Vol 2 (2016)

Normal and Abnormal Vocal Folds Kinematics

High-Speed Digital Phonoscopy (HSDP), Optical Coherence Tomography (OCT) & Narrow Band Imaging (NBI®)

Volume II: Applications

Krzysztof Izdebski, Yuling Yan, Ronald R. Ward, Brian J.F. Wong & Raul M. Cruz

PUBLISHED: 2016-06-02


Kartini Ahmad, Yuling Yan & Diane M. Bless

Abstract: Laryngeal images obtained from HSDI of healthy females were examined with customized software that delineated glottal edges and used the Hilbert transform based method of analysis to provide objective quantification of glottal perturbation; transformed glottal cycles provided visual patterns on the overall vibratory dynamics. Data showed absence of homogenous glottal vibratory patterns: clear (50%), pressed (27%), breathy (15%), or a mixed voice quality (8%). Perturbation range for jitter and shimmer were small and did not discriminate these patterns.

Keywords: HSDI, vocal fold vibration, glottal area waveform, female voice

Akihito Yamauchi, Hiroshi Imagawa, Hisayuki Yokonishi, Takaharu Nito, Tatsuya Yamasoba, Takao Goto, Shingo Takano, Ken-Ichi Sakakibara & Niro Tayama

Abstract: Observation of vocal fold (VF) behavior in young females showed posterior gap and posterior-to-anterior longitudinal phase difference while in young males mucosal wave, anterior-to-posterior longitudinal phase difference, and supraglottic hyperactivity were frequent. In elderly females high incidence of lateral phase difference, atrophic change, anterior gap, and asymmetry were observed. In elderly males axis shift, asymmetry, supraglottic hyperactivity, increased mucosal wave, lateral phase difference, and anterior-to-posterior longitudinal phase difference were frequent. VF vibrations are diverse even in healthy subjects, and hence, this diversity must be taken into account in evaluating VF vibrations.

Keywords: HSDP, age, gender, VF vibrations, asymmetry, wave characteristics

Akihito Yamauchi, Hiroshi Imagawa, Ken-Ichi Sakakibara, Hisayuki Yokonishi, Takaharu Nito, Tatsuya Yamasoba & Niro Tayama

Abstract: Laryngotopography described in Chapter 16 of Volume I is a high-speed digital imaging (HSDI) technique developed by the authors, to show spatial characteristics of vocal fold (VF) vibrations by pixel-wise discrete Fourier transform for brightness curve. Analysis of phonations at a conversational frequency was focused on phase differences (PD) in the anterior-posterior (longitudinal) direction, and in the left-right (lateral) direction. In longitudinal PD, posterior-to-anterior opening type was significantly frequent in young females (all subjects, 43%; young females, 94%; and p<0.001), while anterior-to-posterior opening type was significantly frequent in elderly males (all subjects, 39%; elderly males, 88%; and p<0.001). There were no age- or gender-related differences in lateral PD (all subjects, 65%; and p=0.880).

Keywords: HSDP, laryngotopography, age, gender, phase differences

Wenli Chen & Thomas Murry

Abstract: Dynamic vibratory patterns of normal adults during steady phonation obtained with high-speed digital kymography (DKG) are presented. Steady phonation consists of quasi-periodic harmonics configured in a tilted shape with robust peaks and no spectral smearing. A range of asymmetry between the left and right vocal folds (VF) vibration is also seen in normal voices.

Keywords: kymography, DKG, high-speed imaging, vocal onset gestures, steady phonation

Jack Jiang & Allison Maytag

Abstract: Visualization of the glottis and vocal folds (VF) vibration is crucial to accurate diagnosis of VF pathologies. Simple endoscopy is commonly used to look for obvious structural abnormalities and stroboscopy is used to analyze VF movement during phonation. However, stroboscopy, as a frequency-dependent method, masks aperiodic vibration, a key characteristic of many laryngeal disorders. High-speed digital imaging is better suited for pathologies that cause aperiodic vibration, but it collects a large volume of data, requires expensive, specialized equipment, and is time-consuming to analyze. Digital videokymography extracts data from a single pixel line in the high-speed video and concatenates the images into a kymogram showing VF vibration at that point over time. It is an efficient and sensitive method of obtaining information about parameters quantifying VF vibration, including amplitude, periodicity, and left-right and anterior-posterior asymmetry. Recently, multiline digital videokymography was investigated as a diagnostic tool for distinguishing vibrational pathologies by using kymograms of pixel lines at different points. Nodules and polyps, which are difficult to differentiate using simple endoscopy or stroboscopy, can be distinguished via kymogram based on the lateral phase difference at 25% of the VF from the anterior commissure; polyps show larger lateral phase asymmetry than nodules. Therefore, multiline digital videokymography can prove a useful clinical tool in cases of aperiodic VF vibration.

