中国艺术嗓音医学现状与未来

摘要：艺术嗓音医学是声乐表演艺术和嗓音医学相互融合交叉而形成的一门独立的分支学科，它不但对歌唱表演人才的选拔、训练、声部鉴定具有重要的指导作用，而且在预防和保护演员、歌手的艺术生命及维护其他职业用嗓者的嗓音健康方面也发挥出了十分重要的作用。本文从六大方面阐述了我国艺术嗓音医学的发展现状，从七大方面提出了对艺术嗓音医学发展未来的设想和建议。     

Intralaryngeal application of a miniaturized ultrasonic probe

We developed a method for performing intralaryngeal ultrasonography. Normal larynges were obtained from 10 cadavers and examined using an intraluminal ultrasonic tomography apparatus connected to a radial scanning 20 MHz miniaturized probe. The larynx was placed in a bath filled with physiologic saline. and the probe was inserted through the forceps channel of the fiberscope (6 mm diameter). A horizontal ultrasonic image of the vocal fold was obtained. Histologic sections of the larynx were compared with the ultrasonic images. The mucosa in the membranous region of the vocal fold was comprised of three layers ultrasonographically. The epithelium and superficial layer of the lamina propria were visualized as a high echo (hyperechoic) region, the intermediate layer of the lamina propria was visualized as a low echo (hypoechoic) region and the deep layer of the lamina propria was seen as a hyperechoic region. The vocal fold structure can be visualized by intralaryngeal ultrasonography using the filling method. This method may be clinically useful for the detection of tumors involving the vocal folds.     

Symptoms of vocal attrition in women army instructors and new recruits: results from a survey

Symptoms of vocal attrition were surveyed with a questionnaire in 130 Israeli women army instructors, a high-risk group for vocal attrition, and in 386 Israeli women recruits, presumably a low-risk group. Results showed 1. a high prevalence of symptoms in both groups, but a significantly higher prevalence among the instructors; 2. significant correlation between number of symptoms and rapid, excessive, and loud speech habits in both groups; and 3. significant correlation between number of symptoms and difficulties in performing instructional duties. These findings suggest that 1. vocal attrition is related to both external demands on the voice and idiosyncratic speech habits; and 2. vocal attrition has a significant impact on performance and work-efficiency.     

Measurement of adult vocal fold length

Laryngeal photographs from 165 Taiwanese subjects were taken during microlaryngoscopy. Photographs of the vocal fold during the open phase were chosen. For measuring the vocal fold length, both the photograph of a ruler and the larynx were taken under the operating microscope, thus forming a 'new scale'. Photographs of the vocal fold and the ruler were then processed at the same power of magnification. The length of the vocal folds was measured with the 'new scale'. In 100 patients receiving direct laryngoscopy under neuroleptic anaesthesia, the vocal fold length was 14.6 +/- 1.2 mm (n = 35) for males and 11.1 +/- 1.0 mm (n = 65) for females. In 65 patients under general anaesthesia, the vocal fold length was 15.3 +/- 1.6 mm (n = 23) for males and 13.5 +/- 1.3 mm (n = 42) for females. Statistical analysis revealed a significant difference between both groups and both sexes. Elongation of the vocal fold under general rather than neuroleptic anaesthesia may be important when performing functional surgery of the vocal fold.     

Laryngitis--diagnosis and management

Laryngeal inflammation includes a broad spectrum of pathologies, from infectious processes that need to be managed as airway emergencies, to indolent diseases that mimic head and neck cancer. The importance of a thorough history cannot be emphasized enough as it is the most important step toward developing a differential diagnosis. Vocal pathologies often have a noticeable impact on a person's quality of life and daily activities; therefore, it is key to counsel patients on the course of the disease process. Treatment of specific pathologies depends on the causative pathogen or etiology, as well as the age, vocal demands, and clinical characteristics of the individual.     

Collagen subtypes in human vocal folds

OBJECTIVES: The collagen subtypes in human vocal folds are of particular interest, because each collagen subtype has different features that make it uniquely suited for performing specific tissue tasks and each collagen subtype can affect the tissue properties of the vocal fold lamina propria. METHODS: Human vocal folds from 5 autopsy cases (less than 65 years old) were examined by immunohistochemistry for collagen types I, III, IV, and V and elastin. RESULTS: Collagen type III was distributed throughout the whole lamina propria. Type I was found just beneath the basal membrane, in the deep layer of the lamina propria and in the anterior and posterior maculae flavae. Types IV and V were present in the epithelial and endothelial basal membrane. Three-dimensional images from thick specimens reconstructed with confocal microscopy showed 2 distinct patterns: type III fibers were wavy, collagenous fibers, as previously observed in the vocal folds, and type I fibers were thinner than type III fibers. These results suggest that type III fibers help maintain the lamina propria structure and that type I fibers provide the tensile strength required around the basal membrane and vocal ligament to maintain the vocal fold shape while withstanding vibratory forces.     

