Robert T. Sataloff, M.D., D.M.A.

Vocal Fold Hypomobility

Yolanda D. Heman-Ackah and Robert T. Sataloff

ANATOMY AND FUNCTION with voice production except the cricothyroid muscles span the space OF THE LARYNX cricothyroid muscle. The joint space between the cricoid and thyroid car- between the arytenoid cartilage and tilages on the sides of the larynx. To- The movements of the vocal folds the cricoid cartilage is the cricoary- gether the thyroarytenoid muscle, its of the larynx are coordinated by the tenoid joint. It is critical that the joint specialized mucosal membrane, and activities of the muscles of the larynx, space between the arytenoid and its attachment onto the vocal process the cartilages of the larynx, and the cricoid cartilage is mobile and allows of the arytenoid cartilage are referred nerves that supply the muscles of the a full range of motion of the ary- to as the vocal fold or true vocal fold. larynx. l The larynx sits above the tenoids. If this cartilaginous joint be- The vocal folds come together and trachea and in front of the esophagus. comes immobile, the arytenoid carti- meet in the midline when the thy- The larynx has two identical sides that lage can not move well. Limited roarytenoid, interarytenoid, lateral form a mirror image of each other and mobility of the arytenoid cartilage im- cricoarytenoid, and cricothyroid mus- l is composed of cartilage, muscle, and pairs the mobility of the vocal folds. cles contract. These muscles help to mucous membranes. The muscles of the larynx attach bring the vocal folds together during The cartilage provides the struc- to the cartilages in different lo- swallowing and prevent the passage of tural support for the muscles and mu- cations. The main muscles of the lar- food particles and liquids into the tra- cous membranes similarly to the way ynx are the thyroarytenoids, the chea. Additionally, the laryngeal mus- in which the framework of a house posterior cricoarytenoids, the lateral cles contract to bring the vocal folds provides support for the walls and cricoarytenoids, the interarytenoids, together in voice production. When floors. The main cartilages of the lar- and the cricothyroids. Each side of air is pushed from the lungs past the ynx are the thyroid, cricoid, and ary- the larynx has a thyroarytenoid, a closed vocal folds, a sound is made. tenoid cartilages. The arytenoid carti- posterior cricoarytenoid, and a later- This sound is the voice. If the vocal lages sit on top of the cricoid cartilage al cricoarytenoid muscle. The inter- folds are able to make good contact, and serve as points of attachment for arytenoid muscles sit in the midline and if the movement of the mucosal all of the muscles that are involved of the back of the larynx, and the cover is normal, a clear sound is made.

ϑουρναλ οφ Σινγινγ, Μαρχη/Απριλ 2002 ςολυμε 58, Νο. 4, ππ 321 − 327 Χοπψριγητ 2002 Νατιοναλ Ασσοχιατιον οφ 321 Τεαχηερσ οφ Σινγινγ Yolanda D. Heman-Ackah and Robert T. Sataloff

When the cricothyroid and thy- After the superior laryngeal tient attempts to vocalize. The air roarytenoid muscles contract, they nerve branches, the vagus nerve from the lungs that is normally tense the vocal fold.l When there is a travels into the chest to supply neural trapped below the vocal folds during lot of tension on the vocal fold, a high- innervation to the heart, where it phonation is able to leak through this pitched sound is produced. When helps regulate heart rate and blood gap. The turbulent flow of air there is less tension on the vocal fold, pressure. While in the chest, the re- through the gap produces the sound lower-pitched sounds are produced. current laryngeal nerve separates that is perceived as breathiness. As When the posterior cricoarytenoid from the vagus nerve and courses air from the lungs continues to leak muscle contracts, it pulls the vocal back into the neck, where it enters through the vocal folds, prolonged folds open. The vocal folds open to the larynx. In the larynx, the recur- phonation becomes more effortful. allow the entrance of air into the air- rent laryngeal nerve supplies motor Many describe this sensation as vocal way when a breath is taken and to function to the thyroarytenoid, inter- fatigue. provide breaks between sounds dur- arytenoid, posterior cricoarytenoid, The vocal folds also help to pro- ing phonation. and lateral cricoarytenoid muscles. tect the lungs and the trachea from The larynx receives neural sup- The recurrent laryngeal nerve also aspiration of food and liquids during ply