High Speed Digital Imaging: Clinical & Research Implications

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1 Talk Outline Digital Imaging: Clinical & Research Implications Rita R. Patel, Ph.D., CCC-SLP Assistant Professor Department of Speech & Hearing Sciences Laryngeal imaging Instrumentation Digital Imaging Kymography Current Research Clinical applications Basic science Case Examples Laryngeal imaging Looking at the vocal folds Laryngeal imaging Laryngeal imaging Endoscopy Stroboscopy Assessment of Dysphonia Correlating structure with function Assessment of vocal fold structure Assessment of vocal fold function Histological layers vibrate as 2 structures Body: Vocalis Cover: Epithelium and Lamina Propria Biomechanical structure :2 layers Active [Body] Passive [Cover] Body-Cover Theory Hirano,

2 Laryngeal Imaging Films Stroboscopy Digital Imaging (HSDI) Digital Kymography (Wittenberg et al, 1997) Kymography Video Kymography (Švec et al, 1996) Assessment of function Stroboscopy a current gold standard But Produces apparent motion Stroboscopy: Principle Stroboscopy produces an optical illusion of several segments of different cycles In contrast to continuous light, the stroboscopic light emits rapid pulses These illuminated points are fused together to provide an average vibratory pattern High speed vs. Stroboscopy Montage of glottal cycles Hirano & Bless, 1993 Patel, Dailey & Bless, 2008, Annals of ORL High speed vs. Stroboscopy Schematic representation Stroboscopy Drawbacks Pitch tracking errors Blurred images in disorders, because of pitch tracking problems Aphonic patients strobe light not useful, as no movement will be observed Patel, Dailey & Bless, 2008, Annals of ORL 2

3 Stroboscopy Drawbacks Pitch tracking errors Digital Imaging Instrumentation Temporal resolution of up to 4000 fps Spatial resolution 512 x 256 pixels Both color and black/white recordings Simultaneous acoustic and EGG recordings Xenon light source of 300 watts required Rigid endoscope (70 or 90 ) Digital Imaging Instrumentation Clinical HSDI Indications Unexplained hoarseness on stroboscopy 62% unexplainable findings (n = 126, 252 films) (Patel el al, 2008) 55% unexplainable findings (n = 162, 324 films) (Olthoff et al, 2008) Moderate & Severe hoarseness (Patel, Dailey & Bless, 2008) 100% (41/41) subjects with severe hoarseness 64 % (38/59) subjects with moderate hoarseness Vocal Pathologies Neuromuscular (74%) Epithelial (58%) Subepithelial (53%) Clinical HSDI Indications Acoustic measurements 0.87% jitter 4.4% shimmer SNR less than 15.4dB Clinical HSDI Indications New insights into the post operative cycle-to-cycle variations in tissue vibratory function following treatment of early glottic carcinoma (Mehta et al, 2010) (Patel, Dailey & Bless, 2008) Differentiating adductor spasmodic dysphonia from muscle tension dysphonia (Patel et al, 2011) 3

4 Clinical HSDI Indications Observing transient phenomenon Voice onset and offset (Wittenberg et al, 1995) Glissando (Hoppe et al, 2003) Diplophonia (Kiritani et al, 1993) Tremor (Hertegård et al, 2003) Clinical HSDI Indications Monitoring outcomes in voice therapy (Patel, Pickering, Stemple 2012) Assessment of children (Patel, Dixon, Richmond, Donohue, 2012) Interpretation of HSDI Vibratory features rank ordered Interpretation of HSDI Voice-Vibratory Assessment and Laryngeal Imaging (VALI) Vertical level Vocal fold edge Glottal closure Phase closure Amplitude Mucosal wave Tissue pliability Phase closure Glottal cycle aperiodicities (0% - 3%) (16% - 29%) (38% - 52%) (56% - 63%) (Patel, Dailey & Bless, 2008) (Poburka, Patel & Bless, 2013, Work in Progress) HSDI: Quantitative Analysis High speed glottogram HSDI: Quantitative Analysis Glottal Cycle Montage Richard Wolf KIPS, KayPENTAX 4

