Physiology of Phonation and Approach to a Pt With Hoarseness

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    Relevant Anatomy

    Fundamental components of speech

    Theories of phonation

    Glottic cycle

    Factors affecting phonation

    Objective evaluation of voice-Approach to

    a patient with Hoarseness of voice

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    Situated at the upper endof trachea

    Opposite 3rd6thcervicalvertebrae (males)

    Higher in women andchildren

    Infantssmaller, narrowlumen, funnel-shaped,

    cartilages softer &

    collapse easily

    Larynx

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    Framework

    Cartilages:

    Thyroid cartilage

    Cricoid cartilage

    Aryetenoid cartilage

    Corniculate and Cuneform

    Vocal folds

    Muscle

    Intrinsic

    Extrinsic

    Nerve supply

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    THYROID CARTILAGE

    Shield shaped cartilage Fused at midlineThyroid

    notch ( 90* /120*)

    Superiorly fusion absent-Thyroid notch

    Posteriorly each ala has

    superior and inferior horn Inferior horn articulates with

    facet on cricoid cartilage-

    Cricothyroid joint

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    Arytenoid cartilage

    Paired catilages

    Roughly Pyramidal in

    shape Antero-lateral surfacehas vestibularligament,

    thyroaryetenoid andvocalis muscle.

    Posterior surface-muscular attachments

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    Corniculate cartilage:

    cartilage of Santorini

    Cuneform cartilage:

    cartilage of Wrisberg

    Are small pairedfibroelastic cartilages

    Adds rigidity toaryepiglottic fold.

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    Extrinsic muscles

    Elevators: elevates and displaces larynxanteriorly during swallowing

    Thyrohyoid

    Stylohyoid Digastric

    Geniohyoid

    Mylohyoid

    Stylopharyngeus

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    Extrinsic muscles

    Depressors: displaces larynx downward duringinspiration

    Omohyoid

    Sternohyoid Sternothyroid

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    Intrinsic muscles

    Muscles anatomicallyrestricted to larynx

    Abductors:

    Posterior cricoarytenoid

    Adductors: Cricothyroid

    Lateral cricoarytenoid

    Interarytenoid

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    Posterior Cricoarytenoid

    Attached to a depression onposterior surface of cricoid lamina

    and its fibers run obliquely superior andlateral and attach to muscular process of

    arytenoid. Contraction: abducts, elongates and

    thins vocal fold.

    Brings muscular process medially,posterior and inferior while laterallyrotating and elevating vocal process.

    Role in high pitch singing

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    Interarytenoid

    Transverse and oblique fibres

    Transverse fibres pass from posterior surface of onearytenoid to the other

    Contraction: brings together the arytenoid cartilages.

    Assist closing post portion of glottis Only muscle having dual innervation from Both RLN

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    Thyroarytenoid

    T. internus T. externus

    Contract - brings vocal process and adducts, shortenAnt commissure closer to thickens and

    each other lowers

    the vocal fold

    adducts true and false

    vocal folds

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    Vocal cord

    Antoine Ferrein coined the term

    Located within larynx attached ant-thyroid cartilage and post-arytenoid

    cartilage

    Male vocal folds -17.5 mm to25 mm

    Female vocal folds -12.5 mm and17.5 mm

    3-5 mm thickness

    Folds are pearly white in color -more white in women than in men.

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    Vocal Fold Vocal fold consists of five

    layers:1. Squamous epithelium layer-

    Very thin helps to hold the

    shape of vocal cord.

    2. Superficial layer of the laminapropria-loose fibres and matrix

    aka Reinkesspace

    3. Intermediate layer-elastic &

    collagenous fibres but more

    than superficial layer

    4. Deep layer-high concentration

    of collagen bundles.

    5. Vocalis: Main mass of the

    vocal cord

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    Nerve Supply

    Motor

    Vagus

    Sensory

    Internal laryngeal nerve: supraglottis and the glottis

    Recurrent laryngeal nerve: upper trachea and subglottis

    SLN

    RLN

    Int

    Ext Cricothyroid Muscle

    Thyroarytenoid, Lateral cricoarytenoid,

    Posterior cricoarytenoid, Interarytenoid

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    Theories of Nerve innervation

    Semons law

    Wagner & Grossman Theory

    Modern theory

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    Semons Law

    Rosenbach (1880) & Semon (1881)

    In all progressive organic lesions, abductor fibres of

    recurrent laryngeal nerve, which are phylogenetically

    newer, are more susceptible and thus first to be

    paralyzed compared to adductor fibres.

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    1ststage: only abductor fibres damaged; vocal folds

    approximate in midline; adduction still possible

    (paramedian position)

    2ndstage: contracture of adductors; vocal folds

    immobilized in median position

    3rdstage: adductors become paralyzed; vocal fold

    assumes cadaveric position

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    Abductors affected first ??

