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Stroboscopic Examination

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Terminology• Endoscopy: a technique used by

physicians to view internal parts of the body.

• Laryngoscopy: viewing of the laryngeal area specifically

• Stroboscopy: “strobos- means whirling” indicates the use of a particular type of light during visualization

• Videostroboscopy: makes a permanent record of the vocal fold patterns for post hoc analysis

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Endoscopy

• Rigid endoscopes have an oral insertion

• Flexible endoscopes have a nasal insertion

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Nasoendoscopy

Flexiblescope

Vocal Folds

End ofscope

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Rigid Endoscopy

• Head must be tilted up & back for optimal vision.

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Why Videoendoscopy?• Primary purposes:1. To identify the physiologic correlates of

perceived resonance & voice quality for speech,

2. To document the status of speech anatomy & physiology during speech production,

3. To assist educational & clinical discussion among clinicians, patients, & other interested individuals.

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• Secondary Purposes:

1. Confirmation of medical diagnosis,

2. Improving patient counseling & motivation,

3. Providing biofeedback therapy.

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Who should do videoendoscopy?

• Medical personnel-

-physicians (identify disease process for surgery)

• Nonmedical personnel-

-SLP (need for specialized knowledge about speech production & application clinically)

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Whom is videoendoscopy appropriate?

• Patients who have:

1) Velopharyngeal and/or laryngeal disorder that affect speech production.

i.e. hypernasal patients, cleft palate, vocal fold pathology etc.

2) Have ability to speak & cooperate

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Mechanics of Videostroboscopy• Use of intermittent illumination to aid in

the process of observation,

• High-speed camera photography motion picture,

• Constant light to record images in frames on film & sequentially projected,

• On-line visualization of movement

• Intervals between flashes can be regulated

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• Top: light pulses are regular & produced at the same frequency (still); Bottom: pulses regular but differ 1.5 Hz from the frequency of vibration (motion)

Flash 1 Flash 2 Flash 3 Flash 4

image 1 image 2 image 3 image 4

compositeimage

compositeimage

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A

B

(A) Synchronized flash intervals, illumination occurring at same point of each cycle, motionless(B) Flash intervals occur at faster rate, results in motion.

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Judgment & Interpretation of Vibratory Pattern

• Fundamental frequency• Periodicity• Amplitude of horizontal excursion• Glottal closure• Symmetry of bilateral movement• Mucosal wave

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Fundamental frequency• Fo is read in Hz on the indicator of the

stroboscope,• Range should be noted during the

evaluation,• Interpretation: differentiate between

pathological & physiological1. Stiffer the v.f. tissue, the greater the Fo - increased activity in the CT (physiological example)

- scar formation & sulcus vocalis increase Fo (pathologic example)

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Periodicity• Regularity of successive apparent

cycles of vocal fold vibration

• “periodic”- vibration is considered to be uniform in amplitude and time

• “aperiodic” vibration can vary in amplitude or frequency

• Periodicity can be regular, irregular or inconsistent

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Periodicity• Interpretation:

1. Asymmetry: may be caused by unilateral recurrent laryngeal nerve paralysis, unilateral polyp or unilateral carcinoma2. Interference with homogeneity: may occur by small cysts or a small carcinoma3. Flaccidity: abnormally flaccid or pliable tissue caused by severe RLN paralysis or edematous lesion4. Unsteady Tonus: incapability of maintaining a steady tonus of the laryngeal muscles, seen in spasmodic dysphonia

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Horizontal & Vertical Movements

• Amplitude of Horizontal Excursion

• Amplitude is the extent of horizontal excursion of the v.f.’s during vibration: each fold rated independently

• Ratings are made on a 4 point scale

– small: excursion smaller than normal

– normal: excursion WNL

– great: excursion is greater than normal

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Amplitude• Interpretation:

1. The shorter the vibrating portion, the smaller the amplitude (relative lengths of v.f.’s of men vs. women; or laryngeal webbing)

2. Stiffer the v.f.’s, the smaller the amplitude (normal falsetto voice; carcinoma, papilloma, scar, sulcus vocalis, firm nodule, firm polyp)

3. Greater the mass, smaller the amplitude (carcinoma, granuloma, papilloma, polyp)

4. Greater the Ps, greater the amplitude (loud speech)

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Schematic of amplitude changes

• Center line has no visible movmt.

• first mark (blue) is normal

• second (green), great movmt.