Keywords: digital videokymography, quantification of VF kinematics

Gilles Degottex, Erkki Bianco & Xavier Rodet

Abstract: Current high-speed digital imaging (HSDI) allows thousands of images per second to be obtained, hence it provides significant information on the behavior of the vocal folds (VF) during phonation. Here we present our findings of glottis behavior for normal and exaggerated phonatory modes studied with HSDI, acoustics, and EGG.

Keywords: HSDI, EGG, glottis, voice

Krzysztof Izdebski, Enrico Di Lorenzo, Ronald R. Ward, Yuling Yan & Matthew Blanco

Abstract: Glottal fry voice falls within the lowest range of the human vocalization and is produced voluntarily or as a part of dysphonia. Although acoustics of fry are common, physiologic data are scarce, specifically with regard to glottis behavior. LVS and nowadays HSDP provide a whole new way to visually investigate laryngeal behavior and glottis posturing during any phonatory modes, providing detailed real-time information about laryngeal biomechanics (e.g., mucosal wave, wave motion directionality, glottic area wave form, asymmetry of vibrations within and across vocal folds (VF), and contact area of the glottis. These observations are fundamental to our understanding and modeling of both normal and disordered phonation. In this preliminary report, we focus on direct HSDP in vivo observations of not only the glottic region, but also on the entire supraglottic laryngeal posturing during production of vocal fry. In subsequent reports we examine hiss and over-pressured phonation modes produced in a non-pathological setting. We also contrast these findings to normative phonation and to each other. Analysis includes spatio-temporal vibration patterns of VF, multi-line kymograms, spectral P-FFT analysis, and Nyquist spatio-temporal plots. The presented examples reveal that supraglottic contraction assists in prolonged closed phase of the vibratory cycle and that the prolonged closed phase is long in vocal fry. These findings need to be compared to pathologic phonation containing vocal fry voice in order to arrive at a better differential diagnosis and if/when a better treatment protocol is desired.

Keywords: HSDP, LVS, female voice, vocal fry, mucosal wave, glottic cycle, GAW, PFFT, color analysis, Nyquist plots

Krzysztof Izdebski, Lydia Hyde, Yuling Yan & Matthew Blanco

Abstract: Hissy voice can be interpreted as the sound similar to a sound of a sibilant, either voiced and un-voiced (s/z). This voice quality can be present in pathological phonation or when it is used in normal phonation it is employed to convey emotional expressions to signal disapproval, annoyance, or even contempt. Vocal hiss or hissy voice is not well studied, specifically via physiologic examination of the glottis. In this preliminary study we used HSDP to examine the nature of the vocal hiss at the glottic and supraglottic levels. We decided on HSDP, because this technology provides a whole new way to visually investigate laryngeal behavior and posturing during phonation. It provides detailed real-time information about laryngeal biomechanics that include observations about: mucosal wave, wave motion directionality, glottic area wave form, asymmetry of vibrations within and across vocal folds (VF), and contact area of the glottis including posterior commissure closure. These observations are fundamental to our understanding and modeling of both normal and disordered phonation. In previous reports, we examined vocal fry using HSDP in vivo observations of not only the glottic region, but also on the entire supraglottic laryngeal posturing. Here we contrast hiss phonation mode produced in a non-pathological settings to normative phonation produced by the same speaker. As with fry, analysis included spatio-temporal vibration patterns of VF, multi-line kymograms, spectral PFFT analysis, and Nyquist plots. The presented examples reveal that supraglottic contraction is present in hiss but that it is short in duration. We speculate, that this contractual force allows for VF vibration despite glottic separation. These findings need to be compared to pathological phonation representing the three voice modes to derive a better differential diagnosis.

Keywords: HSDP, LVS, female voice, vocal hiss, supraglottis, mucosal wave, glottic cycle, GAW, PFFT, Nyquist plots

Yuling Yan, Krzysztof Izdebski, Kartini Ahmad & Diane M. Bless

Abstract: Here we provide examples of how Nyqist plot analysis accounts for the changes in vocal fold (VF) kinematics of normal subjects who are undergoing senescence.

Keywords: HSDP, Nyquist plots, VF, senescence, GAW, displacement, asymmetry, jitter, shimmer


Katherine A. Kendall

Abstract: Although videostroboscopy is used most commonly in a clinical setting to image the larynx, it has several drawbacks that can be overcome by using high-speed imaging of the larynx. High-Speed Digital Imaging (HSDI) of the larynx has been performed since the 1930’s but remained impractical for clinical use until recently because of high cost and cumbersome equipment. The development of commercially available high-speed imaging systems using smaller, more affordable cameras has now made it possible to use this technology in a clinical setting. High-speed imaging has the potential to advance the functional assessment of vocal pathophysiology, ultimately improving the ability to diagnose and manage vocal fold (VF) pathology. Recent advances include color imaging and the ability to accurately synchronize and compare VF vibration and acoustic data. However, several barriers to widespread clinical use of this technology remain. This chapter will review recent advances and ongoing challenges in the clinical use of HSDI compared to videostroboscopy.