    Nerve fibres supplying abductors are in periphery of

    recurrent laryngeal nerve

    Muscle bulk for the abductors is less, more

    susceptible

    Phylogenetically, larynxs main function is

    protection, so adductor functions are maintained

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    Wagner & Grossman Theory

    In isolated paralysis of recurrent laryngeal nerve,

    cricothyroid muscle (innervated by SLN) keeps

    vocal cord in paramedian position due to adductor

    function

    In both RLN and SLN palsy, cord lies in

    intermediate (cadaveric) position.

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    Subsystem Voice Organs Role in Sound Production

    Air Pressure System Diaphragm, chest muscles,

    ribs, abdominal muscles

    Lungs

    Provides and regulates air

    pressure to cause vocal

    folds to vibrate

    Vibratory System Voice box (larynx)

    Vocal folds

    Vocal folds vibrate,

    changing air pressure to

    sound waves producing"voiced sound," which is

    frequently described as a

    "buzzy sound"

    Varies pitch of sound

    Resonating System Vocal tract: throat

    (pharynx), oral cavity, nasal

    passages

    Changes the "buzzy sound"

    into a person's recognizable

    voice

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    Sound is produced when aerodynamic phenomena

    cause vocal folds to vibrate rapidly in a sequence ofvibratory cycles with a speed of about:

    110 cycles per second or Hz (men) = Low pitch

    180 to 220 Hz (women) = Medium pitch

    300 Hz (children) = Higher pitch

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    PHONATION:

    Physical act of sound production by means of

    passive vocal fold interaction with the exhaled air stream.

    Prerequisites:

    Adequate respiratory support.

    Appropriate glottal closure.

    Favourable vibratory properties.

    Favourable vocal fold shape.

    Control of vocal fold length and tension are required.

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    THEORIES OF PHONATION

    I. Neuromuscular theory / Clonic Theory /

    Neurochronaxic Theory of Husson, 1953

    II. Myoelastic Aerodynamic Theory of Van den Berg,

    1958

    III. Body- Cover theory/Two Mass Model

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    Myoelastic Aerodynamic Theory

    Widely accepted theory- Van den berg

    AERO - air pressure and flow

    DYNAMIC - movement and change

    MYO - muscular involvement ELASTIC - ability to return to original state

    States that interaction of

    aerodynamic forces and

    mechanical properties of the laryngeal tissues areresponsible for inducing vocal fold vibration and

    generating vocal sound.

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    Body- Cover theory

    Hirano According to this, the vocal folds

    consist of a multi-layered

    vibrator with increasing stiffnessfrom the cover to the body.

    The cover is responsible for mostof the vibratory action of thevocal folds

    Theory can be applied only inmodal register but not in high orlower pitch

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    Air is moved out of the lungs and towards the vocal folds.

    Vocal fold vibrationsequence of Vibratory cycles/Glottic

    cycles

    The nose, pharynx and mouth amplify and modify sound,

    allowing it to take on the distinctive qualities of voice

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    Glottic Cycle

    Adduction of Vocal Folds by voice box muscles, andcartilage.

    Expiration of air from lungs Subglottic pressure.

    Air pressure increases below the glottis until folds forced

    apart.

    Subglottic pressure more than vocal fold resistance.

    Air flow passes through narrowed glottis.

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    1 Column of air

    pressure moves

    upwards towards

    vocal folds in

    "closed" position.

    2, 3Column of air

    pressure opens

    bottom of vibrating

    layers of vocal folds;body of vocal folds

    stay in place.

    4, 5Column of airpressure continues

    to move upwards,

    now towards the top

    of vocal folds and

    opens the top.

    610 The low

    Pressure created behind

    the fast-moving air

    column produces a"Bernoulli effect"

    which causes the

    bottom to close,

    followed by the top.

    10Closure of the vocal

    folds cuts off the air

    column and releases a

    pulse of air

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    Factors causing return of Vocal folds to

    midline1. Air travels faster through the glottis when it is

    narrow. This causes a local drop in air pressure

    (Bernoulli effect)whichcauses the folds to be

    sucked towards each other.

    2. Elastic forces in vocal folds.

    3. Transglottal pressure

    4. Subglottic pressure

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    CHARACTERISTICS OF SOUND

    SOURCE or GLOTTIC SIGNAL

    Quality

    Frequency

    Amplitude

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    Quality

    Depends on: Nature of vocal cords adduction during phonation.

    Regularity of mucosal waves of lamina propria.

