Braz J Otorhinolaryngol.

2009;75(2):188-92.

ORIGINAL ARTICLE

Vocal tract analysis in patients

with vocal fold nodules, clefts
and cysts
Raquel Buzelin Nunes1, Andrea Moreira Veiga
de Souza2, Andre de Campos Duprat3, Marta
Assumpo de Andrade e Silva4, Rejane Cardoso
Costa5, Juliana Gomes Paulino6

Keywords: dysphonia, endoscopy, vocal fold.

Summary
http://www.scielo.br/pdf/rboto/v75n2/
en_v75n2a06.pdf

he supraglottic plan represents an important dimension

in vocal production, and its characterization is very important
in the evaluation and treatment approach of dysphonic
individuals. Aim: to check if certain glottic configurations
are related to specific adjustments in the vocal tract. To use
nasal and laryngeal fibroscopy to assess the frequency of
supraglottic vocal tract adjustments in dysphonic women
with nodules, clefts and cysts. Methods: We assessed 31
dysphonic women, with age ranging between 18 and 45 years,
with vocal alteration and a diagnosis of nodules, middleposterior cleft and cyst, and we carried out a summarized
evaluation of the sensory-motor and oral systems and the
patients were submitted to video-laryngostroboscopy and
nasal and laryngeal fibroscopy. Three distinct groups were
selected: patients with bilateral nodules, clefts and cysts, with
similar glottic configuration. Their vocal tracts were visually
analyzed through exams of nasal and laryngeal fibroscopy,
by speech and hearing therapists and otorhinolaryngologists,
checking the following parameters: supraglottic constriction,
larynx vertical mobility, pharyngeal constriction and tongue
mobility. The data was statistically described and treated.
Results: during visual analysis we did not find statistically
significant differences which would separate the glottic
alterations groups. Conclusion: There was no correlation
between supraglottic tract adjustments with any particular
type of glottic alteration. These are individual behaviors that
generate adjustments and justify the different vocal qualities
in patients with the same type of laryngeal alteration.

NUNES, Raquel Buzelin et al. Vocal tract analysis

in patients with vocal fold nodules, clefts and
cysts. Rev. Bras. Otorrinolaringol. [online]. 2009,
vol.75, n.2, pp. 188-192. ISSN 0034-7299.

1
Masters degree in speech therapy, Pontifcia Universidade Catlica de So Paulo. Speech therapist.
Otorhinolaryngologist at the Espao da Voz, Belo Horizonte. Otorhinolaryngologist of the Prefeitura de B.H.
3
Professor of the Faculdade de Cincias Mdicas, So Paulo. Santa Casa de So Paulo. Otorhinolaryngologist.
4
Professor at PUC, So Paulo. Speech therapist.
5
Otorhinolaryngologist, Audiomigmg.
6
Otorhinolaryngologist, Instituto de Otorrinolaringologia de Minas Gerais.
Pontifcia Universidade Catlica de So Paulo.
Address for correspondence: Av. Pasteur 89 sala 407 Santa Efignia Belo Horizonte MG 30150-290.
CAPES.
This paper was submitted to the RBORL-SGP (Publishing Manager System) on 8 November 2007. Code 4853.
The article was accepted on 13 March 2008.