Keywords: high speed imaging, laryngoscopy, larynx imaging

Yuling Yan & Krzysztof Izdebski

Abstract: Here we provide examples of selected dysphonic cases to demonstrate the value of Nyquist plots and time-frequency method to analyze vocal pathologies.

Keywords: HSDP, Nyquist plots, ADDSD

Julie Barkmeier-Kraemer, Krzysztof Izdebski & Yuling Yan

Abstract: Acoustical, perceptual (sonographic), visual (endoscopic), or physiologic (EMG or EGG) methods are used to support clinical diagnosis of vocal tremor (VoT). The primary auditory test includes subjective clinically graded auditory impression of the generated voice while acoustics include various methods of signal analysis. Visual methods described in the literature encourage characterization of VoT using nasoendoscopy to identify whether VoT is present or absent within specific parts of vocal tract subcomponents or is a part of a more generalized tremor. Because chemical denervation of laryngeal musculature (Botox® injection) is the current VoT treatment approach, making detailed VoT analysis is imperative for determining which laryngeal muscles are involved, hence which muscle(s) are to be targeted for denervation. Consequently, we evaluated gains from a non-invasive VoT analysis using rigid stroboscopic (LVS) and from a HSDI evaluation protocol combined with acoustic patterns of VoT to improve identification of specific laryngeal musculature generating VoT.

Keywords: vocal tremor, stroboscopy, HSDI, acoustics, voice evaluation, visual perception, phonatory function studies, Nyquist plots

Mette Pedersen & Martin Eeg

Abstract: This study examined efficacy of the innate immune defense via the mannose-binding lectin (MBL) in a cohort of 55 dystonic patients, prospectively referred to the clinic with laryngeal mucosal complaints, who were placed on local steroids (budesonid inhaler, 400 µg twice daily) and antihistamines (fexofenadin 180 mg mostly three times daily) with adjuvant lifestyle corrections. Treatment efficacy of the larynx was assessed based on mucosal findings of the vocal folds (VF) examined with phonatory function studies (PhFS) comprising simultaneous high speed digital imagines (HSDI), kymography, electroglottography (EGG), and voice acoustics combined with a visual score of arytenoids edema as these measures are indicative of the magnitude of laryngitis. Lactose and gluten intolerance and immunological analyses of the innate system were made systematically. Results showed that the genetic aspects of immunology did not reveal a role for the innate immune system, represented by the MBL. But an unexpected positive effect of the larynx treatment on dystonia symptoms was found, evidenced by reduction of dystonic complaints and more normative results of PhFS, and a reduction of edema of the inter-arytenoids region. Symptom relief and better quality of life was observed on follow-up for the dystonia complaints.

Keywords: larynx, mucosa, voice, edema, phonatory function studies, HSDI, EGG , dystonia, mannose-binding lectin, innate immune system

Peak Woo

Abstract: The use of high-speed imaging was pioneered by Drs. Moore and von Leden in the 1960’s. Using today’s high-speed digital imaging (HSDI) technology, we can evaluate pathological states of vocal fold (VF) vibration in patients with VF paresis and paralysis that could not be resolved by stroboscopy. Twelve patients with VF paresis (n=8) and paralysis (n=4) underwent evaluation with both stroboscopy and with HSDI. In patients with paralysis and paresis, HSDI shows many differences in vibratory abnormalities that could not be observed with stroboscopy. The vibratory differences between the two sides were greatest in paralysis. Distinctly different fundamental frequency (F0) between the two sides were only seen in the paralysis group while paresis showed phase lag and delay in onset of vibration between the sides. Subtle differences in vibration in patients with paresis could be differentiated by objective image analysis and objective waveform analysis of the HSDI using signal analysis of the digital kymogram derived VF vibrogram (VFV).

Keywords: HSDI, VF paresis, VF paralysis, F0, sidedness, waveform, digital video kymogram, VF vibrogram (VFV)

Kartini Ahmad, Yuling Yan & Diane M. Bless

Abstract: Laryngeal images obtained from HSDI of pathological voices were examined with customized software that delineated glottal edges and used the Hilbert transform based method of analysis to provide objective quantification of glottal perturbation; transformed glottal cycles provided visual patterns on the overall vibratory dynamics. Vibratory patterns in voice-disordered groups vary with pathology and severity. They may show exaggerated, mixed, or deviant vibratory patterns from the normal speaker patterns. Perturbation levels in moderately to severely pathologic speakers were also above the limits of the young and the majority of elderly speakers.

Keywords: HSDI, vocal cord vibration, glottal area waveform, female voice

Krzysztof Izdebski, Ronald R. Ward, Daniel Hartman, Yuling Yan & Matthew Blanco

Abstract: To understand possible reasons for acquiring contact ulcer granuloma (CUG), its elimination by various procedures, and/or its post-treatment recurrence, we studied CUG using High Speed Digital Phonoscopy (HSDP). HSDP allows detailed observations of the manner in which posterior glottis collides during phonatory onset. Findings suggest that the manner of arytenoid collision (i.e., parallel vs. off-axis) is crucial in causation and elimination of CUG.