from two nerves, the superior la- supplies sensation to the vocal folds swallowing. If they are unable to ryngeal nerve and the recurrent la- and to the portions of the larynx and close completely during swallowing, ryngeal nerve. The superior laryngeal trachea below the vocal folds. aspiration may occur. If the sensation nerve supplies motor function to the of the vocal folds and trachea is cricothyroid muscle and sensation to normal, choking or coughing may oc- the parts of the larynx above the vo- SYMPTOMS OF VOCAL cur each time food or liquid is aspi- cal folds. The recurrent laryngeal FOLD HYPOMOBILITY rated. If the sensation is not working nerve supplies motor function to the correctly, aspiration may occur with- remaining muscles of the larynx and A patient who has decreased vo- out signs of choking or coughing, a sensation to the vocal folds and the cal fold mobility will likely experi- phenomenon commonly referred to ence problems with hoarseness, a parts of the larynx below the vocal 2 as "silent aspiration." Whether or not folds. breathy voice, and/or vocal fatigue. the sensation in the nerve is affected The recurrent laryngeal nerve Hoarseness is sometimes perceived depends on whether the mobility and the superior laryngeal nerve are because of abnormal strain in the problems are due to nerve dys- branches of the vagus nerve. Each of muscles around the larynx as the pa- function or other causes and on these nerves is paired, with one of tient tries to bring the vocal folds to- whether the sensory portions of the the pair on each side of the neck and gether. This excess muscle tension nerve are affected by the same prob- larynx. The vagus nerve branches di- may sometimes result in false vocal lem that is limiting the motor func- rectly off the brainstem, the portion fold phonation, which has a more tion of the nerve. of the brain at the base of the skull. raspy or hoarse quality than normal The vagus exits the base of the skull true vocal fold phonation. A breathy and enters the neck, where it branch- quality is produced as a result of air DIAGNOSIS OF VOCAL es twice. The superior laryngeal escape through the incompletely FOLD HYPOMOBILITY nerve is the first branch. It courses closed vocal folds. When there is into the larynx above the thyroid car- paresis (weakness) or paralysis (im- Patients with movement disor- tilage and divides into the internal mobility due to complete nerve dam- ders of the larynx may have com- and the external branches. The inter- age) of the vocal fold, the normal vo- plaints that range from hoarseness, nal branch supplies sensation to the cal fold must compensate for this breathiness with phonation, and vo- portions of the larynx above the vo- weakness by closing to the midline, cal fatigue to problems with swallow- cal folds. The external branch sup- and sometimes closing past the mid- ing, choking, shortness of breath, and plies motor function to the cricothy- line, to meet the other vocal fold. If it aphonia. The patient who has these roid muscle. is unable to do this, there is a gap complaints is generally evaluated by between the vocal folds when the pa the otolaryngologist (an ear,

322 LaryngoSCOPE nose, and throat doctor) or pain, although it may cause a slight lage to a lesser degree, resulting in laryngologist (an ear, nose, and discomfort in the nose. The patient is tilting of the larynx towards the side throat doctor who specializes in seated and awake during the exami- of the weak superior laryngeal nerve treating disorders of the larynx). The nation. The flexible laryngoscope and cricothyroid muscle. physician may ask the patient many al-lows the physician to see the If there are problems with both questions about the symptoms to larynx in its natural position, superior laryngeal nerves, there will help exclude other possible causes without the distortion that be limitations in the ability to pro- and to help narrow the potential list sometimes occurs with holding the duce a high pitch and in the ability to of problems. tongue forward for mirror and rigid stretch the vocal folds on both sides.2 After the physician has telescopic examinations. In viewing This diagnosis may be somewhat dif- completed taking a history of the the larynx in its natural position, the ficult, especially if both nerves are in- patient's problems, he/she will physician can assess changes in jured to the same degree. Both vocal examine the patient. The physical laryngeal muscle tension while the folds will have limitations in their examination