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24/5/2011

3078 - Vol. 70 / Ed 4 / in 2004 Section: Artigo Original Pages: 457 to 462 Authors: Glottal closure in diagnosis of minor structural alterations in children Noemi De Biase1, Paulo Pontes2, Vanessa Pedrosa Vieira3, Simone De Biase4

Keywords: Key words: dysphonia, vocal fold, glottal closure. Abstract: Introduction: The glottal closure varies during phonation, even in subjects who bears no vocal complaints and no alterations on medical examination, according to age, sex, vocal register, fundamental frequency, tension and lesions. There has been noticed complete or incomplete junction of the vocal fold free boarder; when incomplete there are formation of chinks presenting different formats. Objective: Our point is to find in the glottal coaptation mode, during sustained phonation of the vowel / /, in children having minor structural alterations, components that allow us to set them apart from subjects having vocal nodule or from subjects presenting no vocal complaints. Material and Methods: We have used a retrospective study of children's data assisted from 1996 to 2001, composed of children's larynx images that presented diagnosis of minor structural alterations, vocal nodule and also of children not showing any vocal complaints. From these images there has been analyzed the glottal configuration during phonation of the vowel / / and there has been realized statistical analysis to compare the three groups. Results: The triangular chinks are found in the three groups, while the spindle chink only occurred in minor structural alterations. Conclusion: The use of glottal coaptation mode in children as a diagnosis criterion to set the minimal structural alteration apart from the vocal nodule and regular larynx is important when we observe spindle chink, a situation found only in the minimal structural alterations. The triangular chinks were not meaningful to differentiate minimal structural alterations from vocal nodule and from regular larynx. INTRODUCTION Vocal nodule is a benign lesion caused by abusive use of voice and continuous friction

5-8. Apparently. The aspect of minor structural alterations varies according to the changes observed. Vocal impact caused by these changes is strictly related to individual vocal demand and. MSA are considered histological architecture deviations from vocal fold mucous membrane and involve the following conditions: vocal sulcus. not only due to technological advances. incidence of cysts has increased in latest years. laryngeal microweb. taking the appearance of a bilateral nodule. in some cases. gender. as they are associated conditions. the lesion resembles vocal nodules and leads to difficult diagnosis. Also.5 can be observed. Similar situation is observed in the identification of other minor structural alterations.9. and therefore is not considered a lesion2. pocket sulcus and stria sulcus with edema of the lower lip may lead to contralateral reactions. improvement of balance and voice quality is sought. Glottal configuration during phonation varies in accordance with age. When laryngoscopy is used. microscopically.usually in the mid-third region of the vocal folds. In cases of vocal nodules. interfering in voice quality. even if it is a unilateral lesion. Stroboscopy can be useful in assessing MSA larynx. vocal . while the presence of vasculodysgenesis is a strong sign of minor structural alterations. thickening of the epithelium and the basal membrane is verified1. with size and number of alterations present in each larynx. which is clinically expressed exclusively by phonation. Hirano's studies3. once reduction or lack of mucosa wave vibration2. in specific cases -. epidermoid cysts.4. In a study carried out in 1985 with 157 patients. Bouchayer et al. Other cases were identified during surgery only. although vocal therapy leads to poor results and the need for surgical procedure is frequent. which have established the relation of mucosa tunica structures in vocal production.or surgery. leading to good prognosis. for minor structural alterations. this device can visualize hidden sulcus. mucosal bridges and vasculodysgenesis . as they often present discreet signs. Moreover. Accurate diagnosis of laryngeal alterations is relevant as there are a variety of treatment approaches and prognosis9-11. for which vocal therapy is indicated . no previous alterations of the vocal fold architecture are observed before the trauma.5 found out that only 10% of cysts were revealed by the exam and 55% were cases suspected by indirect signs obtained by stroboscopy or the presence of enlarged vessels converging into one single spot.in general they do not appear alone in the larynx. but also to improved knowledge for their recognition2. In this case. information on the vocal fold surface's vessels distribution has shown to be significant in diagnosing laryngeal benign lesions6. Conditions such as epidermoid cysts. Minor structural alteration (MSA) is a congenital variation of the laryngeal anatomy. On the other hand. a nodular bilateral lesion of varied sizes and asymmetrical aspect is revealed. Minor structural alterations are not always evident by laryngoscopy. showed evidence of how small architectural variations can modify the vocal folds' vibration. although vocal repercussion may be considerably significant.