Bilateral vocal cord paralysis associated with laryngeal myxedema

For managing dyspnea caused by bilateral vocal cord paralysis as a complication of thyroidectomy in the acute postoperative period, reversible vocal cord lateralisation is performed at the authors’ departments. However, in the later postoperative period of thyroidectomy when there is no chance for recovery of the recurrent laryngeal nerves, they perform irreversible procedure. Applying these operative techniques satisfactory breathing can be achieved in about 95% of cases avoiding tracheostomy. In 5% of cases there are other comorbidities in the background of unsuccessful operative results which can cause potential dyspnea as well. From these complications the authors emphasize the role of laryngeal obstruction and myxedema as a consequence of hypothyroidism developed after thyroidectomy. Management of severe dyspnea caused by association of these two complications of thyroidectomy means a great therapeutic challenge. Between 01 Jan 1989 and 30 Nov 2008 the authors performed 161 reversible and 135 irreversible vocal cord lateralisations to manage dyspnea caused by bilateral vocal cord paralysis as a complication of thyroidectomy. From these cases four patients had further obstruction due to laryngeal myxedema. By performing endoscopic laryngeal surgeries and applying levothyroxine replacement therapy sufficiently wide glottic chink has been achieved in all the cases. According to the experience of the authors dyspnea caused by bilateral vocal cord paralysis after thyroidectomy needs complex, interdisciplinary therapeutic approach beside glottis widening operations.     

Pediatric type I thyroplasty: an evolving procedure

The treatment of vocal fold paralysis by type I thyroplasty in the pediatric age group has not been reported. From 1990 to 1998, 12 type I thyroplasty procedures were performed on 8 patients between 2 and 17 years of age. The most common cause of vocal fold paralysis was neurologic, followed by vagal injury from a cardiac procedure. The most common indications for the procedure were aspiration and dysphonia. In our early thyroplasty experience, adult techniques and measurements adapted after Isshiki or Netterville were used. Postoperative laryngoscopy showed that in most cases, the placement of the implant was too high. There were variable outcomes in aspiration and dysphonia with this technique. These findings appear to be independent of thyroplasty approach or of implant design type. We conclude that the standard approach for vocal fold medialization in the adult cannot be applied accurately in the pediatric population. In performing pediatric thyroplasty, the anatomically lower position of the vocal fold must be taken into consideration. We have since modified our technique to adjust for accurate identification of the vocal fold line and medialization. The modified approach for vocal fold medialization in the pediatric population is discussed.     

Bilateral vocal cord palsy: the alternative to tracheostomy.

Bilateral abductor vocal cord paralysis remains a difficult management problem for otolaryngologists. The techniques currently used fall into four main types: arytenoidectomy, cordectomy, cord lateralization and laryngeal re-innervation. These techniques invariably require a tracheostomy either prior to or at the time of the main procedure. A technique for managing patients without performing a tracheostomy which is as effective as the previously mentioned procedures and with no greater morbidity in terms of voice production was initially described by Ejnell, et al (1984). The results in three patients using this technique which involves vocal cord lateralization under endoscopic control confirms its ease and efficacy. All three patients were relieved of their presenting dyspnea and had satisfactory postoperative voice production. This appears to be an effective technique for the treatment of patients with bilateral abductor laryngeal paralysis which obviates the need for tracheostomy and its attendant complications.     