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Glottal Closure• Rated as ‘complete” or “incomplete”• Determined by the extent of v.f.

approximation dung the maximum closing of the vibratory cycle

• Complete: glottis completely closed for each cycle

• Incomplete: glottis never closed during cycle

• Inconsistent: glottis completely closed during some cycles and incompletely closed during others

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Glottal Closure

• Interpretation:

1. Impaired adduction of the v.f.’s (RLN paralysis, ankylosis)

2. Nonlinear edge (nodule, polyp, papilloma, carcinoma)

3. Stiff edge (no mucosal wave) (scars, sulcus vocalis)

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(A) complete closure, (B) spindle-shaped gap along entire edge, (C) spindle-shaped gap at middle, (D) hourglass-shaped gap, (E) gap by unilateral oval mass, (F) gap with irregular shape, (G) gap at post. glottis, (H) gap along entire length

A B C D

E F G H

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Symmetry of bilateral movement

• Degree to which the 2 vocal folds provide mirror images of one another during vibration,

• Timing and extent of excursion during vibration, if same then symmetrical, if not asymmetrical,

• Describe asymmetry (i.e. excursion of right fold has a greater amplitude etc.)

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Mucosal Wave• Mucosal waves can be described as:

1. Absent: no observable traveling wave

2. Small: wave is present, but less marked than normal

3. Normal: clearly observable traveling mucosal wave

4. Great: extraordinarily marked wave

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Mucosal Wave• Interpretation:

1. Stiffer the mucosa, less marked the wave (falsetto, scars, papillomas, cysts, fiberoptic nodules)

2. Partially stiff mucosa (wave stops traveling at stiff portion, sulcus vocalis, localized scar, small cyst)

3. Tight or loose glottal closure (decrease in wave, hyper- or hypokinetic phonation)

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Readings

• If you would like extra readings on stroboscopy you may want to refer to:

Hirano & Bless, Videostroboscopic Examination of the larynx, Singular Publishing, 1993.

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Benign Laryngeal Pathologies

• Category 2:– Voice difficulties due to abnormal growths & lesions, tissue

degeneration, joint immobility, or fractures caused by:

• intubation, gastro-esophageal reflux, chronic cigarette smoking inhalation, presbylaryngis, thyroid gland disease, upper respiratory infection, cervical rheumatoid arthritis, & external laryngeal trauma

• Granulomas

– Webs

– Pacydermia laryngis

– Hyperplastic-leukoplakic lesions

– Cricoarytenoid joint fixation

– Bowing

– Infectious laryngitis

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Granuloma• Primary voice symptom: hoarsness

• Description: mass lesions on the vocal process of the arytenoid cartilage in post. larynx, unless large does not effect the vibrating portion of the vocal folds, vascular lesion from tissue irritation in post. larynx

• Etiology: persistent misuse (contact), intubation during surgery, gastroesophageal reflux

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• Acoustic Signs:

– Greater than normal perturbation (jitter & shimmer)

• Measurable Physiological Signs:

– Normal airflow rates

• Observable Physiological Signs:

– Irregularly shaped masses of tissue either at the site of the vocal processes of the arytenoids or elsewhere on the vocal folds

Granuloma

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Treatment

• Antireflux regime (raising head off bed, not eating before retiring, drugs such as propulsin)

• Surgery

• Support by SLP during management process for lesions

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Case 33 (CD 1, Track 33)

• History:

– 65 year old male

– Significant smoking history

– 4 months of mild hoarseness & sore throat

– Frequent heartburn symptoms, acid regurgitation & chronic throat clearing

– Enjoys spicy foods, teas, colas, late night snacks

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Case 33

• Examination Findings:

– Mildly hoarse-harsh

– Videostroboscopy-

• 2 large, smooth, rounded, pearl-colored masses near

vocal process or arytenoids

• Interlock during phonation

• Inhibit complete posterior glottic closure

– Diagnosis: bilateral vocal process granulomas

secondary to chronic reflux laryngitis

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Granuloma (Case 33): Pretreatment

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Case 33

• Treatment:– Dietary & lifestyle changes to decrease GER

– Prescribed Prilosec (Omeprazole), 20 mg orally every 12 hours to inhibit gastric acid secretion

• Treatment Results:– Repeat video 4 weeks after antireflux therapy

– Subjective voice improvement

– Reflux symptoms disappeared

– Near complete resolution of right granuloma

– Left not changed, but more sessile & rounded

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Granuloma (Case 33): Post-treatment

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Discussion

• Chronic gastroesophageal reflux may manifest as laryngeal disease

• May describe heartburn symptoms

• 34% will present with isolated laryngeal symptoms– excess “phlegm”

– chronic throat clearing

– acid regurgitation

– dysphagia

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Papilloma• Primary voice symptom: hoarseness, low

pitch

• Description: multiple wart-like lesions, develop in epithelium & deeper in LP, vocalis muscle,

• Etiology: caused by viruses, may spread to larynx, trachea & bronchi, children (juvenile papilloma) & adults