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From an initial sample of 40 subjects, 31 female subjects aged from 20 to 45 years were selected; this age range
is considered as that with the highest voice efficiency. The
subjects were seen at a private otorhinolaryngology clinic
in October and November 2004, and complained of voice
changes; all had a videolaryngostroboscopic diagnosis of
nodules, middle-posterior clefts or cysts.
In this study the nomenclature for laryngeal alterations defining nodules as generally bilateral benign lesions
occurring on the anterior portion of the vocal folds was
applied. Middle-posterior clefts were geometric images of
the remaining space in the rima glottidis during phonation,
when the opposite vertex to the base generally meets the
middle third of the vocal folds. Cysts were localized closed
cavities within vocal folds.19
Inclusion criteria: female patients complaining of
altered voice for over three months, not undertaking
speech therapy, and never having undergone laryngeal
microsurgery or any prior voice therapy, to avoid influencing the assessment in general.
Exclusion criteria: subjects with mental disorders or
an altered oral sensory-motor system that could interfere
with the assessment, such as: severely altered lip, cheek
or tongue tone or mobility, class two or three occlusion
disorders, dental arcade faults, upper or lower airway
alterations on the day of the examination, use of fixed
appliances or dental prostheses (according to Oliveira
and Pinho, 2001,20 these interfere significantly with speech
adjustments). The researcher thus elaborated an identification protocol for subjects and the sample selection
consisting of data on age, complaint, habits, water intake,
use of voice, profession, and a summarized evaluation of
the oral sensory-motor system: lips, tongue and cheek
(tone and mobility), altered dental occlusion, use of dental
prostheses or orthodontic appliances, joint (ample, closed,
locked, smile, vertical), and face (long, short, medium,
symmetrical or asymmetrical).
Subjects were informed about and signed a free
informed consent form.
An otorhinolaryngologist carried out direct laryngoscopy with a Mashida 30 or Explorent 70 rigid telescope coupled to a Toshiba micro-camera, a Bruel & Kjaer
stroboview source of stroboscopic light; the examination
was recorded on a JVC super VHS videocassette with an
LG 20 television monitor for diagnosing the lesions. The
physician introduced the laryngoscope into the patients
mouth and asked the patient to issue the prolonged vowel //, /i/ and to carry out inspiratory phonation. Local
anesthesia (10% neocaine) was applied when patients
reported discomfort.
The next step was nasofibrolaryngoscopy using a
Mashida ENT 30 P III fibroscope coupled to a Toshiba micro-camera and an Alphatron light source; the device was
introduced into the nostril and placed immediately below
the soft palate to check vocal tract adjustments. Patients

INTRODUCTION
Voice is an important communication mode among
human beings. The glottis, supraglottic area and the respiratory system are essential for producing voice.
The source-filter model for vowel production emphasizes the glottic and supraglottic dimensions that are
responsible for phonation (Fant, 1970). According to this
author, the source is glottic action, or sound generated
by the vibration of vocal folds, and the supraglottic area
operates as a filter by means of resonance. Depending
on the configuration of the supraglottis, which is directly
related with the opening of the mouth, the position of the
tongue, pharyngeal constriction, and the palate, different
harmonic groups are amplified; this generates the formants
and voice quality.
The supraglottic plane is an important aspect of
voice; it should be characterized when assessing and
treating dysphonic individuals, since these patients use
compensatory strategies when producing voice to overcome anatomic and/of functional alterations.2 Medical and
phonoaudiological research, however, has focused mainly
on laryngeal images, and generally have not taken in to
account the supraglottic plane.
Many papers have been written on the supraglottic
plane in normal individuals,3-11,13,14 but few have studied
dysphonic subjects.2,15-18
Patients with specific vocal fold lesions often benefit
from the possibility that vocal tract plasticity may change
the acoustic features of voice. This is also evident when
the voice of patients improves markedly following speech
therapy, although images of the glottis are unchanged.
Because similar glottic configurations in dysphonic
patients may yield different qualities of voice, it was thought that possibly the supraglottic tract may be responsible
for such differences in voice. The question, then, was
How could similar glottic images generate voices that
were so different?
With this in mind, there was an interest in studying
the behavior of the vocal tract in dysphonic female patients diagnosed with similar vocal fold nodules, cysts
and clefts.
OBJECTIVE
The purpose of this study was to verify the frequency and to compare the adjustments made by the supraglottic tract in three groups of female dysphonic patients
diagnosed with nodules, clefts and cysts, and with a similar
glottic configuration, using nasofibrolaryngoscopy.
METHOD
The Research Ethics Committee of the Pontificia
Universidade Catolica de So Paulo approved this study
(no 0164/2003).