Keywords: HSDP, contact ulcer granuloma (CUG), collision off-axis

Krzysztof Izdebski, Raul M. Cruz, Matthew Blanco, Herbert H. Dedo, Thomas Engel & Yuling Yan

Abstract: Amyloidosis refers to an unknown pathogenic process in which abnormally folded proteins are deposited in the extracellular space as macroscopic aggregates. Laryngeal deposits of these proteins are extremely rare. In a combined clinical practice of 45 years we have encountered 13 cases. Dysphonia, rather than ventilation, is a primary symptom, yet little is known about this process in these cases. As far as we can discern, no prior (February 2016) reports observations on vocal folds behavior in laryngeal amyloidosis by laryngovideostroboscopy (LVS), high-speed digital phonoscopy (HSDP), or narrow-band imaging (NBI®) of this condition have been identified in the world literature, except papers published or presented by our group at the Pacific Voice Conferences. Our findings showed that LVS identifies the deposits clearly and that mucosal wave may not be disturbed in a well-executed surgery. NBI® exams showed amyloid as unvascularized, and thus benign, in appearance. HSDP studies provide information about the physiological impact of amyloidosis on the larynx, especially regarding voice effects. Conservative piecemeal surgical removal of amyloid deposits secures proper basic laryngeal functions: airway, aspiration prevention, and voice.

Keywords: amyloidosis, larynx, surgery, HSDP, NBI®, LVS, symmetry, mucosal wave, voice quality, outcomes

Grażyna Demenko, Magdalena Jastrzębska, Krzysztof Izdebski & Yuling Yan

Abstract: We present data on how stress is manifested in the human voice by analyzing acoustic and phonetic structure of live recordings from the Police 997 emergency call center number in Poland. From the data corpus comprising thousands of authentic Police 997 emergency phone calls, a few hundred were automatically selected according to their duration (calls shorter than 3-4 seconds were omitted), and finally from this corpus, voices of 45 speakers were chosen for acoustic analysis and were contrasted to neutral samples. Statistical measurements for stressed and neutral speech samples showed relevance of the arousal dimension in stress processing. The MDVP analysis confirmed statistical significance of the following parameters in voice stress detection: fundamental frequency, pitch variation, noise-to-harmonic-ratio, sub-harmonics, and voice irregularities. In highly stressful conditions, a systematic over-one-octave shift in pitch was observed. Linear Discriminant Analysis based on nine acoustic features showed that it is possible to categorize the following classes of male and female stressed and neutral characteristics.

Keywords: call center interfaces, detection of vocal stress, stress visualization, physiological correlates

Krzysztof Izdebski & Raul M. Cruz

Abstract: Recurrent respiratory papillomatosis (RRP) is a devastating disorder, especially in a professional voice user. The mainstay of treatment is based on immaculate serial removal of regrowing papillomas, usually with a laser. Repetitive laser excisions can cause significant scarring and webbing. The risks of post-operative sequela are exponentially increased with anterior location of papilloma clusters. The resultant dysphonia is not amenable to physiological voice therapy protocols. Additional or adjunctive treatments are eagerly sought by patients to avoid complications. Many of these treatments remain unproven. Recently, bevacizumab (Avastin®) has been advocated as potentially useful. Consequently, we report a case treated with potassium titanyl phosphate (KTP) lasering of papillomas with adjunctive intra-lesional bevacizumab injections. Current outcome of the case is analyzed with both traditional laryngovideostroboscopy (LVS) and High Speed Digital Phonoscopy (HSDP).

Keywords: papilloma, bevacizumab, Avastin®, laser surgery, HSDP, LVS, professional voice user, kymography, P-FFT, RCA

Krzysztof Izdebski, Ronald R. Ward, Lydia Hyde, Yuling Yan & Matthew Blanco

Abstract: In this preliminary HSDP report we focus on in vivo observations of not only of the glottic region, but on supraglottic laryngeal posturing during simulated production of vocal overpressure (VoP) as well. Resultant data were analyzed with spatio-temporal algorithms capable of describing vibration patterns of vocal folds (VF), multi-line kymograms, spectral P-FFT analysis, and Nyquist spatio-temporal plots. Results reveal that supraglottic contraction assists in prolonged closed phase of the vibratory cycle in VoP and that prolonged closed phase is long in VoP, but not as long as in vocal fry. In our opinion, these findings lead to a better differential diagnosis, and hence to a more efficacious treatment.

Keywords: HSDP, LVS, female voice, VoP, dysphonia, mucosal wave, glottic cycle, GAW, PFFT, Nyquist plots

Rita R. Patel, Harikrishnan Unnikrishnan & Kevin D. Donohue

Abstract: It has been estimated that up to 16% of school-age children [1] suffer from voice problems. Long-standing untreated dysphonia can negatively affect children both psychologically and academically. Evaluation of vocal fold (VF) structure and cycle-to-cycle vibratory motion through techniques of direct visualization of the VF is vital for appropriate clinical assessment and measurement of treatment outcomes. In this chapter, we describe the use of high-speed videoendoscopy combined with custom developed laser projection for evaluation of quantitative changes in the lesion size and in the opening and closing phase dynamics of the glottal cycle before and after voice therapy in a child with VF nodules.

