Swelling Checks to Detect Vibratory (Overuse) Injury to the Surface Tissue (Mucosa) of the Vocal Cords

 

 

Definition: Vocal tasks (swelling checks) that detect acute or chronic vocal fold mucosal injury reliably; Secondarily, they can also detect gaps between otherwise normal folds.
Purpose /rationale: To provide persons with a way to detect mucosal trouble for themselves. We are in effect “taking all of the clothes off the mucosa.”
Who they are for: Anyone who uses the voice extensively or vigorously—particularly vocal overdoers.*
What they are not for: Voice training or performance.
When they should be done: When first learning the tasks, they should be done often until the concept of one’s mucosal ceiling is understood (see below). Once both proficiency and ceiling are established, the tests require 20 seconds or less both morning and evening.

TEST I: “HAPPY BIRTHDAY”

  1. In your upper voice range, sing the first phrase of “Happy Birthday” as softly as you can, using a “boy soprano pianissimo.” Resist the temptation to “make it work” by getting louder!
  2. Repeat the phrase at progressively higher pitches.
  3. Verify carefully the pitch at which you falter (onset delays or air escape) or can’t go higher without getting louder. THIS IS YOUR MUCOSAL CEILING PITCH, FOR THIS TASK.
  4. If your mucosa is normal, the “soft voice” and “loud voice” ceilings should be about the same.
  5. If your mucosa is abnormal, the “loud” ceiling should be higher than the “soft.”

TEST II: STACCATO

  1. Sing again “boy soprano pianissimo” using the descending staccato figure so so so so so fa mi re do
    (5-5-5-5-5-4-3-2-1; e.g. G-G-G-G-G-F-E-D-C) Attack each note precisely in the middle of the continuum
    between an aspirated ho and a coupe de glotte. In other words, lightly, precisely, and with a little bounce.
  2. As for “Happy Birthday,” repeat at progressively higher pitches.
  3. Again carefully verify the pitch at which you experience onset delays or air escape or can’t go higher without getting louder. THIS IS YOUR MUCOSAL CEILING PITCH, FOR THIS TASK.

COMMON QUESTIONS

My mucosal ceiling is higher when I do the staccato exercise than it is when I do “Happy Birthday.” What does that mean?

Though needing verification via careful laryngeal examination, this phenomenon suggests that a small gap between the folds, rather than swelling, is the problem.

My mucosal ceiling is higher when I do the “Happy Birthday” exercise than it is when I do staccato. What does that mean?

Again needing verification, this phenomenon suggests a mucosal disturbance rather than a gap as the explanation.

I can figure out my mucosal ceiling easily enough, but how do I know if it is normal?

This can be answered best at the outset by individuals who can compare your performance with that of hundreds of others to whom they have applied these tests (e.g. laryngologist, speech pathologist, voice teacher). It is also helpful at the beginning to correlate your mucosal ceiling with high quality visualization of the vocal folds.

What if my ceiling isn’t normal as compared to others?

The swelling tests are nevertheless just as valuable! Here’s how: Suppose an individual’s initial mucosal ceiling is abnormal because of small vocal nodules, but the person is happy with the voice’s capabilities. Here, the swelling tests can be monitored to help the individual prevent additional mucosal injury, by not allowing the ceiling to descend any further. A different person whose initial ceiling is abnormal might be unhappy with
perceived limitations due to mucosal injury. Now, ongoing use of the swelling tests can confirm the benefits of medical, behavioral (voice therapy) or, eventually, surgical treatments, because the ceiling will rise with successful treatment. Furthermore, these tests can help to avoid recurrent injury.

What if I notice that my ceiling is abnormal (lower) as compared to my usual?

First, consider recent voice use for the possibility that it was “too much.” If so, and/or if the ceiling
remains lowered on subsequent trials of the tests later in the day, “back off” by reducing voice use
until the ceiling returns to your usual pitch, whether “normal” as compared to other persons or not.
Women: Some may find that the ceiling lowers routinely during pre-menstrual days, but returns to normal in a few days.