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were instructed to issue the prolonged vowel /a/ and to

speak spontaneously. Examinations were recorded on VHS
tape using a JVC super VHS videocassette recorder.
Examinations (direct laryngoscopy) were shown separately at a later moment to two other otorhinolaryngologists. The reports were compared, and those with the same
diagnosis were kept in the sample. Of 40 examinations
with coincident reports, otorhinolaryngologists selected
those with similar glottic findings: the same types of clefts
of proportional sizes, the same types of lesions with the
same types of associated clefts, similar size and shape and
similar location on vocal folds. As a result of this process,
nine examinations were excluded; thus, 31 examinations
were left, which were allocated to three groups according
to the similarities. The first group consisted of examinations with bilateral nodules (group 1); the second group
consisted of examinations with cysts (group 2); and the
third group consisted of examinations with clefts (group 3).
The similarity of examinations is of extreme importance in
this study; the choices, thus, was done using this method,
rather than clinical incidence.
Three otorhinolaryngologists and three speech therapists assessed the nasofibrolaryngoscopy examinations
in each of the abovementioned three groups. These professionals had more than five years of experience each in

the study of voice, to provide reliability in judgment.

A protocol adapted to this study was applied to
investigate the following conditions: presence or absence
of supraglottic constriction; vertical motility of the larynx;
presence or absence of pharyngeal constriction; and position of the tongue.
The results of the visual analysis were analyzed
descriptively, followed by a statistical analysis consisting
of a comparison with the Kruskal-Wallis test to verify the
differences among groups. The significance level was 5%
(p= 0.050).
RESULTS
There were 31 female patients allocated to three
groups, as follows: 10 patients diagnosed with nodules, 10
patients diagnosed with clefts, and 11 patients diagnosed
with cysts. Table 1 shows the result of the visual analysis
in the three groups.
A comparative analysis was done by applying the
Kruskal-Wallis statistical test for the adjustments found in
each group; there was no statistically significant difference
among the groups. The adjustments that were observed in
subjects while issuing a sustained vowel and connected
speech (Table 2).

Table 1. Description of the visual analysis (nasofibrolaryngoscopy) of the frequency of supraglottic vocal tract adjustments in three groups
(nodules, clefts, cysts).
Nodules

clefts

cysts

No constriction

30

40

27,3

Middle constriction

10

18,2

Antero-posterior constriction

60

50

36,3

Antero-posterior and middle constriction

10

18,2

Supraglottic constriction:

Vertical laryngeal motility:

ample

20

10

medium

30

60

27,3

restricted

50

30

72,7

no constriction

40

60

45,5

amplified

circular constriction

30

20

36,3

lateral constriction

30

20

18,2

10

30

Pharynx:

Tongue:
anterior
neutral

90

70

11

100

total

10

100

10

100

11

100

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which is similar to that found in other studies.3-6,15,16,21

Other papers have also included only female subjects, probably because dysphonia is more prevalent in
this sex.4,6,15,16,21
Campiotto,4 Campos,5 and Titze et al.8 studied professionals that depend on their voice. In our study, 23 of 31
subjects were professionals that depended on their voice;
11 were teachers and the others were secretaries, salespersons, a lawyer, a telemarketing operator, singers and
actresses. It is thought that supraglottic tract adjustments
occur more often in such professionals, since benefits
may accrue at times from the use of voice. It is common
to see teachers using pharyngeal constriction to help project their voices. Singers usually undertake adjustments of
pharyngeal constriction, antero-posterior constriction and
ample laryngeal vertical motility to increase the volume of
their voices, to project their voices, or to sing a specific
type of music; and actors may move their tongues in many
ways to yield different types of voices. These efforts are
generally not seen in subjects that do not use their voices
professionally for speaking or singing.
The following parameters were noted in the visual
analysis of the supraglottic vocal tract: supraglottic constriction, laryngeal motility, pharyngeal constriction, and
position of the tongue. Studies that also assessed these
points were those of Campiotto4 (of singers), Campos5
and Bezerra6 (of actors), and Denunci22 (of children,
comparing voice quality before and after adenoidectomy
and tonsillectomy.
The visual analysis revealed a marked variety in
adjustment frequency in the three groups (Table 1). Adjustments of the tract were not specific for a given glottic configuration; thus, the features of the supraglottic tract could
not be correlated with each type of glottic change.
An attempt was made in this study to observe
whether specific glottic configurations correlated with
specific adjustments of the supraglottic tract. However,
the comparison of adjustments found in the three groups
revealed no statistically significant differences among them
(Table 2). Individual behaviors generate the adjustments
that explain different voice qualities in patients with the
same type of laryngeal condition. Hara and Velosos15 study
suggests this possibility.
It should be noted that during the visual analysis
of supraglottic adjustments, the researchers realized the
importance of carrying out nasofibrolaryngoscopy in the
diagnosis and treatment of dysphonic subjects, as well as
videolaryngostroboscopy. Unfortunately, an assessment of
supraglottic structures is rarely done in medical routine;
however, a diagnosis of supraglottic adjustments is important in the care of dysphonic subjects, especially those that
use their voice professionally.
This study was an attempt to focus on the supraglottic tract, rather than looking at glottic alterations, given