Keywords: pediatric high-speed videoendoscopy, VF nodules, lesion size, VF kinematics, voice therapy

Ewelina Sielska-Badurek, Katarzyna Jędra & Anna Rzepakowska

Abstract: This chapter describes videokymography application in assessing vocal fold (VF) kinematics resulting from augmentation of the glottis with injection laryngoplasty. All visual images were captured transoraly with Xion EndoSTROB E system and processed with DiagNova’s DiagnoScope Specjalista® software. Results showed improvement in glottic closure, which was well visualized by videokymography.

Keywords: videokymography, videostroboscopy, glottis augmentation, VF paralysis


Agata Szkiełkowska & Beata Miaśkiewicz

Abstract: Imaging techniques of the vocal fold (VF) vibration include laryngovideostroboscopy (LVS) and now high-speed digital imaging (HSDI). To obtain parametric assessment of the vibratory process, new supplementary techniques based on kymography are being developed. Currently these are: 1) digital kymography (DKG), 2) videokymography (VKG), and 3) videostrobokymography (VSK). Kymography enables assessment of vibrations of the VF at the selected glottic locations. Therefore, kymography creates a new diagnostic potential for the objective documentation and monitoring of VF vibrations.

Keywords: laryngovideostroboscopy, HSDI, kymography, dysphonias

Agata Szkiełkowska & Beata Miaśkiewicz

Abstract: VSK has the potential to be an effective tool for the qualitative and the quantitative analysis of vibratory patterns of the vocal folds (VF) in both normal and in pathological voices. We base this opinion on our experiences with VSK exams covering over 2200 cases and on qualitative assessment of kymograms derived from various VF pathologies.

Keywords: videostrobokymography, kymogram, open quotient, closed quotient

Agata Szkiełkowska & Beata Miaśkiewicz

Abstract: Qualitative assessment of kymograms and open quotient (OQ) values were obtained from VSK examination of over 300 patients presenting with vocal fold (VF) immobility or dysmobility. Qualitative assessment showed reduced amplitude of VF vibrations in patients with VF immobility. The OQ values for the anterior, middle, and posterior areas of the VF were higher compared to the control group.

Keywords: Videostrobokymography, unilateral VF paralysis, bilateral VF paralysis, cricoarytenoid joint fixation

Agata Szkiełkowska, Beata Miaśkiewicz, Paulina Krasnodębska & Henryk Skarżyński

Abstract: We evaluated open (OQ) and closed quotients (CQ) of vocal folds (VF) vibratory cycles at three locations (anterior, middle, and posterior glottis) using VSK lines in a cohort of patients with Reinke’s edema (RE). Mean values for OQ were 0.44 at the anterior (a), 0.46 at the middle (m), and 0.52 at posterior (p) locations. The CQ values were 0.56 (a), 0.54 (m), and 0.48 (p), respectively. Results for the whole glottis OQ and CQ were 0.48 and 0.52, respectively. Differences for OQ and CQ measured at each location were significant.

Keywords: Reinke’s edema, videostrobokymography, Yonekawa classification, glottal function, open and closed quotients (OQ, CQ)

Agata Szkiełkowska & Beata Miaśkiewicz

Abstract: Based on videostrobokymographic (VSK) examination of over 1200 dysphonic patients we made qualitative assessments of vocal fold (VF) behavior from multiline kymographs and calculated open (OQ) and closed quotients (CQ) for a variety of benign VF pathologies. Statistical analysis showed correlation between OQ and localization of the phonatory lesion within the glottis. For most patients significantly higher OQ were calculated for anterior, middle, and posterior parts of the glottis when compared to the control group.

Keywords: Videostrobokymography, benign VF pathologies, open and closed quotients

Agata Szkiełkowska & Beata Miaśkiewicz

Abstract: Qualitative assessment of kymograms and OQ values were obtained from VSK examination of nearly 600 patients with hyper- and hypofunctional dysphonia (HyPo & HyPer). In HyPer dysphonia the OQ was significantly lower compared to HyPo dysphonia. These results make VSK in our opinion suitable for monitoring progress of voice treatment.

Keywords: Videostrobokymography, hyperfunctional dysphonia, hypofunctional dysphonia

Marcin Just, Krzysztof Izdebski, Ekaterina V. Osipenko & Natalia M. Kotelnikova

Abstract: We report here on vocal fold (VF) kinematics in one case of the extremely rare VF condition known as “bamboo vocal folds” (B-nodes). Our High Speed Digital Phonoscopy (HSDP) study used the custom made DiagNova processing system to describe the behavior of the VF in this rare case. We believe that this is the first ever HSDP, kymographic, and phonovibrogram study of B-nodes.

