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Home , Cricoarytenoid muscle, Cricoid cartilage, Cricothyroid muscle

LaryngoSCOPE

Vocal Fold Hypomobility

Yolanda D. Heman-Ackah and Robert T Sataloff

Yolanda D. Heman-Ackah, M.D. Robert T Sataloff, M.D.. D.M.A.

ANATOMY AND FUNCTION with voice production except the cricothyroid muscles span the space OF THE . The joint space between the cricoid and car- between the arytenoid and tilages on the sides of the larynx. To- The movements of the vocal the is the cricoary- gether the thyroarytenoid muscle, its folds of the larynx are coordinated by tenoid joint. It is critical that the joint specialized mucosal membrane, and the activities of the muscles of the lar- space between the artenoid and its attachment onto the vocal process ynx, the of the larynx, and cricoid cartilage is mobile and allows of the are referred the that supply the muscles of a full range of motion of the ary- to as the vocal fold or true vocal fold. the larynx. 'The larynx sits above the tenoids. If this cartilaginous joint be- The vocal folds come together and in front of the . comes immobile, the arytenoid carti- and meet in the midline when the thy- The larynx has two identical sides lage can not move well. Limited roarytenoid, interarytenoid, lateral that form a mirror image of each oth- mobility of the arytenoid cartilage im- cricoarytenoid, and cricothyroid mus- er and is composed of cartilage, mus- pairs the mobility of the vocal folds. cles contract. 1 These muscles help to cle, and mucous membranes. The muscles of the larynx at- bring the vocal folds together during The cartilage provides the struc- tach 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 . 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.

H4/AzL 2002 321 S. N. 4. tf. 21-21 2002 M*z,4 . T4 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 branches, the from the lungs that is normally tense the vocal fold.' When there is a travels into the chest to supply neur- trapped below the vocal folds during lot of tension on the vocal fold, a high- al innervation to the heart, where it 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 , 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 sensa- nerve supplies motor function to the tion 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- FOLD HYPOMOBILITY cal folds. The recurrent laryngeal rated. If the sensation is not working correctly, aspiration may occur with- nerve supplies motor function to the A patient who has decreased vo- remaining muscles of the larynx and out signs of choking or coughing, a cal fold mobility will likely experi- phenomenon commonly referred to sensation to the vocal folds and the ence problems with hoarseness, a parts of the larynx below the vocal as "silent aspiration." Whether or breathy voice, and/or vocal fatigue.2 not the sensation in the nerve is af- folds. Hoarseness is sometimes perceived The recurrent laryngeal nerve fected depends on whether the mo- because of abnormal strain in the bility problems are due to nerve dys- and the are muscles around the larynx as the pa- branches of the vagus nerve. Each of function or other causes and on tient tries to bring the vocal folds to- whether the sensory portions of the these nerves is paired, with one of gether. This excess muscle tension the pair on each side of the neck and nerve are affected by the same prob- may sometimes result in false vocal lem that is limiting the motor func- larynx. The vagus nerve branches di- fold phonation, which has a more tion of the nerve. rectly off the brainstem, the portion raspy or hoarse quality than normal of the brain at the base of the skull. true vocal fold phonation. A breathy The vagus exits the base of the skull quality is produced as a result of air DIAGNOSIS OF VOCAL and enters the neck, where it branch- escape through the incompletely FOLD HYPOMOBILITY es twice. The superior laryngeal closed vocal folds. When there is nerve is the first branch. It courses paresis (weakness) or paralysis (im- Patients with movement disor- into the larynx above the thyroid car- mobility due to complete nerve dam- ders of the larynx may have com- tilage and divides into the internal age) of the vocal fold, the normal vo- plaints that range from hoarseness, and the external branches. The inter- cal fold must compensate for this breathiness with phonation, and vo- nal branch supplies sensation to the weakness by closing to the midline, cal fatigue to problems with swallow- portions of the larynx above the vo- and sometimes closing past the mid- ing, choking, shortness of breath, cal folds. The external branch sup- line, to meet the other vocal fold. If it and aphonia. The patient who has plies motor function to the cricothy- is unable to do this, there is a gap be- these complaints is generally evaluat- roid muscle. tween the vocal folds when the pa- ed by the otolaryngologist (an ear,