    1. Incomplete adductionBreathy voice

    2. Insufficient vocal cord adduction for vibration but sufficient

    to produce audible turbulent airWhisper

    3. Irregular mucosal waveform vibrationHoarse

    4. Vocal cords strongly adducted + raised subglottal air

    pressurePressed or Strained voice

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    Frequency

    Number of vibratory cycles/ sec (measured in Hertz)

    Frequency with:

    Length of vocal cord Thinning and stiffening of vocalis muscle

    Jitter or Pitch perturbationshort term variance in

    frequency of vocal cord vibration

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    MODAL REGISTERAka Heavy voice

    Speech and singing frequency (F0100 to 300Hz)

    Vocal foldscomplete adduction, triangular in cross

    section

    Larynxpulled down; PharynxNormal

    Vibration slowly and whole length.

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    PULSE REGISTER

    Aka Glottal fry, Vocal fry or Creaky voice

    Reflects pulsatile nature of laryngeal sound generated

    Occurs during lowest frequency (F020 to 60Hz)

    Feature of normal speech

    Larynxnormal; Pharynxnormal

    Vocal cordlong closed phase

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    Modification of Glottic signalRaw Glottic Signal Modified into speech by

    RESONANCE ARTICULATION

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    VOCAL RESONANCE

    TYPES

    ORAL RESONANCE NASAL RESONANCE

    AFFECTED BY:

    1. Degree of jaw movt.

    2. Mouth opening

    3. Tongue raising4. Pharygeal

    constriction

    AFFECTED BY:

    Velopharyngeal sphincter

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    ARTICULATION

    Synchronized movements of the organs of articulation (e.g.Palate, Tongue, Lips) to change Glottal soundRecognizable

    speech

    Described by SOURCE FILTER MODEL

    SOURCE LARYNX

    FILTERSLips , Tongue, Palate ,Pharynx

    ( Forms Consonants and Vowels)

    Articulatory movement are of two typesVowels and Consonants

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    VOWELS

    These are sounds in which

    there is no obstruction to

    flow of air as it passes

    from larynx to lips. Eg : A, E, I, O, U

    Different vowels are

    produced by :

    Height of tongue

    raising in mouth

    Part of tongue raised

    Position of lips (spread or

    rounded)

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    CONSONANTS

    Sounds produced when there is more definitiveobstruction to air by one or more articulator in theoral tract

    Eg : P, B, M, W, F, T, S, Z, R

    Different consonants are produced by :

    - Place of articulation- Manner of articulation

    - State of larynx

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    CONSONANTS

    Bilabial

    Dental

    Labiodental

    Alveolar

    PalatalVelar

    Glottal

    Based on place

    of articulation

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    CONSONANTS BASED ON PLACE OF

    ARTICULATION

    BILABIAL

    Articulation

    between Upperand lower lip

    P, B, M,W

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    LABIODENTAL

    Top teeth and lower

    lip

    F, V

    CONSONANTS BASED ON PLACE OF

    ARTICULATION

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    DENTAL

    Tongue tip and top

    teeth occlusion

    th in th ink

    th in th at

    CONSONANTS BASED ON PLACE OF

    ARTICULATION

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    ALVEOLAR

    Tongue tip touching ridge

    behind the teeth

    T, D, N, S, Z, R, ch, dj

    CONSONANTS BASED ON PLACE OF

    ARTICULATION

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    PALATAL

    Articulation of

    middle tongue withhard palate

    Y

    CONSONANTS BASED ON PLACE OF

    ARTICULATION

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    VELAR

    Articulation ofposterior tongue and

    soft palate

    K, G, ng

    CONSONANTS BASED ON PLACE OF

    ARTICULATION

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    CONSONANTS BASED ON STATE

    OF LARYNX Consonants are paired- here only difference is whether their

    articulation is accompanied by voicing or not.

    Eg: p and b, t and d, k and g, s and z

    Can be either:

    Voiced b, d, g, z

    Voicelessp , t, k, s, hno vibration of vocal cords

    h does not have a voiced twin so in connected speech,vocalization is not continuous.

    Phonation is switched on and off to signal voiceless

    consonants.

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    Workup

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    Workup

    ANY PATIENT WITH HOARSENESS OF TWOWEEKS DURATION OR LONGER MUST

    UNDERGO VISUALIZATION OF THE VOCAL

    CORDS

    EVALUATION OF A PATIENT WITH

    HOARSENESS INCLUDES THE FOLLOWING:-

    - History

    - Clinical examination

    - Investigations

    HOARSENESS

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    History

    Duration

    Character of onset ( Sudden / gradually progressive)

    Constant or intermittent Vocal nodule/ Chr. laryngitis

    Associated symptoms: Cough/ dyspnoea/ dyphagia/ fever

    Diurnal variation:

    Chronic laryngitis-worse in morning Malignancy- worse in evening

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    Potential triggering factors (Vocal abuse, URTI,

    Change in medications, Exposure to known allergens)

    Exacerbating and ameliorating factors, such as

    improvement with voice rest, or fatigue with use

    Other head and neck symptoms (eg, dysphagia,otalgia, odynophagia)

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    History

    Past H/o:

    History of past surgery involving the neck (especially

    thyroid, carotid, and cervical spine), base of skull, or chest

    History of trauma or endotracheal intubation

    History of reflux or sinonasal disease

    Medical comorbidities which may affect voice (eg,

    rheumatoid arthritis or tremor)

    Psychological stress

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    Personal H/o:

    History of smoking and alcohol use

    H/o weight loss.