Keywords: B-nodes, bamboo VF, hoarseness, VF deposits, autoimmune diseases, phonotrauma, kymography, spatio-temporal analysis, phonovibrograms, L/R asymmetry, HSDP


Ena Freeman & John H. Saxman

Abstract: It may be argued that singing requires a greater precision and control of timing and coordination of onset and offset mechanisms, as dictated by the musical score. Another important difference between sung and spoken phonation is the greater frequency range of phonation and control/precision necessary for smoother transition among registers in singing. HSDI has applied advantages in vocal pedagogy, by providing a direct visual example to help better understand the vocal fold (VF) vibratory mechanism during singing. It may also be used as a delayed visual feedback tool.

Keywords: HSDI, singing voice, spoken voice, spatial and temporal resolution

Antonio Di Corcia & Franco Fussi

Abstract: The purpose of this study was to investigate laryngeal behavior during vocal production of the highest pitched notes of the human vocal range, the so-called whistle register associated with M3 (laryngeal mechanism according to Roubeau’s notion). Observations were carried out using laryngovideostroboscopy (LVS) and High-Speed Digital Imaging (HSDI). Results indicate that at the whistle register, vocal folds (VF) vibration can be significantly reduced with incomplete glottic contact, or it may be absent even with complete glottic contact.

Keywords: laryngeal vibratory mechanism M3, VF, LVS, HSDI, vocal range, whistle register, flute register, hiss register

Philippe H. Dejonckere, Jean Lebacq, Leonardo Bocchi, Silvia Orlandi & Claudia Manfredi

Abstract: Short-term feedback for relevant physiological parameters of voice production may be very useful in singing pedagogy, particularly for acquiring specific technical skills based on motor control. A typical example is the “messa di voce” exercise. High speed single-line scanning of the vibrating vocal folds (VF) provides visual and quantitative information about the most important biomechanical parameters over time. The present experiment demonstrates how this method, nowadays currently used in voice pathology, can also be a meaningful tool for the classical singer. The condition is, however, that the images can be immediately processed by a reliable and user-friendly automatic analysis program. The validity of the program is demonstrated by a strong correlation with the handmade measurements.

Keywords: messa di voce, high-speed single-line kymography, VKG, wave characteristics, glottal volume velocity

Krzysztof Izdebski, Enrico Di Lorenzo, Yuling Yan & Matthew Blanco

Abstract: Here we describe laryngeal kinematics present during extreme heavy metal singing (EHMS). The aim was to explain how EHMS can be practiced without causing true vocal fold (TVF) trauma. The following EHMS vocal qualities known as growl (Gr), scream (Sc), and high & low pitch false vocal folds scratched voice (HPFSV & LPFSV) were investigated in a single subject. Glottis area was observed with distal chip scope (DCS) trans-nasal flexible fiberscopy, trans-oral HSDP, and acoustics. Gr and Sc showed that TVF edges touched only occasionally and glottis stayed open for most of the production time while the false vocal folds (FVF) were active. HPFSV and LPFSV were produced with simultaneous steady and symmetric vibration of the TVF and FVF with the TVF adducted and the FVF partially adducted. The sound spectrographs of Gr and Sc showed a spectrum dominated by noise. It was not possible to distinguish the harmonic structure of the TVF-generated sound, proving the virtual absence of the glottic activity in the production of these aggressive sound qualities. We observed different sets of movements (vibrations) from the supraglottic structures (SGS), generated by FVF, arytenoid caps (AC), and aryepiglottic folds (ARF). These combined vibrations were responsible for creating multi-periodic oscillations that characterize Gr and Sc. We noticed that the activity of SGS during EHMS was different from the sphincter-like activity that we find in dysphonic pathologic phonations that engage SGS. It is our opinion that the brief duration of the glottic closure during Gr and Sc is to produce the safe range of the subglottic pressure (Ps) and to allow for the generation of high airflow required to set the SGS structures in motion. These factors, in our opinion, allow the EHM singers to produce aggressive voice qualities while avoiding phonotrauma to the TVF.

Keywords: heavy metal, extreme metal, growl, scream, scratched voice, HSDP, DCS, sonogram, supraglottic activity, supraglottic phonation, VF vibration, phonotrauma

Krzysztof Izdebski, Enrico Di Lorenzo, Yuling Yan & Matthew Blanco

Abstract: This chapter aims to describe the kinematics of two unusual phonation types: ingressive and whistle. This was accomplished by HSDP investigation and Vocalizer® analysis.