will include a complete patient is talking or singing. There abilities to stretch, making the ability evaluation of all of the structures of are certain vocal maneuvers that the to see subtle abnormalities difficult the head and neck .3 This complete otolaryngologist/ laryngologist will for the examiner. examination is performed because ask the patient to perform during the Occasionally, with superior la- there are some disorders that affect flexible laryngoscopic examination. ryngeal nerve paresis, there is seen many different regions of the head These include various tasks of an abnormality in the ability of the and neck, and they all should be talking, singing, and whistling.3,4 vocal fold on the affected side to assessed. While the patient is per-forming adduct (bring the vocal folds towards Examination of the larynx is these maneuvers, the oto- the midline). Sluggish adduction of initially performed with a light and laryngologist/laryngologist is evalu- the vocal fold is best seen when the mirror. The mirror is often warmed ating the motion and mobility of the patient tries to engage in vocal ma- first with water, a flame, or heated vocal folds. neuvers that involve a rapid move- beads to prevent it from fogging dur- The patient will be asked to ment of the vocal folds.3 These vocal ing the examination. The tongue is per-form several tasks that require maneuvers involve performing such often held forward, and the mirror is stretching and lengthening the vocal repetitive tasks as saying /i/-/hi/, al- placed into the mouth and positioned folds. These tasks may include ternating a quick sniff with saying above the back of the tongue to per- counting at several different pitches /i/, and saying /pa/-/ta/-/ka/.3 Be- mit adequate visualization of the lar- and/or sliding from a low pitch to a cause the ability to do these maneu- ynx. On examination with the mir- high pitch while saying the sound vers involves the rapid movement of ror, the physician may see obvious /i/.3 If there is a primary problem in the vocal folds, subtle differences in movement disorders of the larynx. the superior laryngeal nerve, this vocal fold motion are easily revealed. Because subtleties in movement dis- will be evidenced by an inability to If the recurrent laryngeal nerve orders are difficult to assess with lengthen the vocal fold with high- is injured, there may be abnormali- mirror examination, the otolaryngol- pitched phonation.2 If the weakness ties in adduction or abduction ogist will almost always perform ei- is severe, there can be a tilt of the (opening the vocal folds). The ther flexible or rigid laryngoscopy, or larynx towards the side of the posterior cricoarytenoid muscle both, for better examination of the weakened superior laryngeal nerve performs the abductor functions of mobility and structure of the vocal and/or cricothyroid muscle.2 The the vocal folds. The thyroarytenoid, folds.1,3,4 larynx tilts to-ward the side of the interarytenoid, and lateral weakness on lengthening because cricoarytenoid muscles perform the Flexible Laryngoscopic the cricothyroid muscle on the adductor functions. Abnormalities in Examination normal side pulls the thyroid adduction are evaluated by the same A flexible laryngoscope is a thin, cartilage anteriorly (forward) and maneuvers as stated above. lighted telescope (endoscope) that is down toward the cricoid cartilage; Differentiating problems with the placed through the nose and into the the paretic cricothyroid muscle is superior laryngeal nerve versus the throat and usually does not cause weak and pulls the thyroid carti recurrent laryngeal nerve when

Μαρχη/Απριλ 2002 323 Yolanda D. Heman-Ackah and Robert T. Sataloff

limited adduction is seen can be dif- long as there is not associated muscle ETIOLOGY OF VOCAL ficult. In general, if the problem is or nerve injury. This muscular effort FOLD HYPOMOBILITY with the superior laryngeal nerve, is typically seen as a tensing of the one should also see problems with thyroarytenoid muscle during vocal Vocal fold mobility can be affected tensing and stretching the vocal maneuvers without a concomitant by disorders of the cricoarytenoid folds. If the problem is with the re- change in the position of the vocal joint, the parts of the brain and nerves current laryngeal nerve, problems fold. that supply the larynx, or the muscles with adduction alone or in combina- of the larynx. tion with abduction, but not tensing Rigid Strobovideolaryngoscopy or stretching the vocal folds, should Cricoarytenoid Joint