distributed by three diagnoses: minor structural alterations. MATERIAL AND METHODS Retrospective data study of children under the age of 10 years assisted in the period between 1996 and 2001. tension and lesions. indicating greater susceptibility of women and children to lesions caused by trauma of the vocal fold's mid-third region19. in which this condition is usually verified in case of vocal nodule18. presence of posterior or mid-posterior triangular chink is associated with low values of glottis proportions19-21. Criterion to enter the MSA group was the presence of minor structural alteration diagnosed by videonasofibroscopy and confirmed by microlaryngoscopy during surgical procedure. The sample included images of children's larynges. 18 images of larynges with minor structural alterations. from subjects with vocal nodule or those without vocal complaints. In this context. at the Larynx Institute of Sao Paulo. even in subjects without vocal complaints or clinical alterations12-16. and no vocal complaints. confirmed by surgical procedure or vocal therapy. differently from adults. The vocal nodule group consisted of children presenting the following conditions: bilateral front-to-front nodular lesion in the mid-third of the vocal folds' membranous portion. during sustained phonation of the vowel / /. which in turn is a parameter for the relation between length of the membranous and the cartilaginous portions of the vocal fold. Glottal configuration is often determined by glottis proportion. images of routine videolaryngoscopy of subjects without vocal complaints or alterations/lesions in the vocal folds were selected. fundamental frequency. abusive and under pressure use of voice. in cases of incomplete coaptation. with voice improvement and significant reduction of nodules. Complete or incomplete coaptation of the vocal fold free border was verified. presence of mid-posterior triangular chink has favored diagnosis of vocal nodule18. Diagnosis of minor structural alteration was established through direct microlaryngoscopy during surgical procedure indicated for treatment of dysphonia. Children and young women's larynges present lower values of glottic proportion as compared to male adults. Posterior or midposterior triangular chinks may follow minor structural alterations in children. mid-posterior triangular chink. as the impact zone in the vocal fold varies during adduction. In children without vocal complaints. Recent studies have demonstrated that glottal configuration is related to individual's higher or lower predisposition to develop vocal granuloma or nodule17-18. children submitted to microsurgery for laryngeal nodule removal. OBJECTIVE The purpose of this study was to find elements in the glottal closure mode that could allow us to differ children with minor structural alterations. formation of chinks of different shapes was observed. 11 . vocal nodules. For the group of children with normal larynx. Among the examined children.register.

were grouped.either posterior triangular or mid-posterior chinks . Laryngoscopy images were randomly edited in tapes and had no diagnostic identification. which were formerly not accessed by Garcia's mirror examination .9 years .images of larynges with vocal nodules.8 boys and 3 girls. are shown in Table 1.7 years. diagnosis is only determined or confirmed through surgical investigation or clinical analysis exam. there are still some difficulties that are inherent to the lesions and resultant from laryngoscopy use. secondary to nodular lesion of the mid-third area. which can be followed by anterior chink (figure 1c). as well as the control group. midposterior triangular chink (FTMP) of the same shape and length extending beyond the vocal process of arytenoids . irregular. Glottal configuration during phonation of vowel / / was analyzed and classified into complete closure or without chink (SF) and incomplete closure or with chink (CF).5. triangular configuration and limited to intercartilaginous area (figure 1a). The videonasolaryngoscopy images were analyzed in the first medical visit. Frequently. and double-spindle chinks were included in the group denominated "Others". identified according to site and shape.Test for K proportions (independent frequencies) . the sample was small.7. However. A statistical analysis was conducted for group comparison. including the following tests: .Chi-square test of adherence (dependent frequencies) As only accurately diagnosed cases with long follow-up periods and consistent to admission criteria could be selected. where cases of posterior chinks . DISCUSSION Study and evaluation of the larynx under certain physiological conditions and with highquality imaging were possible due to technological improvement.8. Other types of chinks.10 boys and 10 girls. mean age of 8. and 20 images of regular larynges were investigated. such as parallel. reaching the vocal folds' membranous portion (figure 1b and 1d). which has enabled more accurate clinical diagnoses of vocal alterations and identification of small lesions. ages ranged from 3 to 12 years. The control group included children aged 5 to 11 years. mean age of 6. mean age of 7. and spindle chink (FF) (figure 1e).Test for two proportions (independent frequencies) . children's ages in the MSA group ranged from 3 to 11 years. particularly in MSA cases2. among which 14 were boys and 4 were girls. RESULTS Incidence of each type of glottal closure observed under each specific pathological condition. In the vocal nodule group. Incidence of glottal closure may also be checked in Graph 1.2 years .i.e. Two otorhinolaryngologists who were not involved in tape edition carried out images' evaluation. as follows: posterior triangular chink (FTP).11. Clinical diagnosis is .