Keywords: HSDP, VF vibration, ingressive, whistle, GAW, Nyquist plot, FFT

Enrico Di Lorenzo & Giovanna Trantino

Abstract: The aim of this study was to describe the kinematics and acoustics of female extreme singing (FES) and to compare these features to male extreme singing (MES). Since the female vocal tract (VT) is smaller than that of the male’s, the overall resonatory characteristics of FES will differ from MES while the technique at the vocal fold level is not expected to show significant differences. Fifteen well-trained female extreme singers underwent flexible transnasal endoscopy (FTE) while performing growl (Gr) and scream (Sc) to reveal the activity of the true vocal folds (TVF) and the supraglottic structures (SGS). The simultaneous audio files were analyzed by sound spectrography. During both Gr and Sc, FTE showed simultaneous activation of TVF and SGS. TVF appeared to remain open (without detectable contact of the TVF edges) during all observed phonations in all cases while SGS showed different levels of activation between the different subjects. However, SGS appear to always be active. When compared to male extreme singers, female singers showed SGS activation and higher inter-individual variability. During Gr, FTE showed the larynx in a low position with an increase of all diameters of the vocal tract. During Sc, the larynx appeared to be in neutral position with a decrease of latero-lateral or anteroposterior diameter. Spectrographic analysis showed vocal spectrum was dominated by noise, but regular in intensity and frequency. During Gr in men, most sound energy was found in the lower part of the spectrum and a wide distribution of noise was found in spectrum during Sc. While male and female Sc show similar acoustic patterning, female Gr was less deep than the male one with the low sound energy concentration placed slightly higher in females than in males. The results showed that FES is essentially performed similarly to the MES with SGS activation and open position of the VF. Nevertheless, some differences in the role of TVF and the perceptual and instrumental depth of Gr was found. It is our opinion that these differences are related to the different dimensions of male and female vocal tract and to the lack of a strong and structured aesthetic tradition of female extreme singing.

Keywords: heavy metal, extreme metal, death metal, black metal, scream, growl, female voice, phonotrauma, sonogram, fibroscopy, flexible transnasal endoscopy

Felix I.C.R.S. de Jong, Wivine Decoster, Sara Vandertwee, Lien Decruy & Harm K. Schutte

Abstract: The vocal fold (VF) mucosal wave pattern during register change was assessed by videokymography (VKG). Various patterns were observed. VKG proved to be a suitable method to observe rapid mucosal wave changes during register transition.

Keywords: VKG, register transition, voice, mucosal wave


David Shamouelian, Tjoson Tjoa & Brian J.F. Wong

Abstract: This chapter discusses the history of OCT and the adoption of this technology for laryngology.

Keywords: OCT, intra-operative, office-based

David Shamouelian, Tjoson Tjoa, Veronika Volgger & Brian J.F. Wong

Abstract: Here we discuss pertinent information on clinical applications of OCT in context of non-malignant laryngeal mucosal pathologies. We also demonstrate applicability of OCT to the studies of vocal fold (VF) kinetics.

Keywords: laryngeal OCT, lamina propria, basement membrane, true VF, subglottis, epiglottis, laryngeal hyperkeratosis, VF polyp, VF cyst, respiratory papillomatosis, VF granuloma, Reinke’s edema, Polarization Sensitive OCT, VF vibration, Doppler OCT, ex vivo, in vivo

Tjoson Tjoa, David Shamouelian, Veronika Volgger & Brian J.F. Wong

Abstract: This chapter describes advantages and pitfalls of OCT in assisting diagnosis of laryngeal carcinoma.

Keywords: OCT, laryngeal carcinoma, laryngeal tumors, laryngeal malignancy

Gangjun Liu, Marc Rubinstein, Brian J.F. Wong & Zhongping Chen

Abstract: We describe here how OCT imaging can be applied to studying human vocal fold (VF) vibration. We show that OCT is earning a significant place within technological armamentarium for VF examination, especially as a tool for non-invasive VF “biopsy.” Doppler OCT is a functional extension of OCT, which can provide information beyond morphology. Doppler OCT is a promising technique for quantitative, non-contact imaging of VF vibration.

Keywords: OCT, ODT, SSOCT/ODT, VF, lesions, biopsy, cancer, F0

Caroline Boudoux, Fouzi Benboujja, Romain Deterre, Mathias Strupler, Jordan Garcia & Christopher J. Hartnick

Abstract: Understanding vocal fold (VF) structure and development is primordial in developing new methods to prevent and treat pathologies. Optical microscopy techniques have the potential to impact the field of pediatric laryngology through their ability to non-invasively image sub-surface structures with high resolution and contrast. In this chapter, we describe and discuss three optical imaging modalities for applications to clinical laryngology: optical coherence tomography (OCT), reflectance confocal microscopy (RCM), and nonlinear microscopy (NLM).

Keywords: pediatric VF imaging, emerging medical imaging technologies, OCT, confocal microscopy, nonlinear microscopy, endoscopy


Krzysztof Izdebski & Raul M. Cruz

Abstract: Here we review the most contemporary NBI® literature pertaining to laryngeal applications. This review is based on PubMed and Google Scholar listings as of July 7th, 2015 and on personal communications.