Disorders 23 Rigid strobovideolaryngoscopy be seen. > allows a more magnified and optically The cricoarytenoid joint can be- Abnormalities in abduction are superior view of the vibratory come immobile from inflammatory frequently evaluated by having the function and structure of the vocal processes in the joint space. These patient sniff and by having the pa- fold.4 Strobovideolaryngoscopy in- processes can include such entities as tient whistle.3 Both of these maneu- volves the use of synchronized flash- rheumatoid arthritis, gout, other vers require that the vocal folds open ing lights through the telescope to arthritides, trauma, arytenoid carti- in very brisk maneuvers. If the recur- evaluate the function of the mucosal lage dislocation during endotracheal rent laryngeal nerve is injured at its wave of the vocal fold. This procedure intubation, laryngeal fracture, and insertion into the posterior cricoary- is performed with a rigid telescope surgical manipulation in the region of tenoid muscle, the vocal fold will have 513 placed through the mouth with the the arytenoid cartilages. - In- problems with abduction. If the injury tongue held forward. The patient is flammation causes problems with to the nerve occurs at the level of the awake and seated in a forward po- joint mobility similar to the way in- thyroarytenoid or lateral crico- sition during the examination. The flammation in the fingers of the hand arytenoid muscles, there will be iso- chin is held slightly upright in a can cause problems with movement lated abnormalities in vocal fold ad- "sniffing" position, which helps to pull of the joint spaces there. Inflamma- duction. If there is a problem with the the base of the tongue forward so tion causes scarring of the tissues nerve at any point before it enters the that the larynx can be viewed more around the joint. When the tissues larynx, there will be abnormalities in easily. Occasionally, a sensation of are scarred, they inhibit the ability of both abduction and adduction. gagging is experienced during the the cartilages to move within the joint When the muscles are examination; otherwise, the exami- space, resulting in decreased mobility. completely paralyzed or near totally nation does not cause much discom- paralyzed, the vocal folds do not fort. This magnified view of the vocal Muscle Disorders move on the side that is affected; folds can give the physician informa- however, a Jostle's sign is seen.3 A Dysfunction of the muscles of tion regarding structural lesions on Jostle's sign is a movement of the the larynx can cause abnormal vocal the vocal folds that may contribute to arytenoid on the affected side during fold mobility also. Laryngeal myas- the vocal complaint or that have vocalization. The passive movement thenia gravis, amyloidosis, edema, arisen as a result of the paresis. Once of the arytenoid on the affected side myositis, muscle atrophy, and muscu- a movement disorder of the larynx is occurs as a result of contact with the lar dystrophies are some of the disor- identified, laryngeal electromyogra- other arytenoid, which presses ders that may affect muscle function. phy (LEMG) is ordered to help exam- against it during adduction. The result is vocal fold hypomobility. ine more accurately the integrity of If the abnormality is in the Myasthenia gravis is a disorder the neuromotor (the nerve and mus- movement of the cricoarytenoid joint of the neuromuscular junction. My- cle) system. Laboratory studies, biop- and not in the vocal fold muscles or asthenia gravis can occur in multiple sies, and imaging studies may help nerves, the vocal fold will be hypo- muscle systems throughout the body guide the diagnosis and management mobile as well. There will be evidence or it can occur as an isolated entity in of movement disorders as well. of some muscular effort as the larynx.11,14,15 The primary disor- der in myasthenia gravis is that the