5 HSDI: Quantitative Analysis Edge Detect GAW Phonovibrogram Computation KIPS, KayPENTAX Phonovibrogram Computation Phonovibrogram Computation PVG Visualization PVG Visualization A P A 5

6 PVG Visualization A Case examples: HSDI P symmetry A regularity / stability Normal Voice Onset & Offset Muscle tension Dysphonia Pre Therapy Stroboscopy Motion Analysis Muscle tension Dysphonia Post Therapy Stroboscopy Motion Analysis Patel, Liu, Galatsanos & Bless, 2011 Patel, Liu, Galatsanos & Bless, 2008, in review 6

7 Vocal fold vibrations Vocal fold vibrations 2/26/2013 Muscle tension Dysphonia Pressed Vocal Fry Spasmodic Dysphonia Spasmodic Dysphonia Adductor Spasmodic Dysphonia Voice break Vocal fold cyst Pseudocyst Typical Phonation Inhalation Phonation 7

8 Measurement of Treatment Outcomes Measurement of Treatment Outcomes Granuloma Measurement of Treatment Outcomes Measurement of Treatment Outcomes Pre voice therapy Post voice therapy Onset Time: 0.14 seconds Onset Time: seconds Voice Break: Glissando Pediatric Voice Assessment 10 year old Glottal Cycle Montage 78.57% children (5-10 years) posterior gap (Patel et al, 2011, Int. J. of Pediatric ORL) VF closure more shutter-like, opening zipper-like (Döllinger et al, 2011, Laryngoscope) 8

9 Quantifying Vocal Development Quantifying Vocal Development 1.2 Male Child Vibratory Amplitude mm Left Fold Right Fold Vibratory Amplitude = 0.25 mm ±0.04mm 0.4 Membranous to Cartilage Length Child Female Male ms Adult Female Vibratory Amplitude = 0.88 mm ±0.04mm 0.8 mm ms Adult Male Vibratory Amplitude = 0.93 mm ±0.02mm mm ms Vocal Nodules: 10year old Vocal Nodules: 8 year old HSDI Limitations More powerful light Recording duration limited to 4-6 seconds Kymography Kymograph is a spatio temporal image that show a fixed horizontal line in the vocal fold image over time Sound playback not simultaneous with video High speed image Kymograph a Open Rigid endoscopy only Large data storage files Closed Time (ms) b Opening Limited normative & disordered data d c Closing Customize footer: View menu/header and Footer February 17,

10 Kymography Videokymography (Švec et al, 1996) Digital kymography (Wittenberg et al, 1997) time KayPENTAX TM Interpretation of Kymograph Cycle-to-cycle variability Right-left asymmetry Presence, type and extent of mucosal wave Open phase features Closed phase features Ventricular fold motion (Švec, 2004) Closed Time (ms) Kymograph a d b c Open Opening Closing Interpretation of Kymograph Kymography Applications Extent of mucosal wave propagation Visibility of upper and lower margins of vocal folds Assessing opening and closing phases Detecting ventricular phonation (Švec et al, 1998) Kymographic Patterns y Normal Kymographic Patterns Vocal Fry MTD High Pitch time Loud time 10

11 Kymographic Patterns Right vocal fold paralysis Kymography Advantages Less expensive Less data stored & processed Recording duration unlimited Good spatial resolution (768 pixels) Good temporal resolution ( images/sec) Extreme vocal performance Disadvantages Documentation on videotape / photograph tedious Distortion of spatial information if scope not perpendicular Anterior posterior modes difficult Lacks full image Visualize several times Kymograph Accessory!! HSDI & Kymography Summary New possibilities for aiding decision making of voice disorders Information useful for clinic practice as well as basic research Voice Foundation 2008 HSDI & Kymography Research on vocal physiology Vibration is influenced by: Pitch Loudness Phonation Mode Age Gender Disease Improved hardware Flexible nasoendoscopy Improved software semi-automated analysis Thank you patelrir@indiana.edu 11

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