Keywords: NBI®, larynx, histology, malignant and non-malignant findings, efficacy, neo-angiogenic findings, new technology, in-office applications, OR applications, Ni classification, IPCL

Ekaterina V. Osipenko & Natalia M. Kotelnikova

Abstract: Here we discuss the significance and the effectiveness of NBI® endoscopy in the early differential diagnostics of laryngeal tumors and vascularized lesions, based on our NBI® experience at The Federal Research Clinical Centre of Otorhinolaryngology in Moscow, Russia. We conclude that this novel optical technology is of paramount significance in the early identification of pathological (malignant and viral) changes in the laryngeal structures.

Keywords: NBI® endoscopy, larynx cancer, pre-cancerous states, neoplasms, early diagnostics

Giorgio Peretti, Renzo Mora, Cesare Piazza & Francesco Mora

Abstract: Many authors have shown how NBI® plays different roles in the management of laryngeal cancer [1] during preoperative diagnostic work up, in the intra-operative setting, and during post-treatment (i.e., surgery, radiotherapy or chemo- radiotherapy) follow-up. The most relevant limitation of NBI® is certainly the possibility of generating, at least in the early phase of the learning curve, an increased number of false positives with consequently unjustified biopsies. Introduction of the NBI® system to routine laryngological practice may drastically change diagnostic strategies for early detection of carcinomas in laryngeal lesions and may lead to minimally invasive treatment of laryngeal diseases at an earlier stage than is presently possible.

Keywords: SCC, NBI®, optical biopsy

Krzysztof Izdebski & Raul M. Cruz

Abstract: NBI® technology has only recently been applied to observe laryngeal pathology and it is being used predominantly when examining cases suspicious for malignancy or for RRP. However, many other pathological conditions in the larynx feature abnormal vascular components. This group of dysphonias includes benign laryngeal conditions. Hence, we report here on how NBI® exposes benign lesions of the laryngeal mucosa and leads to improved diagnosis and management of dysphonias.

Keywords: NBI®, VF, dysphonias, efficacy, WL, vascular blush, neovascularization, benign phonatory lesions, vascularity, B-nodes, vocal fatigue, CUG

Ekaterina V. Osipenko, Krzysztof Izdebski, Raul M. Cruz & Natalia M. Kotelnikova

Abstract: We report here on vocal fold (VF) appearance in five cases of bilateral mucosal lesions referred to in the literature as “bamboo vocal folds” or as B-nodes. Our study contrasted the WL and the NBI® avascular appearance of these lesions in the VF mucosa. Among other factors, we concluded that B-nodes are unlikely to be caused by VF trauma. Treatment implications are mentioned.

Keywords: B-nodes, bamboo VF, hoarseness, VF deposits, autoimmune diseases, NBI®

Anna Rzepakowska & Ewelina Sielska-Badurek

Abstract: The methods of “biological” endoscopy are intensively developing in recent years. The images obtained with these methods display more details of mucosa structure in order to make the clinical diagnosis as most accurate and close to histopathology as possible. Such aim is particularly important in premalignant changes of the larynx mucosa. We present our experience in the assessment of the laryngeal lesions with one “biological” endoscopy method, Narrow Band Imaging (NBI®). Based on the assessment of the appearance of blood vessels within the lesion and in the surrounding mucosa of the larynx with NBI®, we can with high sensitivity determine the risk of high-grade dysplasia or invasive cancer. In addition, NBI® is a useful and more accurate tool than white light (WL) endoscopy in the evaluation of the extent of the laryngeal mucosa, thus providing more precise staging. Also in patients after radiotherapy and post-radiation changes of laryngeal mucosa, the NBI® method appears very promising in the diagnosis of cancer recurrence.

Keywords: laryngeal lesions, dysplasia, leukoplakia, non-invasive laryngeal carcinoma, invasive laryngeal carcinoma, NBI®, LVS


Jarosław Sova, Joanna Cieszyńska, Jarosław Kijewski & Paweł Jesikiewicz

Abstract: The aim of this study is to present a 3D digital reconstruction of normal and pathological vocal folds (VF) at rest and during phonation as well as discuss research and clinical applications of this emerging technology. Video recordings of the human glottis were recorded using a newly developed endoscope (ENT Viewer®, Sinutronic, Gdansk, Poland). This system is capable of obtaining images with stroboscopic (LVS) or without stroboscopic (LV) illumination. The LVS and LV images were processed digitally and were processed into a 3D video reconstruction. The 3D video reconstructions of VF kinematics are presented. The images obtained during LV and LVS are compared in a 1:1 scale to the images obtained from such imaging techniques as MRI, CT scans, and 3D prints; dimensions and distance scaling are estimated digitally.

Keywords: 3D video reconstruction, VF 3D imaging, LVS, LV, VF kinematics, distance scaling

Jarosław Sova, Jarosław Kijewski, Matthew Blanco & Krzysztof Izdebski

Abstract: The aim of this study was to present a 3D digital reconstruction of vocal fold kinematics in production of extreme vocalization known as growl, used by extreme heavy metal performers. The results show remarkable contribution to sound production by the vertical and lateral motions of the supraglottic structures.

Keywords: growl, extreme vocalization, 3-D reconstruction, HSDP