    Occupation, hobbies, and habits impacting voice use

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    Differential diagnosis of hoarseness

    Voice quality Differential diagnosis

    Breathy Vocal cord paralysis

    Abductor spasmodic dysphoniaFunctional dysphonia

    Hoarse Vocal cord lesion

    Muscle tension dysphoniaReflux laryngitis

    Low-pitched Reinke's edema

    Vocal abuse

    Reflux laryngitis

    Vocal cord paralysis

    Muscle tension dysphonia

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    Differential diagnosis of hoarseness

    Voice quality Differential diagnosis

    Strained Adductor spasmodic dysphonia

    Muscle tension dysphoniaReflux laryngitis

    Tremor Parkinson disease

    Essential tremor of the head and neck

    Spasmodic dysphonia

    Muscle tension dysphonia

    Vocal fatigue Muscle tension dysphoniaVocal cord paralysis

    Reflux laryngitis

    Vocal abuse

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    Examination of the nose for patency, obstructing

    lesions, foreign body, or evidence of allergy

    Examination of the oral cavity for mass lesions,

    mucosal abnormalities, tonsil size, and motorfunction of the palate and tongue

    Palpation of the neck for mass lesions

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    LARYNGEAL EXAMINATION

    INDIRECT LARYNGOSCOPY

    FLEXIBLE LARYNGOSCOPY

    RIGID LARYNGOSCOPY

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    INDIRECT LARYNGOSCOPY

    AdvantagesQuick

    Inexpensive

    Minimum

    Equipment

    Disadvantages

    Gag

    Non physiologic

    No permanent

    image capability

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    DIRECT LARYNGOSCOPY

    70 or 90-degreetelescope.

    Advantages:

    Best optic image Magnifies image

    Video documentation

    Disadvantages:

    Gag,

    Non physiologic

    Expensive

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    FLEXIBLE LARYNGOSCOPY

    Advantages:Well tolerated

    Physiologic

    Video documentationpossible

    Disadvantages:

    Time consuming

    Expensive

    Resolution limited by

    fiberoptics

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    RIGID LARYNGOSCOPY

    Advantages:Best images

    Video

    documentation

    Disadvantages:

    Expensive

    Nonphysiologic

    Gag

    Requirement of

    General Anaesthesia

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    VIDEOSTROBOSCOPY

    Done to evaluate the vibratory patterns of the vocal folds thatoccur too rapidly to be visualized by the unaided human eye.

    Is an illusion of slow motion

    Light source - flashing Xenon tube

    Permits accurate visualization of epithelial abnormalities whichare missed out on IDL due to fast vibrations

    Evaluation criteria include:

    1. Symmetry

    2. Amplitude

    3. Periodicity

    4. Mucosal wave propagation

    5. Glottal closure.

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    OTHER TESTS

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    OTHER TESTS

    LABS: TFT

    PLAIN FILMS: Chest xray, Lateral Neck, Foreign body r/o.

    CT SCAN: Cancer, Unknown diagnosis, Persistent or

    recurrent pain and hoarseness, trauma.

    MRI : R/o Multiple cranial neuropathies- Evaluate skull base

    and brainstem.

    LARYNGEAL EMG

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    LARYNGEAL EMG One of the most specific and sensitive test to determine the presence

    of vocal fold paralysis. Differentiate Bilateral vocal fold fixation and Neurogenic Vocal fold

    paralysis

    To confirm the presence of dystonia and in identifying which muscles

    are most involved. MyogenicNormal frequency of firing but decreased amplitude (A)

    NeurogenicDecreased frequency but occasional normal amplitudes

    (B)

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    PANENDOSCOPYINDICATIONS

    To do biopsy of suspicious lesions

    Laryngeal cancerTumour extend, any secondaries

    Hoarseness patients without any diagnosis at the end of all

    routine investigations.

    Persistent or recurrent vocal symptoms

    Patients with malignancies with new onset of hoarsenss.

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    References Ballengers 16thedition

    Scott brown 7thedition

    Cummings 5thedition OCNA 40 (2007) 991-1001

    NCVS.org-national centre for voice and speech.

    Voiceproblem.org ( Washington voice consortium)

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    Thankyou