Pulsed angiolytic laser treatment of ectasias and varices in singers

OBJECTIVES: Varices and ectasias in singers are typically the result of phonotraumatic shearing stresses and/or collision forces on the microcirculation within the superficial lamina propria. These lesions can be debilitating in performing vocalists because of the effect of recurrent hemorrhage and/or as a contributing factor to the morbidity of other mass lesions such as polyps, nodules, and cysts. Phonomicrosurgical treatment of performers is understandably approached with great trepidation, as the vocal liability of surgically disturbing the superficial lamina propria and epithelium must be balanced with the inherent detrimental vocal effect(s) of the lesion(s). Pulsed angiolytic lasers that emit radiation at high absorbance peaks of oxyhemoglobin were examined to determine whether they were an efficacious treatment approach for ectasias and varices based on these lasers' mechanisms of action and prior experience in phonomicrosurgery. METHODS: A prospective trial was done in 39 patients (40 procedures in 54 vocal folds) without complication to evaluate the effectiveness of a 585-nm pulsed dye laser (PDL; 25 cases) and a 532-nm pulsed KTP laser (15 cases) in a noncontact mode to treat 65 varices and 43 ectasias. Twenty-nine of 39 patients had varices and ectasias associated with other phonotraumatic mass lesions that required resection. Results: All patients have resumed full vocal activities, and no patient has had a subsequent hemorrhage or vocal deterioration. CONCLUSIONS: Both the 585-nm PDL and the 532-nm pulsed KTP laser were found to be efficacious and relatively safe treatment modalities for vascular abnormalities of the vocal folds in singers. Noncontact selective photoangiolysis of the aberrant vessels prevented future bleeding without substantial photothermal trauma to the overlying epithelium and surrounding delicate superficial lamina propria, thereby allowing for optimal postoperative mucosal pliability and glottal sound production. However, the pulsed KTP laser was substantially easier to use because of its enhanced hemostasis due to its longer pulse width. Vessel wall rupture was commonplace during use of the 585-nm PDL, but rarely occurred during photoangiolysis with the 532-nm pulsed KTP laser.     

Vocal fold paralysis following carotid endarterectomy.

Injury to the vagus nerve or one of its branches during carotid endarterectomy (CEA) can result in vocal fold paralysis (VFP). This study assessed prospectively 73 patients undergoing CEA. A total of 76 procedures were performed in these patients over a one-year period. All patients underwent pre-operative and post-operative assessment of vocal fold mobility by indirect laryngoscopy and/or flexible nasendoscopy. All patients had normal vocal fold mobility pre-operatively. Eight patients (10 per cent) complained of hoarseness after surgery and in three patients (four per cent) examination confirmed an ipsilateral VFP. This persists in all three patients at six-month follow-up. Vocal fold assessment is important in patients undergoing CEA, particularly when performing second side surgery. We recommend that patients should be informed of the risk of VFP following CEA when obtaining consent.     

Comparative Histology and Vibration of the Vocal Folds: Implications for Experimental Studies in Microlaryngeal Surgery

Objectives/Hypothesis To determine the most suitable animal model for experimental studies on vocal fold surgery and function by a histological comparison of the microflap surgical plane and laryngeal videostroboscopy (LVS) in different species of animals. A second goal was to determine how the layered vocal fold structure in humans and three different animal species affects surgical dissection within the lamina propria. Study Design Prospective laboratory. Methods Three larynges each from dogs, monkeys, and pigs were compared with three ex vivo human larynges. Microflap surgery was performed on one vocal fold from each larynx. Both the operated and nonoperated vocal folds were examined histologically using stains specific for elastin, mature collagen, and ground substance. Based on the histological results, LVS was performed on two dogs and two pigs after first performing a tracheotomy for ventilation and airflow through the glottis. Arytenoid adduction sutures were placed to facilitate vocal fold adduction. Results The distributions of the collagen and elastin fibers were found to differ among the species with concentrations varying within species. Unlike the human vocal fold, which has a higher elastin concentration in the deeper layers of the lamina propria, both the pig and the dog had a thin band of elastin concentrated just deep to the basement membrane zone in the superficial layer. Just deep to this thin band, the collagen and the elastin were less concentrated. The monkey vocal fold had a very thin mucosal layer with less elastin throughout the mucosa. The microflap dissections in each of the dog, pig, and human vocal folds were similar, being located within that portion of the superficial lamina propria where the elastin and mature collagen are less concentrated. The microflap plane in the monkey vocal fold was more deeply located near the vocalis fibers. Despite the differences in elastin concentration, the microflap plane in both the dog and the pig was found to be similar to that in humans. The dog anatomy was much more suitable for microsuspension laryngoscopy and stroboscopic examination. The dog vocal folds vibrated in a similar fashion to human vocal folds with mucosal waves and vertical phase differences, features not seen in the pig vocal folds. Conclusions Based on both the histological and stroboscopic results, the dog was believed to be a more suitable animal model for studies on vocal fold surgery, acknowledging that no animal's laryngeal anatomy is identical to that of the human. The dog LVS model presented allows for longitudinal laryngeal studies requiring repeated examinations at multiple time periods with histological correlation applied at sacrifice.     

