea during Exercise
Interesting Cases
Young Vocal Abuser #1
• Bilateral true vocal fold lesions; 6-years; female
– Vocal fold nodules
• History/Chief Complaint
–
–
–
–
Chronic hoarseness
History of phonotrauma; yelling/screaming
Diagnosed with ADHD; on medication
Reflux medication for 6 months; no improvement
Voice Evaluation
Pre-treatment
• pVHI = 39
• CAPE-V = 49
Post-treatment
• pVHI = 43
• CAPE-V = 19
– Moderate
rough, breathy, strained
•
•
•
•
•
F0 = 261 Hz
NHR = .152
Intensity = 76 dB
Airflow = 184 ml/s
Pressure = no data
– Mild/mod
rough, breathy, strained
•
•
•
•
•
F0 = 243 Hz
NHR = .113
Intensity = 74 dB
Airflow = 180 ml/s
Pressure = no data
Laryngeal Images
Voice Samples
Pre-treatment
10 Months
Post-treatment
Treatment
• Treatment dose
– 19 sessions @ 30-minutes for 10 months
• Compliance
– Defiant towards authority figure within treatment sessions
– Non-compliant outside treatment sessions
• Treatment type
– Vocal hygiene
• Decrease phonotrauma; increase hydration
– Visual biofeedback using “Voice Games”
• Visi-Pitch IV (KayPENTAX, 2007; 2009)
• Match pitch, control intensity, and increase maximum phonation
times (Ranged from 2 to 9 seconds)
Young Vocal Abuser #2
• Bilateral true vocal fold lesions; 8 years; male
– Left vocal fold cyst; right vocal fold contra-lateral lesion
• History/Chief Complaint
– Chronic hoarseness
– Trial therapy of anti-reflux medication (Prevacid)
Voice Evaluation
Pre-treatment
• pVHI = 29
• CAPE-V = 61
Post-treatment
• pVHI = 18
• CAPE-V = 8
– Mod/Severe
rough, breathy, strained
•
•
•
•
•
F0 = 287 Hz
NHR = .122
Intensity = 81 dB
Airflow = 198 ml/s
Pressure = no data
– Mild Breathy
•
•
•
•
•
F0 = 258 Hz
NHR = .114
Intensity = 88 dB
Airflow = 160 ml/s
Pressure = no data
Laryngeal Images
Voice Samples
Pre-op
Pre-therapy
1 Week
Post-op
6 Months
Post-therapy
Treatment
• Treatment dose
– 9 sessions @ 30-minutes for 6 months
• Compliance
– Parent/patient good participation within/outside treatment
sessions
• Treatment type
– Vocal Hygiene
• Decrease phonotrauma; increase hydration
– Vocal Function Exercises
• Initial session Power Exercises’ duration M = 14 secs
• Final session Power Exercises’ duration M = 25 secs
– Resonant Therapy
• Accomplished 20-syllable sentences w/ forward-focused resonance
Patient 3: Airway Reconstruction
• 18 yo female
• Hx: PPI/ SGS; multiple airway reconstruction
sxs
• Dilemma: Airway too narrow to support
breathing for athletics
Pre-Op information
Pre-Op
Type I: Fo 196.59 Hz
NHR: .10
F0 Range: 172.51-545.57Hz
Io: 70.4; Max Io: 97.3 dB
MPT: 19 sec
AA: 150 ml/sec; Est Ps: 5.013
cm/H2O
• CAPE-V OS: 8 (-30)
• VHI: F-19; P-20; E-20; T-59
•
•
•
•
•
•
Pre-Op:
• GC: Ant gap
• SG:L-M compression (mild)
• VL: Level
• Edges: Straight edges
• AM: Restricted L CAJ; Fixed
R CAJ
• VS: TVFs
• Mildly altered stroboscopic
parameters
Management
Medical/ Surgical
• Airway expansion (LTR) to
address posterior glottic
and tracheal narrowing
• Vocal fold injections
• Rotated arytenoid flap
Behavioral
• Modified VFE with FF
• Worked with recorded
samples
• Attempted to engage TVFs
Post Op Course
Post-OP
• Type II; Avg. F0: 115.55 Hz
• Range (95-208Hz)
• NHR:.16
• Io: 64.23; Max Io: 79.03
• MPT: 9.26 sec
• AA: 163 ml/; Est Ps: 6.746
cm/H2O
• CAPE-V: OS-74
• pVHI: F-23;P-20;E-30; T-73
Post-OP
• GC: Incomplete
• LC: partial
• SG: L-M (severe)
• VL: level
• Edges: straight
• AM: restricted/fixed
• VS: Ventricular folds
• No stroboscopic parameters
• High speed
J
Pre
Post
Patient 4: Vocal Fold Paralysis
• 10 yo female
• Hx: Prematurity; PDA ligation; L VF paralysis
• “soft voice”
M
Pre-OP
• Type 1; Avg Fo: 248.86Hz
• Fo Range: 205-297Hz
• NHR: .11
• Io: 65.17; Max Io: 80.17
• MPT: 9.15 sec
• AA: 160 ml/sec; Est Ps: 10.2
cm/H2O
• Cape-V: OS-68
• pVHI: F-12;P-18;E-5;T-35
Pre-OP
• GC: Posterior gap
• SC: 0
• VL: Level
• Edges: clean and straight
• AM: Fixed L; normal R
• VS: TVFs
• Mildly altered vibration
Management
Medical / Surgical
#1. Gortex medialization
with Arytenopexy
#2. Revision
Behavioral
• Local therapy
• Modification of VFEs
M
Post-OP
• Type 1; Avg. Fo: 280.10
• Range: 206.39-594.28Hz
• NHR: .14
• Io: 73; Max: 82.7
• MPT: 9.29 secs
• AA: 90 ml/sec; Est. Ps: 12.13
cm/H2O
• CAPE-V: OS-20;
• pVHI: F-0;P-2;E-0;T-2
Post-OP
• GC: smaller PG
• SG: 0
• VL: R lower
• Edges: clean and straight
• AM: Fixed-L; Normal R
• VS: TVFs
• Mild asymmetry
Endoscopy/Stroboscopy Samples
Pre
Post
Other Interesting Cases
R “pre”
R “post”
Interesting Cases
M
E
Research
• Voice Registry
– Outcomes following airway reconstruction surgery
• Perceptual-CAPE V
• Supraglottic phonation
• pVHI/CAPE V
•
•
•
•
Nodules study
Treatment study/ Telepractice
High speed
Collaborative projects
Teachers’ Perceptions of Individuals
with Voice Disorders
• S. Cotton Zacharias: Teachers’ perceptions of
adolescent females who have a voice disorder
– Personality traits
– QOL
It takes a team..
ThankYou!