Do I need to cancel everything until the ceiling recovers?

This depends on the severity of the lowering of the ceiling. Generally, however, careful strategy concerning amount and manner of voice use during this time will allow the mucosa to recover while you continue to work or perform.

Are there common pitfalls in use of the swelling tests?

First and foremost, is the tendency to adjust how the voice is produced when the voice begins to falter. A singer will, for example, unconsciously get a bit louder or use a slight glottal attack to “make it work,” thereby reducing the sensitivity of the tasks. Another might be to perform them without a pitch reference at hand, so that the value of comparing with one’s known “ceiling” pitch is lost. A third might be to become a bit too obsessive and easily “spooked” with any ceiling change. And finally, comes the tendency to “lose the habit!”

* Vocal overdoer: Defined as an individual with both of the following:
  1. A high propensity to use the voice. Generally, “sixes and sevens” on a 7-point (maximum) intrinsic talkativeness scale.
  2. A high extrinsic opportunity or invitation to use voice, based on family, social, vocational, and avocational considerations.

Motivated Laryngeal Examination

A “Motivated” laryngeal examination is an examination in which the clinician “pushes” the larynx to reveal its secrets. If topical anesthesia is used, this can be done without undue discomfort to the patient, and laryngeal images can be close and clear rather than far and fuzzy.


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Siren

An uninterrupted sound that begins very low in a person’s vocal range and ascends to a very high pitch, sometimes the highest possible pitch that person can produce. A single siren could also go from low to high and back to low one or more times without interruption. A clinician might ask a patient to perform a siren during the vocal capability battery in order to assess pitch range capability or even vocal skill.

Projected voice

A voice that is perceptibly “thrown” or “called out,” as when talking to a group of 20 or more people. A clinician might ask a patient to project the voice during the vocal capability battery in order, for example, to reveal weakness not evident or only slightly apparent at normal speaking voice volume, to detect vocal inhibition, or to unmask a nonorganic voice disorder.

Vocal commitments

Events or circumstances that permit, invite, or demand much voice use. A person’s vocal commitments could include his or her occupation, childcare, rehearsals and performances, hobbies or even volunteer activities to which a person is highly committed, sports, and so forth. Heavy vocal commitments and innative talkativeness are the two potential sources of vocal overuse and, unsurprisingly, are often seen together.

Vocal loudness scale

A scale from 1 to 7 that we use to describe the loudness of a person’s typical speaking voice as compared with one’s experience of the rest of the human race. For example, someone whose vocal loudness seems to be unexceptional and does not draw any attention to itself—average, in other words—might be considered a “4.” The person who speaks so softly that everyone who encounters him or her has to strain to understand might be a “1.” The person whose voice is (often unconsciously) so loud that one needs to step back or hold the telephone away from the ear might be considered a “7.” See also: disorder of vocal loudness perception.

Narrow-band illumination

The use of only two narrow wave bands of light (blue and green) during an endoscopic examination, so as to make blood vessels and other tissues in the mucosa more visible. Blood vessels become more visible under narrow-band illumination because both of the wave bands are easily absorbed by hemoglobin in the blood. In addition, the blue and green wave bands in narrow-band illumination each penetrate the tissue to differing degrees, so that blood vessels near the mucosal surface appear as a different color from blood vessels deeper in the tissue.

In the field of laryngology, narrow-band illumination can help an examining clinician to identify the vascular changes that characterize a range of disorders, including recurrent respiratory papillomatosis, capillary ectasia, glottic sulcus, ulcerative laryngitis, and others. It can also help to identify subtle, hazy leukoplakia. The technology, developed by Olympus, is officially called Narrow Band Imaging™. KayPentax offers a different, software-based method for highlighting vascularity and other tissue characteristics, which is called iScan™.


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Videoendoscopic swallowing study (VESS)

A method of evaluating a person’s swallowing ability by means of a video-documented physical examination, looking from inside the throat. Also called the fiberoptic endoscopic evaluation of swallowing (FEES). The videoendoscopic swallowing study (VESS) is to be distinguished from the videofluoroscopic swallowing study (VFSS), which is an x-ray-based assessment.