324 LaryngoSCOPE body makes antibodies to the recep- the body. Accumulation in the larynx nerve can occur anywhere along tors on the muscle to which acetyl- adds to the weight of the muscles, in- their courses from the brainstem to choline binds.15 Antibodies are pro- hibiting their mobility. the larynx. The term paresis denotes teins that the immune system in the Edema can also create a mass ef- weakness and is the term used to de- body makes routinely, whose main fect on the muscles of the larynx and scribe the function of a nerve that is functions are to recognize foreign result in abnormalities in vocal fold partially injured and partially func- materials, like bacteria and viruses, mobility. Edema is frequently a result tioning. The term paralysis is used to and to rid the body of these foreign of inflammation. Any kind of trau- describe total absence of neural func- materials. Occasionally, and for un- ma, such as irradiation, infection, tion. Injury to the vagus, superior la- known reasons, the immune system penetrating injuries, and blunt in- ryngeal, and recurrent laryngeal mistakenly recognizes normal tissues juries to the neck and larynx, can nerves can be the result of infection, as foreign, and makes antibodies cause edema. compression, metabolic abnormali- against them, a condition referred to Myositis is an abnormal inflam- ties, or direct injury. Infection typi- as an autoimmune disorder. Myas- mation localized to the muscle. In- cally results from viruses such as the thenia gravis is an autoimmune dis- flammatory blood cells accumulate herpes virus." Infection of the nerve order in which the antibodies attack in the muscle, and an inflammatory may also result from the bacteria that and destroy the neuromuscular junc- reaction, characterized by tender- cause syphilis and Lyme disease.21,22 tions of muscles. This destruction re- ness, increased blood flow, increased Compression of the nerve can occur sults in an inability of the muscle to fluid, and increased inflammatory in response to abnormal masses that receive signals from the nerve. When cells, ensues. Myositis can occur in press against the nerve, such as lung this occurs, the muscle is unable to response to trauma or infection, but cancer, lymphoma, metastatic can- contract fully in response to neural sometimes is idiopathic.11,15,20 The cer, thyroid tumors, or other tumors impulses, and there is paresis and inflammatory fluid and the damage of the skull base, neck, or chest. possibly paralysis of the muscle. Be- to the muscle membrane from the in- Aneurysms, which are abnormal di- cause only those neuromuscular flammation can interfere with the latations of the blood vessels, may al- junctions that come in contact with normal transmission of electrical im- so enlarge and cause compression of the abnormal antibodies, which are pulses from the nerve through the the nerves. Direct injury to the nerve present sporadically in the blood, are muscle, causing hypomobility of the may occur during surgery, during attacked in myasthenia gravis, there vocal fold. penetrating or blunt trauma to the are some muscles and muscle fibers Muscular dystrophies are genet- neck, chest, or skull base, or as a re- that are unharmed. This results in ic disorders that are characterized by sult of endotracheal intubation. De- variability in the muscles' abilities to abnormal muscle metabolism.'5 pending upon how much injury is contract once signaled. With laryn- Eventually, muscle atrophy ensues in caused, each of these mechanisms geal myasthenia gravis, this typically many muscles throughout the body, can cause paresis or paralysis of the is seen as fluctuating asymmetries in including the larynx.11,20 As the nerves that supply the larynx. the ability of the vocal folds to move muscles in the larynx atrophy, they Metabolic abnormalities that can quickly. begin to lose their strength and are cause disorders in the nerves include Amyloidosis is a generalized no longer able to move as quickly as diabetes mellitus and thyroid systemic disorder that can involve normal or to produce the same de- hormone abnormalities. The abnor- the larynx and can also involve other gree of muscle tension, resulting in mal nerve function caused by thyroid tissues in the body, most commonly sluggish and bowed vocal folds. abnormalities is sometimes rever- the kidneys.'5-19 An abnormal accu- sible; however, that caused by dia- mulation of a ground substance that Nerve Disorders betes mellitus is usually irreversible. contains antibodies is deposited in Primary neural disorders may The exact mechanism by which thy- the tissues of the body in amyloido- also cause decreased vocal fold mobil- roid hormone abnormalities cause sis. This substance is amorphous and ity. Injury to the superior laryngeal nerve dysfunction is not fully under- is somewhat like gelatin in the way nerve and/or the recurrent laryngeal stood, but usually reverses once the that it accumulates in the tissues of