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Papilloma

• Measurable Physiological Signs:

– Increases stiffness may cause increased pressure

• Observable Physiological Signs:

– Present as whitish cluster of tissue (raspberry)

– Interfere with glottic closure

– Increased stiffness impedes horizontal excursion &

mucosal wave will be absent in the area of lesion

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Case 35 (CD 2; Track 2)

• History:

– 28 year old female

– Presented with long history of recurrent

laryngeal papillomas dating 7 years back

– Six previous procedures for removal of

lesions

– Experiencing dysphonia at time of testing

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Case 35

• Examination Findings:

– Perceptually- severely breathy hoarse quality with high pitch breaks occasionally

– Maximum phonation time = 5 seconds

– Acoustic Analysis-• Fundamental frequency = 180 Hz

• Jitter %= 3.4

• Shimmer= 0.56 dB

• Harmonic to noise ratio= 1.0 dB

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Case 35• Examination findings:

– Videostroboscopy:• Papillomatous tissue distributed over the left true vocal

fold, obscuring fold from direct view

• Right fold not involved

• Glottic chink exists during phonation

• False folds adduct during phonation

– Diagnosis: Recurrent laryngeal papillomas

• Treatment:• CO2

laser ablation

• Post operative speech therapy

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Papilloma (Case 35): Pretreatment

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Case 35

• Treatment Results:

– CO2laser excision of papillomas

– Returned for speech therapy 2 weeks post surgery

– Perceptual improvement of voice• Episodic hoarse voice with shrill-like outbursts

• Discussion:

– Cauliflower-like lesions caused by infection with the human papilloma virus (HPV)

– Benign neoplasm

– Multiple recurrences

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Papilloma (Case 35): Post-treatment

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Blunt or Penetrating Trauma

• Etiology: Strangulation, penetrating

neck wound, blunt trauma resulting

from blow to the neck, fracture of

larynx

– Require medical/surgical treatment

– Voice restoration after surgery

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Inhalation & Thermal Trauma

• Etiology: Inhalation of gases, smoke or steam– Chemical traceobronchitis– Hot fumes cause reflex closure of the glottis

(protects trachea & respiratory tracts

• Symptoms: Inflammation, burns, soot around nose or mouth, respiratory distress, stridor, wheezing, hoarseness.

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Inhalation Trauma: Anterior Web Formation

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• Occurs when myoelastic tension is diminished, causing concavity from the midline of glottis

• Etiology: Aging degenerative changes, weakness or hyponicity of laryngeal muscles (RLN damage)

Vocal Fold Bowing: Presbylaryngis

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Vocal Fold Bowing: Presbylaryngis• Perceptual:

– Higher than normal pitch (Thinning)– Hoarse-breathy quality– Pitch breaks– Tremor

• Acoustic Findings:– Increased jitter % shimmer– Reduced S/N ratio (increased noise)– Elevated subglottal pressure– Increased airflow

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Case 27 (CD 1; Track 27)

• History:– 80 year old female– 6 month history of deteriorating voice– 16 months later- Thyroidectomy– Chronic hoarseness as chief symptom– Aspiration of thin liquid– Vocal fatigue– Shortness of breath– Left vocal fold paralysis was suspected

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Case 27

• Examination Findings:– Extrinsic laryngeal region WNL– Perceptually severely hoarse-breathy with shrill

overlay– MPT= 7 seconds

• Acoustic Findings:• Fundamental frequency= 369 Hz

• Jitter %= 1.2

• Shimmer= 0.62 dB

• Harmonic to noise ratio= 1.5 dB

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Case 27

• Aerodynamic Findings:– Mean airflow= .496 l/sec

– Subglottal pressure= 10.6 cm H20

– Glottal Resistance= 200 cm/ H20 /lps

• Videostroboscopy:– Chink across entire length– Bowed vocal folds (more on left side)– Both folds were symmetrical & motile

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Vocal Fold Bowing (Case 27): Pretreatment

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• Treatment Recommendations:– Unilateral medialization of the left cord– Voice therapy to follow– Isshiki thyroplasty rather than folds injection of

collagen or fat was considered

• Treatment Results:– Left medialization thyroplasty– Marked improvement in glottal competency across

midline– Mild compromise of airway secondary to surgery– Left fold is edematous– Right fold remains bowed

Case 27

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Vocal Fold Bowing (Case 27): Post-treatment

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Vocal Fold Bowing (Case 27): Post-treatment-Phonation

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Discussion

• Bowed vocal folds caused by normal aging &

progressive muscle atrophy

• Exhibited by those with long standing

weakness, paresis, & atrophy of vocal folds

secondary to nerve damage

• Results in spindle shaped glottal chink