I was asked to give a brief update at the Saunder's Symposium for the Department of Otolaryngology at The Ohio State University in 2012. This was a great honor. The videos have been removed due to size of the file.

1. High Speed Laryngeal Imaging
Saunders Symposium – 2012
Ryan M. Hendricker, M.D.
Laryngology and General Otolaryngology
Medical Director,Voice and Swallowing Disorders Center
Midwest Ear, Nose &Throat S.C.
8600 State Route 91
Peoria, IL 61615
Phone: 309-691-6616
Email: ryan.m.hendricker@osfhealthcare.org
Website: mw-ent.com

2. Disclosures
 None

3. Greetings from Peoria, IL

4. Objectives
 Briefly review the history of laryngeal
imaging
 Compare the parameters of stroboscopy to
high speed video
 Discuss the advantages and disadvantages of
high speed video imaging

5. Objectives
 Briefly review the history of laryngeal
imaging
 Compare the parameters of stroboscopy to
high speed video
 Discuss the advantages and disadvantages of
high speed video imaging

6. History of Laryngeal Imaging
 Mirror 1780s-early 19th century
 Glottoscope 1829
 Direct laryngoscopy 1850’s
 First stroboscopic descriptions 1895-1932
 Fiberoptics 1950’s
 Transnasal fiberoptic laryngoscopy 1970’s
 High speed video 1970’s
 Electrical stroboscope 1970
 Distal chip technology late 1990’s
Woo, P. Stroboscopy. Plural Publishing 2010.

7. Gold Standard: Stroboscopy
 Most widely available/used modality
 Collection of still images from subsequent
glottal cycles
 Stroboscopic light desynchronized to create
perception of glottal cycle
Woo, P. Stroboscopy. Plural Publishing 2010.

8. Gold Standard: Stroboscopy

9. Gold Standard: Stroboscopy
 Features typically analyzed
 Fundamental frequency
 Symmetry of motion
 Periodicity
 Mucosal wave
 Presence/absence
 Amplitude
 Glottic Closure
Woo, P. Stroboscopy. Plural Publishing 2010.

10. The Problem with Stroboscopy
 Cannot examine intra-cycle changes or cycle
to cycle variability
 Patient must be able to have some degree of
sustained phonation (pitch tracking)
 Difficult to examine onset/offset
 So…what about all our patients with…
 Aperiodic vibration/scar
 Muscle tension dysphonia
 Spasmodic dysphonia
 Voice breaks
 Diplophonia
Deliyski, D., and Robert Hillman. “State of the Art Laryngeal Imaging: Research and
Clinical Implications.” Curr Opin Otolaryngol Head Neck Surg. 2010 June:147-152.

11. Other options?
 High speed videoendoscopy (HSV)
 Videokymography (VKG)
Deliyski, D., and Robert Hillman. “State of the Art Laryngeal Imaging: Research and
Clinical Implications.” Curr Opin Otolaryngol Head Neck Surg. 2010 June:147-152.
Jiang, J. et al. “Mucosal Wave Measurement andVisualization Techniques.” JVoiceVol.
25, No 4, 395-405.

12. Videokymography
 Videokymography (VKG) is a high-speed
imaging modality that is often used to
supplement stroboscopy for irregular
vibratory patterns
Deliyski, D., and Robert Hillman. “State of the Art Laryngeal Imaging: Research and
Clinical Implications.” Curr Opin Otolaryngol Head Neck Surg. 2010 June:147-152.
Jiang, J. et al. “Mucosal Wave Measurement andVisualization Techniques.” JVoiceVol.
25, No 4, 395-405.

14. High Speed Videoendoscopy (HSV)
 Advantages
 Overcomes limitations of stroboscopy
 Full visualization and objective measurement of
periodic/aperiodic vibration
 Can visualize unstable phonatory characteristics
 Can visualize transient behaviors
 Phonatory breaks
 Laryngeal spasms
 Cough
 Pitch onset/offset
 Throat-clearing
 Laughing
Deliyski, et. al. In Press. Presented atTheVoice Foundation May 2012. Philadelphia, PA

15. What about High Speed?

16. Problems with High Speed Video
 Insufficient frame rates
 Lack of meaningful practice guidelines
 Lack of “normals” for comparison
 Physical limitations
 Structures become invisible at higher velocities
due to temporal averaging (blurring)
 Different phonatory behaviors produce drastically
different glottal configurations (pressed, breathy,
normal, etc.)
 Gender differences
 3D world, 2D images; scope limitations
Deliyski, et. al. In Press. Presented atTheVoice Foundation May 2012. Philadelphia, PA

17. Mucosal Wave
 What is it?
 Superficial tissue displacement/propagation of the
epithelium and SLP from inferior to superior surface
 2d/3d
 What amount of lateral excursion is normal?
 What degree of asymmetry is expected?
 Different for HSV and stroboscopy?
Deliyski, et. al. In Press. Presented atTheVoice Foundation May 2012. Philadelphia, PA

18. Mucosal Wave: Normophonic Patients
 What is it?
 Superficial tissue displacement
 2d/3d
 What amount of lateral excursion is normal?
 What degree of asymmetry is expected?
 Different for HSV and stroboscopy?
 Gender**
Deliyski, et. al. In Press. Presented atTheVoice Foundation May 2012. Philadelphia, PA
*Shaw et al. Mucosal Wave: A Normophonic Study AcrossVisualization Techniques. JVoice
22, No. 1, 23-33.

19. The Required Speed of High-Speed
Videoendoscopy for Specific
Clinical Voice Assessment Protocols
 Compared frame rates from 16,000 fps to
2,000 fps
 1st noticeable difference
 When did it change clinical diagnosis (e.g.,
presence/absence of mucosal wave)
Deliyski, et. al. In Press. Presented atTheVoice Foundation May 2012. Philadelphia, PA

20. The Required Speed of High-Speed
Videoendoscopy for Specific
Clinical Voice Assessment Protocols
 Features examined
 Mucosal wave magnitude
 Mucosal wave extent
 Amplitude asymmetry
 Phase asymmetry
 Aperiodicity
 Glottal edge*
 Loss of glottal contact
 Mucous bridge breaking
Deliyski, et. al. In Press. Presented atTheVoice Foundation May 2012. Philadelphia, PA

21. The Required Speed of High-Speed
Videoendoscopy for Specific
Clinical Voice Assessment Protocols
 1st noticeable difference
 Minimum of 8,000 fps required
 Clinical change
 Minimum of 4,000 fps
 A rate of 8,000 fps is free from visually
perceivable feature degradation
 Rates greater than 5,333 fps have minimal
degradation
 Rates less than 2,667 fps should be clinically
interpreted with caution
Deliyski, et. al. In Press. Presented atTheVoice Foundation May 2012. Philadelphia, PA

22. Summary
 High speed digital imaging is not new…but
technology is changing
 Practice parameters and flexible endoscopy
application are needed for widespread high-
speed utility
 Stroboscopy is still the work-horse, but there
are significant limitations in pathologic voices