322 LaryngoSCOPE nose, and throat doctor) or laryngolo- pain, although it may cause a slight lage to a lesser degree, resulting in gist (an ear, nose, and throat doctor discomfort in the nose. The patient is tilting of the larynx towards the side who specializes in treating disorders seated and awake during the exami- of the weak superior laryngeal nerve of the larynx). The physician may nation. The flexible laryngoscope al- and cricothyroid muscle. ask the patient many questions about lows the physician to see the larynx If there are problems with both the symptoms to help exclude other in its natural position, without the superior laryngeal nerves, there will possible causes and to help narrow distortion that sometimes occurs be limitations in the ability to pro- the potential list of problems. with holding the tongue forward for duce a high pitch and in the ability to After the physician has complet- mirror and rigid telescopic examina- stretch the vocal folds on both sides.2 ed taking a history of the patient's tions. In viewing the larynx in its This diagnosis may be somewhat dif- problems, he/she will examine the natural position, the physician can ficult, especially if both nerves are in- patient. The physical examination assess changes in laryngeal muscle jured to the same degree. Both vocal will include a complete evaluation of tension while the patient is talking or folds will have limitations in their all of the structures of the head and singing. There are certain vocal ma- abilities to stretch, making the ability neck.3 This complete examination is neuvers that the otolaryngologist/ to see subtle abnormalities difficult performed because there are some laryngologist will ask the patient to for the examiner. disorders that affect many different perform during the flexible laryngo- Occasionally, with superior la- regions of the head and neck, and scopic examination. These include ryngeal nerve paresis, there is seen they all should be assessed. various tasks of talking, singing, and an abnormality in the ability of the Examination of the larynx is whistling.34 While the patient is per- vocal fold on the affected side to initially performed with a light and forming these maneuvers, the oto- adduct (bring the vocal folds towards mirror. The mirror is often warmed laryngologist/laryngologist is evalu- the midline). Sluggish adduction of first with water, a flame, or heated ating the motion and mobility of the the vocal fold is best seen when the beads to prevent it from fogging dur- vocal folds. patient tries to engage in vocal ma- ing the examination. The tongue is The patient will be asked to per- neuvers that involve a rapid move- often held forward, and the mirror is form several tasks that require stretch- ment of the vocal folds. 3 These vocal placed into the mouth and positioned ing and lengthening the vocal folds. maneuvers involve performing such above the back of the tongue to per- These tasks may include counting at repetitive tasks as saying /i/-/hi/, al- mit adequate visualization of the lar- several different pitches and/or slid- ternating a quick sniff with saying ynx. On examination with the mir- ing from a low pitch to a high pitch /i/, and saying /pu/-/to/-/ku/.3 Be- cause the ability to do these maneu- ror, the physician may see obvious while saying the sound /i/.3 If there vers involves the rapid movement of movement disorders of the larynx. is a primary problem in the superior the vocal folds, subtle differences in Because subtleties in movement dis- laryngeal nerve, this will be evi- vocal fold motion are easily revealed. orders are difficult to assess with denced by an inability to lengthen If the recurrent laryngeal nerve mirror examination, the otolaryngol- the vocal fold with high-pitched ogist will almost always perform ei- is injured, there may be abnormali- phonation.2 If the weakness is se- ties in adduction or abduction (open- ther flexible or rigid laryngoscopy, or vere, there can be a tilt of the larynx ing the vocal folds). The posterior both, for better examination of the towards the side of the weakened su- cricoarytenoid muscle performs the mobility and structure of the vocal perior laryngeal nerve and/or crico- abductor functions of the vocal folds. folds.' thyroid muscle.2 The larynx tilts to- The thyroarytenoid, interarytenoid, ward the side of the weakness on and lateral cricoarytenoid muscles Flexible L.aryngoscopic lengthening because the cricothyroid perform the adductor functions. Ab- Examination muscle on the normal side pulls the normalities in adduction are evaluat- A flexible laryngoscope is a thin, anteriorly (forward) ed by the same maneuvers as stated lighted telescope (endoscope) that is and down toward the cricoid carti- above. Differentiating problems with placed through the nose and into the lage; the paretic cricothyroid muscle the superior laryngeal nerve versus throat and usually does not cause is weak and pulls the thyroid carti- the recurrent laryngeal nerve when