How it works:

To perform a VESS, a clinician uses a fiberoptic or distal-chip nasolaryngoscope. The clinician begins by examining the structure and function of the patient’s palate, tongue, pharynx, and larynx, including sensation, if desired. Next, to assess the patient’s swallowing capabilities and limitations, the clinician positions the tip of the nasolaryngoscope just below the nasopharynx and, looking downward into the throat, asks the patient to swallow a series of colored substances with a range of consistencies (e.g., blue-stained water, blue-stained applesauce, and orange-colored crackers).

As the patient swallows these substances, the clinician watches to see if any significant traces remain in or reappear in the space above, around, or within the larynx, rather than disappearing into the entrance to the esophagus. If significant traces remain in view, or if any material spills into the opening of the larynx or down the trachea, the patient may have presbyphagia. If significant traces initially disappear but then re-emerge upward from the esophageal entrance, the patient may have cricopharyngeal dysfunction, with or without a Zenker’s diverticulum.

Benefits of the videoendoscopic swallowing study:

This method has particular value for patients who are bedfast and cannot travel to the radiology suite, or for patients whose swallowing function is rapidly evolving (improving, usually), such as those recovering from a mild stroke. For clinicians experienced with this technique, VESS can also often be used with new patients complaining of dysphagia during the initial consultation as a robust and—depending on patient history—potentially stand-alone method of diagnosis and management. Sometimes, the VESS findings, along with a patient history of solid food lodgment at the level of the cricoid cartilage or cricopharyngeus muscle, will indicate when VFSS should also be obtained to assess for possible cricopharyngeal dysfunction. Even in this latter circumstance, when VFSS is called upon to confirm a suspected diagnosis, VESS will have already oriented the examiner to the nature and severity of the problem. In most follow-up circumstances other than after cricopharyngeal myotomy, VESS is generally more efficient and inexpensive than VFSS.


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Videos:

Videoendoscopic Swallowing Study (VESS)
This video features an example of a 100-year-old patient undergoing VESS.

Videofluoroscopic Swallowing Study (VFSS)

An x-ray-based method of evaluating a person’s swallowing ability. The videofluoroscopic swallowing study (VFSS) is also sometimes called the modified barium swallow, or the “cookie swallow.”

In a radiology suite under fluoroscopy (which creates moving rather than still x-ray images), the patient is asked to swallow barium in thin liquid and paste consistencies, and then in paste on a cookie or cracker. The barium bolus is followed radiographically through the mouth, throat, and into the esophagus. Both lateral and anteriorposterior views are recorded and, depending on the facility, a simple screening sequence of the subsequent movement down the esophagus is also recorded.


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Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos

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Lateral x-ray of the neck while swallowing barium

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Lateral x-ray of the neck while swallowing barium (seen as a dark column). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.
X-ray after myotomy

Cricopharyngeal dysfunction: after myotomy, resolved (2 of 2)

After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos

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VFSS of the neck while swallowing barium

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Lateral x-ray of the neck while swallowing barium (the dark material seen here in the throat). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.
urgically divided muscle can no longer narrow the upper esophageal passageway

Cricopharyngeal dysfunction: after myotomy, resolved (1 of 2)

After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Videos:

Barium Swallow (Barium Esophagram)
This video presents a clear visual example of a barium swallow, a test that involves having the patient swallow a barium solution while using x-rays to observe the flow of the barium, which can reveal swallowing deficiencies.
Cricopharyngeal Dysfunction: Before and After Cricopharyngeal Myotomy
This video shows x-rays of barium passing through the throat, first with a narrowed area caused by a non-relaxing upper esophageal sphincter (cricopharyngeus muscle), and then after laser division of this muscle. Preoperatively, food and pills were getting stuck at the level of the mid-neck, and the person was eating mostly soft foods. After the myotomy (division of the muscle), the patient could again swallow meat, pizza, pills, etc. without difficulty.