Μαρχη/Απριλ 2002 325 Yolanda D Heman-Ackah and Robert T. Sataloff abnormality is corrected.11,23-25 Dia- fibers. When regeneration occurs, usually is enough for the muscle to betes mellitus is thought to cause nerve some of the fibers may misconnect maintain its tone and avoid atrophy. dysfunction through its effects on and connect with nerve fibers that blood flow to the nerves. Diabetes neighbor their original ending with- causes long-term nerve problems be- in the nerve sheath, a process called CONCLUSION cause it results in the abnormal accu- synkinesis. When synkinesis occurs, mulation of glucose and its metabolites impulses that the brain tries to send Vocal fold hypomobility can re- in the smaller vessels that supply the to one muscle may be directed sult from a myriad of disorders of nerves, which eventually occlude the through this misconnection to anoth- nerves, muscles, or cricoarytenoid vessel lumen.15,26 When the blood er muscle. For instance, the recurrent joint function. Vocal fold hypomobili- supply to the nerves is diminished, the laryngeal nerve innervates both the ty may manifest with symptoms that nerves begin to lose their function. posterior cricoarytenoid muscle and range from breathiness, vocal fatigue, Compression, infection, and the thyroarytenoid muscle. If the re- and decreased range to aphonia, aspi- nerve injury cause nerve dysfunction current laryngeal nerve is injured and ration, and shortness of breath. La- because they cause inflammation of synkinesis occurs, the posterior ryngeal electromyography, imaging the protective sheath that surrounds cricoarytenoid muscle may be rein- studies, biopsies, and laboratory stud- the nerve. The structure of the nerve nervated by nerve fibers that origi- ies may aid in the diagnosis of the eti- within this sheath is similar to the nally innervated the thyroarytenoid ology of the disorders. Management structure of a sausage with-in its muscle. Normally, when the brain of vocal fold hypomobility varies, de- skin. When the sheath becomes signals the thyroarytenoid muscle to pending upon the identification of the inflamed, it swells. This swelling de- contract for speech, it signals the pos- causative disease process, and can creases the diameter within the terior cricoarytenoid muscle to relax include medical, surgical, or rehabili- sheath and impinges on the nerve so that the vocal folds can come to- tative voice therapies. that it encases. As this swelling gether. After synkinesis, the signal squeezes the nerve, it becomes more from the brain to the thyroarytenoid difficult for electrical impulses to muscle may be rerouted to the poste- NOTES pass through, which results in weak- rior cricoarytenoid muscle via this ness of the muscles innervated by the misconnection. When the person tries 1. R. T. Sataloff, "The Human nerve. As long as the constriction is to speak, the posterior cricoarytenoid Voice," Scientific American 267 (1992):108-15. not severe and the nerve remains in- muscles will contract, opening the tact in the face of the swelling, the vocal folds and causing a breathy 2. G. Dursun et al., "Superior function of the nerve will eventually voice. Laryngeal Nerve Paresis and return as the swelling subsides and If the nerve is severed during Paralysis,"Journal of Voice 10 the structures within the nerve are surgery or as the result of neck trau- (1996):206-11. regenerated. ma, paralysis of the muscles inner- If swelling is severe, it may com- vated by the nerve will result. Unless 3. R. T. Sataloff, "The Professional pletely constrict the nerve and cause the nerves are surgically reconnected, Voice: Physical Examination," Jour- the part of the nerve with the most reinnervation is unlikely to occur nal of Voice 1 (1987):191-201. severe constriction to die, as though it spontaneously and permanent paral- had been strangled. If this occurs, as ysis will ensue. In general, the ab- 4. R. T. Sataloff, J. R. Spiegel, and M. long as the sheath remains intact, the sence of innervation results in muscle J.Hawkshaw, Strobovideolaryngoscopy: Results nerve will regenerate when the atrophy and degeneration. If surgical and Clinical Value," Annals of swelling decreases, and it will use the reinnervation is performed, it likely Otolaryngology, Rhinology, and inside of the sheath as a "highway" to will result in synkinesis for similar Laryngology 100 (1991):725-27. find the other intact end of the nerve. reasons as explained above. Even Each nerve within a nerve sheath with synkinesis, however, the neural 5. A. Grossman, J. R. Martin, and H. contains hundreds of nerve input received by the muscle S. Root, "Rheumatoid Arthritis of the Crico-arytenoid Joint," Laryngoscope 71 (1961):530-44.