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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 affect- tensing and stretching the vocal maneuvers without a concomitant ed 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 current laryngeal nerve, problems fold. nerves that supply the larynx, or the with adduction alone or in combina- muscles of the larynx. tion with abduction, but not tensing or stretching the vocal folds, should Rigid Strobovideolaryngoscopy Cricoarytenoid Joint Disorders be seen.23 Rigid strobovideolaryngoscopy The cricoarytenoid joint can be- Abnormalities in abduction are allows a more magnified and optical- come immobile from inflammatory frequently evaluated by having the ly superior view of the vibratory processes in the joint space. These patient sniff and by having the pa- function and structure of the vocal processes can include such entities as tient whistle. 3 Both of these maneu- fold.4 Strobovideolaryngoscopy in- rheumatoid arthritis, gout, other vers require that the vocal folds open volves the use of synchronized flash- arthritides, trauma, arytenoid carti- in very brisk maneuvers, if the recur- ing lights through the telescope to lage dislocation during endotracheal rent laryngeal nerve is injured at its evaluate the function of the mucosal intubation, laryngeal fracture, and insertion into the posterior cricoary- wave of the vocal fold. This proce- surgical manipulation in the region tenoid muscle, the vocal fold will dure is performed with a rigid tele- of the arytenoid cartilages. 5 '3 In- have problems with abduction. If the scope placed through the mouth with flammation causes problems with injury to the nerve occurs at the level the tongue held forward. The patient joint mobility similar to the way in- of the thyroarytenoid or lateral crico- is awake and seated in a forward po- flammation in the fingers of the hand arytenoid muscles, there will be iso- sition during the examination. The can cause problems with movement lated abnormalities in vocal fold ad- chin is held slightly upright in a of the joint spaces there. Inflamma- duction. If there is a problem with "sniffing" position, which helps to tion causes scarring of the tissues the nerve at any point before it enters pull the base of the tongue forward around the joint. When the tissues the larynx, there will be abnormali- so that the larynx can be viewed are scarred, they inhibit the ability of ties in both abduction and adduction. more easily. Occasionally, a sensation the cartilages to move within the joint When the muscles are complete- of gagging is experienced during the space, resulting in decreased mobility. ly paralyzed or near totally para- examination; otherwise, the exami- lyzed, the vocal folds do not move on nation does not cause much discom- Muscle Disorders the side that is affected; however, a fort. This magnified view of the vocal Dysfunction of the muscles of Jostle's sign is seen.3 A Jostle's sign is folds can give the physician informa- the larynx can cause abnormal vocal a movement of the arytenoid on the tion regarding structural lesions on fold mobility also. Laryngeal myas- affected side during vocalization. the vocal folds that may contribute to thenia gravis, amyloidosis, edema, The passive movement of the ary- the vocal complaint or that have myositis, muscle atrophy, and muscu- tenoid on the affected side occurs as arisen as a result of the paresis. Once lar dystrophies are some of the disor- a result of contact with the other ary- a movement disorder of the larynx is ders that may affect muscle function. tenoid, which presses against it dur- identified, laryngeal electromyogra- The result is vocal fold hypomobility. ing adduction. phy (LEMG) is ordered to help exam- Myasthenia gravis is a disorder If the abnormality is in the ine more accurately the integrity of of the neuromuscular junction. My- movement of the cricoarytenoid joint the neuromotor (the nerve and mus- asthenia gravis can occur in multiple and not in the vocal fold muscles or cle) system. Laboratory studies, biop- muscle systems throughout the body nerves, the vocal fold will be hypo- sies, and imaging studies may help or it can occur as an isolated entity in mobile as well. There will be evi- guide the diagnosis and management the larynx.' 1,14,15 The primary disor- dence of some muscular effort as of movement disorders as well. 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 order in which the antibodies attack herpes virus." Infection of the nerve 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.2' .22 tions of muscles. This destruction re- ness, increased blood flow, increased Compression of the nerve can occur suits 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." 520 The cer, thyroid tumors, or other tumors impulses, and there is paresis and inflammatory fluid and the damage possibly paralysis of the muscle. Be- to the muscle membrane from the in- of the skull base, neck, or chest. cause only those neuromuscular flammation can interfere with the Aneurysms, which are abnormal di- junctions that come in contact with normal transmission of electrical im- latations of the blood vessels, may al- the abnormal antibodies, which are pulses from the nerve through the so enlarge and cause compression of present sporadically in the blood, are muscle, causing hypomobiity of the the nerves. Direct injury to the nerve attacked in myasthenia gravis, there vocal fold. may occur during surgery, during are some muscles and muscle fibers Muscular dystrophies are genet- penetrating or blunt trauma to the that are unharmed. This results in ic disorders that are characterized by neck, chest, or skull base, or as a re- variability in the muscles' abilities to suit of endotracheal intubation. De- abnormal muscle metabolism. 1-5 contract once signaled. With laryn- Eventually, muscle atrophy ensues in pending upon how much injury is geal myasthenia gravis, this typically caused, each of these mechanisms is seen as fluctuating asymmetries in many muscles throughout the body, including the larynx. 11,20 As the can cause paresis or paralysis of the the ability of the vocal folds to move nerves that supply the larynx. quickly. muscles in the larynx atrophy, they begin to lose their strength and are Metabolic abnormalities that Amyloidosis is a generalized can cause disorders in the nerves in- systemic disorder that can involve no longer able to move as quickly as normal or to produce the same de- clude diabetes mellitus and thyroid the larynx and can also involve other hormone abnormalities. The abnor- gree of muscle tension, resulting in tissues in the body, most commonly mal nerve function caused by thyroid 15 - sluggish and bowed vocal folds. the kidneys. 19 An abnormal accu- abnormalities is sometimes rever- mulation of a ground substance that sible; however, that caused by dia- Nerve Disorders contains antibodies is deposited in betes mellitus is usually irreversible. the tissues of the body in amyloido- Primary neural disorders may The exact mechanism by which thy- sis. This substance is amorphous and also cause decreased vocal fold mobil- roid hormone abnormalities cause is somewhat like gelatin in the way ity. Injury to the superior laryngeal nerve dysfunction is not fully under- that it accumulates in the tissues of nerve and/or the recurrent laryngeal stood, but usually reverses once the

