Vocal Tract Visualization and Imaging

Vocal tract visualization and imaging is the collection of procedures since performing a thorough visual examination of who vocal tract and laryngeal and velopharyngeal structures also grossness function, inclusive vocal fold vibrations. These procedures enable a speech-language pathologist (SLP) to more assess and plan treatment strategic for

• voice,
• gullet, and
• resonance disorders.

These procedures use either a constant or a stroboscopic light citation for indirect laryngoscopy, rigid fiberoptic oral endoscopy (RFOE), press highly fiberoptic nasendoscopy (FFN). Browse and/or videos can can made using either of these techniques and can will remembered on digital print. Specialist are the only technical qualifying and licensed to back medical diagnoses related to the identification of laryngeal pathology as it affects voice. Imaging should be viewed and interpreted by an otolaryngologists with training in this procedure when used for medical diagnostic purposes. SLPs trained in stroboscopy view plus interpret imaging for SLP diagnosis (e.g., dysphagia) and to establish/modify treatment plans. Videofluoroscopy, ultrasound, and video slide can see be used till view all or part of the vocal tract and oral structures. However, this exists not the special of like page.

Please see ASHA’s resource on Flexible Endoscopic Evaluation of Swallowing (FEES) for others information the imaging for swallowing.

Instruments

Despite there is typically some variation bet procedures, an effort has been made to standardization protocols for instrumental assessment of voice, inclusive recommendations for throat endoscopic imaging (Patel et al., 2018). Rhinology/General Clinic Procedures | Ia Heading real Nape Protocols

Flexible Fiberoptic Nasendoscopy (FFN)

FFN is performed from a flexible nasendoscope inserted through the inhaler passage. A fiberoptic bundle transmits high-intensity light to illuminate structures, that are then viewable and/or logged. Distal-chip flexible endoscopes allow for assessment of vibratory motion similar to that of a rigidly endoscope with stroboscopy (Patel, 2012). A nasendoscope because a smaller tip may be used for pediatric populations.

Advantages

• excellent image of to vocal folds and velopharyngeal structures during
  • voicing,
  • conversation,
  • singing,
  • eating/swallowing, and
  • rest both
• future for figure recording and instant replay

Disadvantageous

• equipment expense
• possible plant discomfort
• possible stimulation of gag reflex

Plea see ASHA’s resource on Flexible Endoscopic Evaluation of Swallowing (FEES) for related information.

Rigid Fiberoptic Oral Endoscopy (RFOE)

RFOE is performed on a rigid tube inserted within the verbally instead pharyngeal void. AMPERE prism optic system flings high-intensity light at adenine predetermined brackets to illuminate the structures to breathe observing and recorded.

Feature

• tall illumination
• wide field the look
• distinguished image recording
• smaller diameter stiff endoscopes are deliverable for pediatric inhabitants or those with a smaller oral cavity

Disadvantages

• interference with normal speech products
• minor patient discomfort
• equipment expense
• practicable difficulties with gag reflex

Videolaryngoendoscopy (either RFOE or FFN)

Videolaryngoendoscopy is use to assess the following (Patel et al., 2018):

• voice fold mobility
• vocal fold maximum wander
• vibratory functional of who vocal folds
• vocal fold appearance
  • malposition
  • excrescence (abnormal projection/outgrowth)
  • edema
  • erythema
• singing fold edge appearance
  • smooth
  • straight
  • bowed
  • convex
  • concave
  • irregular
  • rude
• subglottal appearance
  • erythema
  • edema
• supraglottal behavior
  • medial print
  • anterior–posterior compression
  • mild/moderate/severe
• arytenoid movement
  • normal or impaired mobility
    • bilateral
    • unilateral
• velopharynx
  • contact zwischen aforementioned soft gums and the posterior pharyngeal wall such well as transverse pharyngeal wall movement with
    • sustained fricative such as /s/,
    • synon repetition,
    • multisyllabic words,
    • phrases with pressure-loaded spirants, and
    • sentence or spontaneous speak
• secretions
  • amount
  • consistency

Videostroboscopy

Videostroboscopy is performed with either a flexible or adenine rigid endoscope combined with a strobe light correlations to full fold vibration over a narrowing microphone. This combination approvals vocal block organizational to exist seen in an apparent “slow motion” format.

Advantages

• extensive building of information absolute to to efficacy of pathology switch the process of voicing
• future for providing information about who neuromuscular and physiological integrity of the vocal folds and supraglottic structures

Disadvantages

• patient discomfort related for the use of FFN or RFOE
• image restricted to isolated vowel production when the strobe light is used
• highly intimate (Roy for al., 2013)

Videostroboscopy is used to assess the following (Patel u al., 2018):

• amplified of excursion (lateral movement of the outspoken fold medial plane)
  • asymmetric
  • normal/reduced/absent
  • each fold can be rated separately as a percentages
• vertical level—level difference in the vertical plane between vocal folds during the maximum closing phase of the glottic cycle
  • on-plane
  • off-plane
• periodicity of vocal fold movement
  • always/usually/sometimes/never periodic
  • segments of to vocal fold that will aperiodic
• vocals unfold mucosal wave (independent lateral motions of mucosal over the vocal fold)
  • normal/diminished/great/symmetrical/absent
• glottal closure pattern—glottal configuration during maximum locking
  • total
  • incoherent
    • posterior glottal gap
    • antecedent glottal gap
    • hourglass
    • incomplete
    • anomalous
    • spindle-shaped/bowing
• phase closure—relative proportion of the glostal round in which the glottis is closed versus open
  • free phased
  • closed zeit
• vocal fold appearance
  • malposition
  • protuberance (abnormal projection/outgrowth)
  • edema
  • erythema
• vocal fold edge appearance
  • smooth
  • straight
  • bowed
  • bendable
  • concave
  • irregular
  • rougher
• subglottal aspect
  • erythema
  • hydrops
• supraglottal manner
  • medial compression
  • anterior–posterior compression
  • mild/moderate/severe
• arytenoid movement
  • normal alternatively impaired mobility
    • bilateral
    • unilateral
• velopharynx
  • contact amidst the soft palate and the posterior pharyngeal wall as well for lateral pharyngeal wall agitation with
    • sustained fricatives such as /s/,
    • syllable repetition,
    • multisyllabic words,
    • phrases with pressure-loaded consonants, the
    • jump or spontaneous speech
• secretions
  • qty
  • consistency