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6. I. A. Polisar, "The Crico-arytenoid 16. H. Hellquist et al., "Amyloidosis of 26. C. R. Shuman and B. Weissman, Joint. A Diarthrodial Articulation the Larynx," Acta Otolaryngologica "Recurrent Laryngeal Nerve In- Subject to Rheumatoid Arthritic In- (Stockholm) 88 (1979):443-50. volvement as a Manifestation of volvement," Laryngoscope 69 (1959): Diabetic Neuropathy," Diabetes 17 1129-64. 17. A. M. Berg et al., "Localized Amy- (1968):302. loidosis of the Larynx: Evidence for 7. M. W. Bridger, A. F. Jahn, and A. Light Chain Composition," Annals W. van Vostrand, "Laryngeal of Otolaryngology, Rhinology, and______Rheumatoid Arthritis," Laryngology 102 (1993):884-89. Yolanda D. Heman-Ackah, MD., is Assis- Laryngoscope 90 (1980):296-303. tant Professor of Laryngology and Profes- 18. J. D. Bennett and C. R. Chowdhury, sional Voice Care in the Department of 8. G. V. Lawry et al., "Laryngeal In- "Primary Amyloidosis of the Lar- Otolaryngology—Head and Neck Surgery volvement in Rheumatoid Arthritis. ynx," Journal of Laryngology and at the University of Illinois at Chicago. She A Clinical, Laryngoscopic, and Otology 108 (1994):339-40. is the director and founder of the Voice Computerized Tomographic Study," Center at the University of Illinois at Arthritis and Rheumatology 27 19. J. E. Lewis et al., "Laryngeal Amy- Chicago. She has authored and coauthored (1984):873-82. loidosis: A Clinicopathologic and numerous publications in the fields of Immunohistochemical Review," Oto- laryngology and professional voice care, 9. M. Goodman, W. Montgomery, and laryngology Head and Neck Surgery including award-winning scientific journal L. Minette, "Pathologic Findings in 106 (1992):372-7. articles, book chapters, and a book. Gouty Cricoarytenoid Arthritis," Archives of Otolaryngology 102 20. S. Mandel et al., "Laryngeal EMG: (1976):27-9. Electromyographic Evaluation of Vocal Fold Disorders," Journal of Robert Thayer Sataloff, MD., D.M.A., is 10. F. R Paulsen, K. Jungmann, and B. Singing 55, no. 2 (Nov/Dec 1998): Professor of Otolaryngology—Head and N. Tillmann, "The Cricoarytenoid 43-8. Neck Surgery, Thomas Jefferson University; Joint Capsule and its Relevance to Chairman, Department of Otolaryngolo- Endo-tracheal Intubation," 21. R. Rabkin, "Paralysis of the Larynx gy—Head and Neck Surgery, Graduate Anesthesia and Analgesia 90 Due to Central Nervous System (2000):180-85. Syphilis," Eye, Ear, Nose, and Throat Hospital; Adjunct Professor, Department of Monthly 42 (1963):53. Otorhinolaryngology, University of Penn- 11. R. T. Sataloff, Professional Voice: sylvania; Adjunct Professor, Department The 22. C. Neuschaefer-Rube et al., "Ein- of Otolaryngology—Head and Neck Science and Art of Clinical Care, 2nd seitige Rekurrensparese bei Verdacht Surgery, Georgetown University School of auf Lyme-borreliose." (Unilateral ed. (San Diego, CA: Singular Pub- Medicine; and Chairman, The Voice lishing Group, 1997). Recurrent Nerve Paralysis in Suspected Lyme Borreliosis), Hals, Foundation; and Chairman, The American Institute for Voice and Ear Research. He 12. R. T. Sataloff et al., "Arytenoid Dis- Nasen, Ohrenheilkunde 43 (1995): 188-90. location," Journal of Voice 1 (1987): has authored more than 500 publications, 368-77. including twenty books. 23. A. J. McComas et al., "Neuropathy in Thyrotoxicosis," New England 13. R. T. Sataloff, I. D. Bough, and J. Journal of Medicine 289 (1973):219- R. Spiegel, "Arytenoid Dislocation: 21 Diagnosis and Treatment," Laryn- goscope 104 (1994):1353-61. 24. A. Misiunas et al., "Peripheral Neu- REPRINTED BY PERMISSION 14. R. F. Nieman, J. R. Mountjoy, and ropathy in Subclinical Hypothy- OF THE NATIONAL ASSOCIA- E. L. Allen, "Myasthenia Gravis roidism," Thyroid 5 (1995):283-86. TION OF TEACHERS OF Focal to the Larynx. Report of a SINGING, INC. Case," Archives of Otolaryngology 101 25. C. F. Torres and R. T. Morley, (1975):569-70. "Hypothyroid Neuropathy and Myopathy: Clinical and Electrodiag- 15. J. D. Wilson et al., eds., Harrison's nostic Longitudinal Findings,"Jour- Principles of Internal Medicine, 12th nal of Neurology 237 (1990):271-74. ed. (New York: McGraw-Hill, 1991).

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