H4U4L 2002 325 Yolanda D. Heman-Ackah and Robert T. Sataloff abnormality is corrected. 1123-25 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- CONCLUSION causes long-term nerve problems be- in the nerve sheath, a process called cause it results in the abnormal accu- synkinesis. When synkinesis occurs, Vocal fold hypomobility can re- mulation of glucose and its metabolites impulses that the brain tries to send in the smaller vessels that supply the to one muscle may be directed suit from a myriad of disorders of nerves, which eventually occlude the through this misconnection to anoth- nerves, muscles, or cricoarytenoid vessel lumen. 1526 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 dysfunc- current laryngeal nerve is injured ration, and shortness of breath. La- tion because they cause inflamma- and synkinesis occurs, the posterior ryngeal electromyography, imaging tion of the protective sheath that sur- cricoarytenoid muscle may be rein- studies, biopsies, and laboratory stud- rounds the nerve. The structure of nervated by nerve fibers that origi- ies may aid in the diagnosis of the eti- the nerve within this sheath is simi- nally innervated the thyroarytenoid ology of the disorders. Management lar to the structure of a sausage with- muscle. Normally, when the brain of vocal fold hypomobility varies, de- in its skin. When the sheath becomes signals the thyroarytenoid muscle to pending upon the identification of inflamed, it swells. This swelling de- contract for speech, it signals the pos- the 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 thyroa,ytenoid difficult for electrical impulses to muscle may be rerouted to the poste- NOTES pass through, which results in weak- rior cncoarytenoid muscle via this ness of the muscles innervated by the misconnection. When the person 1. R. T. Sataloff, "The Human Voice," nerve. As long as the constriction is tries to speak, the posterior cricoary- Scientific American 267 (1992):108- not severe and the nerve remains in- tenoid muscles will contract, opening 15. tact in the face of the swelling, the the vocal folds and causing a breathy G. Dursun et al., "Superior Laryngeal function of the nerve will eventually voice. 2. If the nerve is severed during Nerve Paresis and Paralysis,".Journal return as the swelling subsides and of Voice 10 (1996):206-11. the structures within the nerve are surgery or as the result of neck trau- regenerated. ma, paralysis of the muscles inner- 3. R. T. Sataloff, "The Professional If swelling is severe, it may com- vated by the nerve will result. Unless Voice: Physical Examination," Jour- pletely constrict the nerve and cause the nerves are surgically reconnect- nal of Voice 1 (1987):191-201. the part of the nerve with the most ed, reinnervation is unlikely to occur severe constriction to die, as though spontaneously and permanent paral- 4. R. T Sataloff, J . R. Spiegel, and M. J. it had been strangled. If this occurs, ysis will ensue. In general, the ab- Hawkshaw, "Strobovideolaryngosco- py: Results and Clinical Value," as long as the sheath remains intact, sence of innervation results in mus- cle atrophy and degeneration. If Annals of Otolaryngolog,y, Rhinology, the nerve will regenerate when the and Laryngologg 100 (1991):725-27. swelling decreases, and it will use the surgical reinnervation is performed, inside of the sheath as a "highway" it likely will result in synkinesis for 5. A. Grossman, J. R. Martin, and H. S. to find the other intact end of the similar reasons as explained above. Root, "Rheumatoid Arthritis of the nerve. Each nerve within a nerve Even with synkinesis, however, the Crico-arytenoid joint," Laryngoscope sheath contains hundreds of nerve neural input received by the muscle 71 (1961):530-44.