Endoscopic laser arytenoidectomy for the treatment of bilateral vocal cord paralysis

Most patients with bilateral vocal cord paralysis have a fairly satisfactory voice, but their airway is usually compromised. The management of such patients presents a challenge to the otolaryngologist-head and neck surgeon. Numerous surgical procedures have been developed in an attempt to improve the patients's airway insufficiency without leaving him with a breathy, weak voice. Arytenoidectomy is currently the most reliable method of treating patients with bilateral vocal cord paralysis. Although both endoscopic and external approaches have been described for performing an arytenoidectomy, the endoscopic technique is more desirable since it requires no incision and theoretically allows for the immediate assessment of airway size. The addition of the CO2 laser to the surgical armamentarium offers certain refinements to the technique of endoscopic arytenoidectomy. Eleven patients with bilateral vocal cord paralysis of the larynx have been treated by endoscopic laser arytenoidectomy by the authors utilizing a technique developed by the two senior authors and subsequently taught to over 200 participants of the CO2 laser workshops sponsored by the Department of Otolaryngology-Head and Neck Surgery at Northwestern University Medical School; 10 of the 11 patients have been successfully decannulated. The technique and problems of this operation will be discussed.     

Laserchirurgie an der unteren Nasenmuschel,der Zunge und des Stimmbandes in vitro beim Menschen

Summary Using an argonlaser with a power of 1–100 W experiments on incision and coagulation of tissue are described for different focussing conditions. The laser power for performing laser surgery on the lower human turbinates, the tongue and the vocal cords is determined. For laser application on the turbinates a power of 2 W is sufficient for coagulation of tissue. Higher powers are necessary for laser incision of the tongue. The bloodless procedure is demonstrated in animal experiments performing a hemiglossectomy on the tongue of the anesthezised rabbit. The advantages of laser surgery are discussed. The macroscopical changes of the tissue after laser irradiation is described and possible clinical applications are mentioned.     

Etiología y tratamiento de la parálisis laríngea: estudio retrospectivo de 108 pacientes

ObjectivesTo review the aetiology and treatment of laryngeal paralysis diagnosed at our hospital and to describe the available therapeutic options.MethodsRetrospective review of medical records of 108 patients diagnosed with unilateral and bilateral vocal fold paralysis between 2000 and 2012, identifying the cause of paralysis and its treatment.ResultsOf the 108 cases analysed, 70% had unilateral vocal fold immobility and 30% bilateral immobility. The most frequent aetiology in both cases was trauma (represented mainly by surgical injury), followed by tumours in unilateral paralysis and medical causes in bilateral paralysis. Half of the patients with unilateral paralysis (38) were treated surgically, with medialization thyroplasty. In bilateral vocal fold immobility, the treatment consisted of tracheostomy in patients with threatened airway (40%). We planned to widen the air passage in 9 patients (27%), performing cordectomy in most of them.ConclusionsThe aetiology observed in our patients is similar to that described in the literature. In cases of unilateral vocal fold paralysis, we believe thyroplasty is the procedure of choice. In bilateral paralysis, it is possible to perform cordectomy in selected patients once the airway has been secured.     

Extending the inferior limits of supracricoid partial laryngectomy: a clinicopathological correlation

OBJECTIVES/HYPOTHESIS: The study examined preoperative clinical characteristics that can be used to predict secure inferior margins of glottic squamous cell carcinoma extending toward the cricoid cartilage when performing organ preservation surgery of the larynx. STUDY DESIGN: The study was retrospectively performed using 31 serially sectioned whole-organ total laryngectomy specimens with associated preoperative clinical data. METHODS: Histopathologic and clinical variables including true vocal cord (TVC) fixation, cricoarytenoid joint invasion, subglottic extension (SGE) of tumor, and prior radiation were examined as independent and multivariate correlates of cricoid cartilage invasion. RESULTS: All tumors with subglottic extension of 15 mm or less and without arytenoid fixation were free of cricoid invasion. Of tumors invading cricoid with subglottic extension of 15 mm or less, all had a fixed arytenoid cartilage and local cricoid invasion type only. Correcting for subglottic extension using multivariate analysis, cricoarytenoid joint invasion and fixed true vocal cord independently predicted cricoid invasion. However, in a multivariate model together, true vocal cord mobility adds no predictive power to cricoarytenoid joint invasion. Prior radiation of the larynx did not significantly change the predictive capacity of these variables. CONCLUSION: Preoperative assessment of arytenoid mobility and extent of subglottic extension are reliable predictors of cricoid invasion by glottic squamous cell carcinoma. Organ preservation surgery is oncologically safe in the setting of glottic squamous cell carcinoma with subglottic extension of 15 mm or less and without arytenoid fixation.     