Table 2. Description of the comparison among groups of adjustments when issuing a sustained vowel and connected speech, followed by the significance level (p < 0.050)
ADJUSTMENT

Significance (p)

No supraglottic constriction

0.815

Middle supraglottic constriction

0.619

Antero-posterior supraglottic constriction

0.644

Ample laryngeal motility

0.313

Medium laryngeal motility

0.573

Restricted laryngeal motility

0.229

Pharynx with no constriction

0.660

Amplified pharynx

1.000

Circular pharyngeal constriction

0.988

Lateral pharyngeal constriction

0.518

Ample tongue

0.125

Neutral tongue

0.125

Tongue with elevated dorsum

1.000

Kruskal-Wallis test

DISCUSSION
A daily clinical observation of dysphonic patients
with similar diagnoses and different qualities of voice
generated an interest in verifying whether the status of
the supraglottic plane could explain such differences.
Subjects work in different professions and have unique
individual behaviors and anatomic features. The first
challenge, therefore, was to select subjects with similar
glottic features. This difficulty meant that there were only
31 subjects in the study sample, which were allocated to
three groups according to the glottic configuration. These
groups were defined based on the aim of investigating
whether subjects had similar or dissimilar behaviors of
the supraglottic plane.
The sample consisted only of females because of
the high rate of dysphonia in women. Differences in glottic
proportions, and the length and shape of the supraglottic
tract were the reasons why both sexes were not chosen.
Three otorhinolaryngologists and three speech
therapists with expertise in voice carried out the visual
analysis of the supraglottic tract. A consensual assessment
was chosen to increase the reliability of the results. The
referees found it difficult to assess the type of pharyngeal
constriction and especially the position of the tongue
during the visual analysis. A joint evaluation was very
relevant, underlining the importance of multidisciplinary
work in which knowledge exchanges and reflection leads
to novel approaches and professional development in both
areas of expertise.
The age in the sample ranged from 20 to 45 years,

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that the tract is usually left aside. Voice is the product of

a connection between a source (glottis) and a filter (vocal
tract); voice quality, thus, should not be correlated only
with glottic changes.
This study revealed a deficiency in the use of
available methods and a need to create new protocols to
evaluate all aspects of voice.

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Paulo, 2003 (Monografia de Especializao - Irmandade Santa Casa
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Am.1998:104(1):471-87.
8. Titze IR, Story BH. Acoustic interaction of voice source with the lower
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CONCLUSION
A visual analysis of the supraglottic tract in dysphonic women with different glottic configurations revealed
that:
Adjustments of the tract are not specific for a certain
glottic configuration, and the features of the supraglottic
tract may not be correlated with each type of glottic alteration.
No statistically significant difference was found in
a comparison of adjustments found in the three groups.
Individual behaviors generate such adjustments, which
explains the different qualities of voice in patients with
the same type of laryngeal condition; therapy should, thus,
be individualized.
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