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6. 1. A. Po6sar. "The Crico-arvtenoid 16. 11. Hellquist et al., "Amvloidosis of 26. C. R. Shurnan 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," Laiyngoscope 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. W Light Chain Composition," Annals van Vostrand, "Laryngeal Rheuma- of Otolargngology, Rhinolog.y, and toid Arthritis," Laryngoscope 90 Laryngology 102 (1993):884-89. Yolanda D. Heman-Ackah, M.D., is Assis- (1980) :296-303. tant Professor of Laryngoloqy and Profes- 18. J. D. Bennett and C. R. Chowdliuty, sional Voice Care in the Department of 8. G. V. Lawry et al., "Laryngeal In- "Primary Amyloidosis of the Lar- volvement in Rheumatoid Arthritis. ynx," Journal of Laryngologj and Otolaryngology -Head and Neck Surgery A Clinical, Laryngoscopic, and Otology 108 (1994):339-40. at the University ofIllinois at Chicago. She Computerized Tomographic Study," is the director and founder of the Voice Arthritis and Rheumatology 27 19. J. E. Lewis et al., "Laryngeal Amy- Center at the University of Illinois at (1984):873-82. loidosis: A Clinicopathologic and liii- Chicago. She has authored and coauthored munohistochemical Review," Oto- numerous publications in the fields of laryngology Head and Neck Surgery 9. M. Goodman, W. Montgomery, and laryngology and professional voice care, L. Minette, "Pathologic Findings in 106 (1992):372-7. including award-winning scientific jour- Gouty Cricoarytenoid Arthritis," nal articles, book chapters, and a book. Archives of Otolaryngology 102 20. S. Mandel et al., "Laryngeal EMG: (1976):27-9. Electromyographic Evaluation of Vocal Fold Disorders," journal of Singing 10. F P. Paulsen, K.Jungmann, and B. N. 55, no. 2 (Nov/Dec 1998): 43-8. Robert Thayer Sataloff, M.D., D.M.A., is Tillmann, "The Cricoarytenoid Joint Professor of Otolaryngology-Head and Capsule and its Relevance to Endo- Neck Surgery, ," Anesthesia 21. R. Rabkin, "Paralysis of the Larynx ThomasJefferson University, and Analgesia 90 (2000):180-85. Due to Central Nervous System Chairman, Department of Otolaryngolo- Syphilis," Eye, Ear, Nose, and Throat pg-Head and Neck Surgery, Graduate Monthly 42 (1963):53. 11. R. T. Sataloff, Professional Voice: The Hospital; Adjunct Professor, Department of Science and Art of Clinical Care, 2nd 22. C. Neuschaefer-Rube et al., "Em- Otorhinolaryngology, University of Penn- ed. (San Diego, CA: Singular Pub- seitige Rekurrensparese bei Ver- sylvania; Adjunct Professor, Department lishing Group, 1997). dacht auf Lyme-borreliose." (Unilat- of Otolaryngology-Head and Neck eral Recurrent Nerve Paralysis in 12. Surgery, Georgetown University School of R. T Sataloff et al., "Arytenoid Dis- Suspected Lyme Borreliosis), Hals, location," Medicine; and Chairman, The Voice Journal of Voice 1 (1987): Nasen, Ohrenheilkunde 43 (1995): 368-77. 188-90. Foundation; and Chairman, The Anieri- can Institute for Voice and Ear Research. 13. R. T. Sataloff, I. D. Bough, and J. R. 23. A. J. McComas et al., "Neuropathy He has authored more than 500 publica- Spiegel. "Arytenoid Dislocation: in Thyrotoxicosis," New England tions, including twenty books. Diagnosis and Treatment," Laryn- Journal of Medicine 289 (1973):219- goscope 104 (1994):1353-61. 21.

14. R. F. Nieman, J. R. Mountjoy, and 24. A. Misiunas et al., "Peripheral Neu- E. L. Allen, "Myasthenia Gravis ropathy in Subclinical Hypothy- Focal to the Larynx. Report of a roidism," Thyroid 5 (1995):283-86. Case," Archives of Otolar,ngologg 101 (1975):569-70. 25. C. F Tones and R. T Moxley, "Hypothyroid Neuropathy and 15. J. D. Wilson et al., eds., Harrison's Myopathy: Clinical and Electrodiag- Principles of Internal Medicine, 12th nostic Longitudinal Findings,"Jour- ed. (New York: McGraw-Hill, 1991). nal ofNeurology 237 (1990):271-74.

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