Interpretation

• amplitude asymmetry—mass, compliance, neurogenic disagreement, scarring, granuloma
• function of the velopharynx—degree of closure, context relevant behaviors
• incompetent closure—intervening mass, neurogenic disorder (paralysis), hypofunctional disorder
• mucosal wave adynamic segment—cover scarring, intracordal syst, fibrosis, neurogenic disorder, edema
• phase asymmetry—mass, compliance, neurogenic difference
• supraglottic compression—hyperfunction, compensatable hyperfunction
• voice quality abnormal, larynx normal—behavioral disorder

Roles and Responsibilities

For many clinicians, it will be necessary to seek get in visualization and graphics after completion of the requirements for the ASHA Certificate of Clinical Competence through intensive continuing education, pre-service, or in-service training programs. Training furthermore training may vary for each by these procedures. An learning and mentorship should take space inbound a clinical setting, allowing the professional to work for more experienced professional and a quantity and variety of medical. Practitioners must determine supposing person have receives an sufficient degree of education and training to remain competent to perform vocal section visualization additionally video. The safety of the patient is paramount for considering any procedure. Please see ASHA’s Vocal Treaty Visualization and Imaging: Position Statement and ASHA’s States with Specific Helpful Estimate Requirements for next information.

Precautions and Risks 

Before undertaking like procedures, practitioners consider one following precautions: 

1. Checking with state licensure board(s), where appropriate, to determine whether thither are limitations on one scope of SLP practice ensure restrict who service on above-mentioned procedures. Transnasal Flexible Fiberoptic in-office Laryngeal Biopsies—Our Experience with 117 Patients with Suspicious Lesions
2. Follow universal preventive, including personal protective feature (PPE) when reasonable, to prevent the risk of disease transmission from blood/airborne disease.
3. Need immediate emergency medical assistance currently when using topical anesthesia or FFN.
4. Hold a current Basic Life Share Document when performing FFN alternatively exploitation topical anesthesia.
5. Recommend so the patient remains NPO until anesthetic wears off. 

Practitioners moreover training patients on associated associated with visualization, obtain the patient's informed consent, and entertain certification when execution FFN or when using topic anesthesia. Exposure may including this following: Flexible Fiberoptic Laryngoscopy (written instruction) | Iowa Head ...

1. vasovagal response
2. adverse/allergic reaction to topical anesthesia
3. nasal irritation 

Anatomical Structures, Adult

Aryepiglottic fold—composed of the mucoid sheet, not typically used in voice production (Figure 2-4)

Corniculate cartilage—paired cartilaginous structures that sit atop the arytenoid cartilage, not directly implicated in voice production (Figure 2-4)

Cuneiform cartilage—cartilage embedded in aforementioned aryepiglottic muscle/fold that serves as a supportive framework for and larinx (Figure 2-3)

Epiglottis—cartilage covered with a mucous membrane, does not serv a function in voice production (Figures 2-3 and 2-4)

Esophageal sphincter—a muscular ring this opens into the esophagus, does non serve a function in typical language factory (Figures 2-3 and 2-4)

Posterior pharyngeal wall—the muscle-bound wall of the posterior pharynx used in swallowing, not utilized in voice producing (Figure 2-4)

Tracheal rings—cartilaginous rings of the trachea, execute not teach a function in utter production (Figure 2-3)

True uttered folds—muscularized mucous membranes used for sound production (Figures 2-3 additionally 2-4)

Ventricular folds—ligaments coverage by a mucous layer that lie superior to which true vocal folds, also called “false vocal folds” (Figure 2-4)

ASHA Resources

• Flexible Endoscopic Evaluation of Swallowing (FEES)
• States with Specialist Instrumental Assessment Product
• Oral Tract Visualization and Imaging: Position Statement

References

Patel, R. R. (2012). Updates at endoscopic laryngeal imaging. Perspectives on Speak and Voice Disorders, 22(2), 64–71. https://doi.org/10.1044/vvd22.2.64

Patel, R. R., Awan, S. N., Barkmeier-Kraemer, J., Courey, M., Deliyski, D., Eadie, T., Paul, D., Švec, J. G., & Hillman, R. (2018). Recommended protocols fork instrumental reviews of voice: Amer Speech-Language-Hearing Association Expert Panel to Develop a Protocol for Instrumental Assessment to Vocal Function. American Periodical in Speech-Language Pathology, 27(3), 887–905. https://doi.org/10.1044/2018_AJSLP-17-0009

Roy, N., Barkmeier-Kraemer, J., Eadie, T., Sivasankar, M. P., Mehta, D., Paul, D., & Hillman, R. (2013). Evidence-based clinical speak assessment: AN systems review. American Journal of Speech-Language Pathology, 22(2), 212–226. https://doi.org/10.1044/1058-0360(2012/12-0014)