Surgical utility of a new carbon dioxide laser fiber: functional and histological study

OBJECTIVES/HYPOTHESIS: The objective was to investigate the functional and histological properties of surgical procedures using a new carbon dioxide (CO2) laser fiber. STUDY DESIGN: In vitro and in vivo animal models. METHODS: In vitro experiments using porcine true vocal cord and arytenoid cartilage were designed to study the histological effects of using a photonic band-gap fiber assembly for CO2 laser energy delivery. Continuous and pulsed-wave settings at different wattages were tested. In vivo endoscopic surgery on canine larynges and buccal mucosa were performed to examine functional and short-term healing when performing photonic band-gap fiber assembly-assisted laser surgery. RESULTS: In vitro experiments showed consistent cutting with the photonic band-gap fiber assembly using either straight or 90 degrees bent-tip fibers. The surrounding tissue in these experiments showed little collateral thermal damage with the average range of thermal width from 14.1 to 18.8 microm in vocal cords and from 5.2 to 10.5 microm in cartilage. Similarly, thermal depth ranged from 28.0 to 350.0 microm in vocal cords and from 269.7 to 739.6 microm in cartilage. In vivo experiments demonstrated ease in maneuvering and flexibility for cutting. There was minimal blood loss, smoke plume, or carbonaceous debris. There were no postprocedural complications. Normal oral intake was noted on postprocedural day 1. There was no evidence of stridor or respiratory distress. Seven days after the procedure, re-epithelialization was complete in the buccal incisions and nearly completed in the laryngeal incisions. CONCLUSION: The photonic band-gap fiber assembly produced reliable results in cutting with functional characteristics representing an improvement over current technology. The device shows promise as an effective tool for minimally invasive procedures that are amenable to use of the CO2 laser.     

Vocal fold injection: review of indications, techniques, and materials for augmentation

Vocal fold injection is a procedure that has over a 100 year history but was rarely done as short as 20 years ago. A renaissance has occurred with respect to vocal fold injection due to new technologies (visualization and materials) and new injection approaches. Awake, un-sedated vocal fold injection offers many distinct advantages for the treatment of glottal insufficiency (vocal fold paralysis, vocal fold paresis, vocal fold atrophy and vocal fold scar). A review of materials available and different vocal fold injection approaches is performed. A comparison of vocal fold injection to laryngeal framework surgery is also undertaken. With proper patient and material selection, vocal fold injection now plays a major role in the treatment of many patients with dysphonia.     

Riedel's thyroiditis

Invasive fibrous (Riedel's) thyroiditis is a rare thyroid condition of unknown origin that may be associated with inflammatory fibrosclerosing processes elsewhere in the body. Although the condition is benign and self-limiting, its importance lies in its ability to clinically mimic carcinoma almost completely, necessitating performing an open biopsy to establish the correct diagnosis. In a review of over 700 thyroid operations performed at Loma Linda (Calif) University Medical Center in the past 15 years, we encountered only one documented case of Riedel's thyroiditis. Our patient presented with a firm thyroid mass, vocal cord paralysis, and symptoms of esophageal compression. Surgery was performed to obtain a definitive diagnosis and prevent the possibility of subsequent additional tracheal compression with airway compromise. The pathologic findings, as well as the medical and surgical treatment of this condition, are reviewed.     

小儿喉尖锐湿疣43例临床分析

目的：探讨小儿喉尖锐湿疣的治疗方法。方法：对43例小儿喉尖锐湿疣进行手术治疗，26例在表面麻醉下行直接喉镜喉肿瘤切除术，17例在全身麻醉下行气管插管、支撑喉镜喉尖锐湿疣切除术，其中13例同时行疣组织上臂内侧皮下埋植术、干扰素声带黏膜下注射。结果：随访35例，痊愈26例，好转7例，死亡2例；其中，气管切开7例，拔管困难3例。结论：本病病变范围大，复发率高，应用支撑喉镜行喉肿瘤摘除术，疣组织上臂内侧皮下埋植术及干扰素辅助治疗，可更精确切除肿瘤和减少复发，避免气管切开术后拔管困难。