that is. other parameters are taken into consideration. Anatomical aspects of the larynx vary in consistence with gender and age2. However. but gives rise to a concavity in this region reducing the friction force during phonation. Such anatomical configuration leads to frequent posterior opening of the larynx during phonation. resulting in 75% of glottal closure observed in our control group (Table 1). Videolaryngoscopy images of the lesion not always yield to a diagnostic decision and. Other minor structural alterations associated with vessels are called vasculodysgenesis. surgery or clinical therapy. leading to low values of glottis proportion. while the membranous portion is relatively small19.18. One parameter includes the presence of enlarged vessels traveling transversally to the vocal fold. although FTMP is considered an aspect of a vocal nodule.considering its lamina propria is not altered and vessels are similar to those observed in larynges of patients with no vocal complaints or lesions9. FF was observed nearly in one-third of individuals presenting minor structural alterations (Table 1. Glottal closure during phonation is always observed for diagnostic determination. At early age. observation of the triangular chink during laryngoscopy does not seem to help in differentiating vocal nodule from minor structural alteration. more than half of the cases of minor structural alterations maintained a non-lesion infantile larynx pattern . as it occurs with adults. consistent with vocal behavior.18. when diagnostically confirmed cases of minor structural alteration are observed . although this kind of study is less frequent than with adults.once all cases refer to patients submitted to microsurgery of the larynx and therefore examined by direct microlaryngoscopy . Presence of FTMP. Technological improvement has enabled more comprehensive evaluation of children's larynx and. is a sign of important trauma at the triangle vertex during phonation. even when compared to values found in female adults15. the vocal nodule's site. In fact. there are no outstanding anatomical differences related to gender. as glottis configuration is strongly related to predisposition to certain benign lesions of larynx associated with the impact zone during adduction of vocal folds9. this chink does not cause trauma at the vocal nodule development site.21. any alteration is scrutinized during clinical examination. The relative difference between membranous and intercartilaginous regions is subtle and is reflected by glottis proportion. This chink is observed in the presence of vocal nodule and may help eliminating suspected minor structural alteration. which are relevant in differential diagnosis of vocal nodule .fundamental as to choose treatment among vocal therapy. with or without anterior opening. with sudden reductions or with a twisted or spring aspect9.FTP or FTMP (Graph 1). Consequently. therefore. in case of a nodularlike lesion. determining whether it is a vocal nodule or a minor structural alteration is imperative. as reported in a study with adult population18. In this sense. which differs in adults according to gender2. This aspect explains the differences observed between the incidence of vocal nodule and granuloma in both gender17. This fact explains the high incidence of vocal nodules in children. However.it is evident that posterior openings are still very frequent. One of the most outstanding difference is larynx size. which is in accordance with the values reported by Crespo21.4. Graph1). .4. they are relevant for characterization and understanding of the physiology and alterations typically observed in this age range20.17. which changes the impact zone during phonation.

Cornut G. Phonosurgery: Assessment And Surgical Management Of Voice Disorders. as in this condition there are no alterations in the mid-third region and no efforts to phonation. FF findings may express the occurrence of modifications during formation of lamina propria components observed in minor structural alterations. Cornut G. Gonçalves MI. 98: 791-5.. its higher incidence among regular larynx subjects is expected compared to the other analyzed groups. Epidermoid Cysts of Vocal Cords. Hirano M. Bouchayer M. Monday LA. Epidermoid Cysts. Bless DM. although posterior or mid-posterior triangular chinks are indicative of vocal nodule. CONCLUSIONS The use of glottal closure mode during phonation in children as a diagnostic criterion to differ minor structural alteration of the vocal nodule from regular larynx is relevant when a spindle chink is found. Hammarberg B. 7. 13 (1):2-6. 1991:21-7. Bastian RW. Pontes P. Hirade Y. Yoshida T.25-41. Roch JB. they were not significant to differentiate minor structural alteration from regular larynx. 1991. In: Ford CN. Concerning FTP. Behlau M. Alterações Estruturais Mínimas Da Laringe (AEM). Sulci. In this sense. Loire R. 4. Basement membrane zone injury in vocal . Vocal fold Cover Minor Structural Alterations: . 2. or even that a compensatory tension resulting from minor structural alterations can lead to posterior closure during phonation. Ann Otol Rhinol Laryngol 1983. Ann Otol Rhinol Laryngol 1989. Phonosurgical Anatomy of The Larynx. Behlau M. In: Gauffin J. New York: Raven Press. Witzig E. Considerações básicas. 67: 446-66. Hirano M. particularly collagenous fibers. Sweden: Singular. And Mucosal Bridges of the true vocal cord: a report of 157 cases. Improved Surgical Technique For Epidermoid Cysts Of The Vocal Fold. 6. Microsurgery for Benign Lesions of The Vocal Folds. Bouchayer M. Acta Awho 1994. 3. Gray SD. Ear Nose Throat J 1988. REFERENCES 1. Laryngoscope 1985. while it is considered to be the result of histological changes involving fibrous proteins present in the vocal fold lamina propria. as this condition is only observed in minor structural alterations.The presence of this chink is statistically significant in minor structural alterations cases as it determines diagnosis. Gonçalves MI. Stockolm. 5. Roch JB. Cornut G. Pontes P. Sanada T. 1087-93. p. 92: 124-7 8. Bouchayer M.nodules. Vocal fold physiology.

20. SP: Lovise. Feder. Pontes P. Carapicuíba. Sataloff RT. Ann Otol Rhinol Laryngol 2001. Glottal configuration associated with fundamental frequency and vocal register. 9. Forrest LA. Murry T.22-43. Behlau M. Voice surgery. 12. Tese de doutorado: Universidade Federal de São Paulo . 11. Pontes P. Pontes P. Ear Nose Throat J 1987. 18. . 13. 110(8): 765-9. p. Behlau M. Kyrillos L. 1993. Abbs. De Biase NG. 1983. 115(4): 261-6. Mosby. Growth development and aging of human vocal folds. 16. Pontes P. 14. 19. 2(4): 175-85. according to type of glottal configuration. 3: 149-54. Xu JJ. p. As fendas glóticas e a terapia fonoaudiológica. Exame Laringológico. Endoscopic Microsurgery. RJ. JH. 10:34-7. J Voice 1998. Crespo NA. Pinho S. In: Bless D. Woodson GE. De Biase N. Vocal Fold Physiology. T. 51-60. Sataloff R. Kyrillos L. 10. Um pouco de nós sobre voz. In: Behlau M. proporção glótica e ângulo de abertura das pregas vocais em crianças. Spiegel J. Videostroboscopic evaluation of the larynx. Bless D. Otolaryngol Head Neck Surg 1995. 227-68. Distribution of subjects studied. In: Gould WJ. p. Pontes A. 1995. Configuration et rapport glottic: um essai pour comprendre la fente glottique postérieure.. St Louis. 17. Behlau M. Kurita S. Kyrillos L. São Paulo. Pinho SMR. De Biase N. 15. Phonoscope 1999. Avaliação E Tratamento Das Disfonias. Coaptação glótica.Diagnostic Errors. Phonoscope 1999. Vocal Nodules and Laryngeal Morphology. Spiegel JR. São Paulo: Pró-fono. 16(3): 408-14.Escola Paulista de Medicina. Hirano H. 66: 289-98. Acta Awho 1991. Pontes A. 2(3): 129-35. Pontes PAL. 1995. Importance of glottic configuration in the development of posterior laryngeal granuloma. Pontes P. Behlau M. Pontes P. Rev Laryngol 1994. San Diego: College-Hill. J Voice 2002. Nakashima. Hirano M. São Paulo. 1993. Vascular Characteristics Of The Vocal Fold Cover In Control Larynges and Larynges with Benign Lesions. In: Ferreira LP. p 143-66. Disfonias funcionais: avaliação otorrinolaringológica dirigida à fonoterapia. 21. Treatment of Benign Cysts and Tumors of The Larynx. 12(1): 44-9. Table 1.

Posterior triangular chink in minor structural alteration . in percentage. FF: spindle chink. according to type of glottal configuration. Figure 1. Nodule. FTP: posterior triangular chink. FTMP: mid-posterior triangular chink with or without anterior opening. Telelaryngoscopy during sustained phonation of vowel / / showing chinks.SF: without chink. FF: spindle chink. a. and the control group. FT: posterior triangular and mid-posterior chinks. Graph 1. Normal SF: without chink. Distribution of subjects with no minor structural alteration. vocal nodule. MSA. MSA: minor structural alteration.

b. Mid-posterior triangular chink in vocal nodule e. Mid-posterior triangular chink in minor structural alteration c. Mid-posterior triangular chink with anterior opening in minor structural alteration d. Spindle chink in minor structural alteration .