|
by M. Nasser Kotby and the team of the Ain Shams University, Faculty of Medicine, Unit of Phoniatrics
The activities of the Ain Shams group in Cairo in the field of vocology represent a notable struggle that began when we decided to lay the foundations of the field of vocology and human communication disorders. The mere focus on the needs of people with vocal and communication disorders was a matter of debate and the atmosphere did not help prioritize funding. Despite this attitude, services were initiated and have reached a very effective level in a region that earlier was totally deprived.
Our understanding of the term vocology is that it includes all aspects of human voice from basic sciences to clinical and surgical management to the science and art of singing and singers' training.
Research
The interest of our team in vocology started in 1965 with a question raised about the action/function of the small internal laryngeal muscles and the relation of the various groups of muscles to each other. The tool to investigate and answer the question was laryngeal electromyography (LEMG). A PhD dissertation was written with description of a standardized method for per-cutaneous LEMG reports on the action of the internal laryngeal muscles in health and disease (Kotby, 1967, 1975).
Further studies were later carried out on specific aspects of the subject (Kotby and Haugen, 1970a, b, c, d). After a period of three decades of applying LEMG, our team felt it necessary to share their concern regarding some remaining difficulties in the technique. These points were discussed in a state-of-the-art article (Kotby et al., 1992a).
The interest in the larynx continued in the field of structure and function. The pattern of attachment of the laryngeal muscles at the base of the arytenoid cartilage was studied in an attempt to explain some of the controversial findings resulting from the studies on LEMG. A proposed mechanism/mode of action of the various small internal laryngeal muscles individually and in combinations was presented (El-Sammaa, 1980; Mossallam et al., 1986a; Mossallam et al., 1987).
The same group investigated the branching and the fiber distribution as well as the fiber size spectrum of the inferior laryngeal nerve, aiming to relate the neural and muscular structure to the functional outcome illustrated in their LEMG studies (Kotby and El-Sammaa, 1981). Further investigations in the structure and function of the vocal folds and ventricular bands were carried out (Kotby et al., 1991a; Kotby et al., 1992b; Riad & Kotby, 1995).
A program of research was launched to investigate the histo-pathological nature of the small mucosal benign lesions of the vocal folds as polyps, nodules, Reinke's edema, and contact granulomas. Both light microscopy and ultra structure studies support the notion that these lesions are non-neoplastic, non-inflammatory, probably arising as a result of vocal trauma. The commonalities between these lesions, histologically and clinically, allowed the team to propose grouping them under one group referred to as Minimal Associated Pathological Lesions (MAPLs) of the vocal fold (Kotby et al., 1980; Kotby & Ghali, 1983; Kotby et al., 1983; Mossallam et al., 1986b; Kotby et al., 1988).
Clinical Area
In the clinical domain, efforts focused on establishing a comprehensive protocol of assessment (diagnosis) of voice disorders. The protocol included the elementary qualitative bedside tools and extended to the more quantitative and quasi-objective measures (Kotby, 1986). Central in this protocol are: systematic patient interview, Auditory Perceptual Assessment of the patient's voice by the expert clinician's ears, video-stroboscopy, and standardized voice recording.
As the glottis is a transformer that changes aerodynamic energy into acoustic energy (voice), the instrumental measures for the assessment of voice have included aerodynamic and acoustic aspects. The aerodynamics of voice disorders were investigated and became part of the protocol (Kotby et al., 1990). Related to this domain is inverse filtering (Kotby et al., 1998a; Hegazi et al., 1999). In acoustics, certain perturbation measures were applied (Kotby et al., 1992c; Kotby et al, 1993a; Kotby et al, 1996).
A further study assessed critically the diagnostic value of the acoustic parameters (Kotby et al., 1998b). A related aspect in acoustics, Voice Range Profile, was applied (Kotby and Orabi, 1995). Video-kymography (Bassiouny et al., 2000), and voice quality in neurological disorders of the larynx (Kotby et al., 1995a) are additional areas our team studied as part of the assessment protocol.
Our team has a special interest in non-organic voice disorders as they represent a major category of the patient population we see. We investigated habitual aphonia early in our program (Kaiser et al., 1978). Out of clinical necessity, the team carried out a series of studies focused on the nature, development, and management of childhood dysphonias (Kotby et al., 1994; Kotby et al, 1998c). We planned a study to investigate the importance of psychogenic stress in the causation of non-organic voice disorders (Kotby et al., 2001).
The team has applied the Kleinsasser endolaryngeal microsurgical techniques for decades. The main surgical application is extirpation of the small benign mucosal lesions of the vocal folds using basically cold metal tools. Laser is applied in restricted indications.
Lately the team started the application of Botox injection in the thyro-arytenoid muscles in cases of spasmodic dysphonia. This condition is not common in Egypt. The results of Botox injections are promising but the recurrence of symptoms is, as expected, rather eminent. A re-injection within two to three months is the rule.
The team has special work in the management of paralytic glottal gaps. Small gaps up to 1.5 mm proved to respond favorably to conservative behavior re-adjustment voice therapy [BRAT] (Kotby et al., 1991b, Bassiouny, 1998). Gaps up to 3.5 mm respond well to vocal fold augmentation using autogenous fat (Kotby et al., 2003).
The team worked on one of the voice therapy methods, namely the Smith Accent Method, for several years. We applied the technique to a host of non-organic voice disorders as well as to some selected cases of organic voice ailments. Efficacy studies were published (Kotby et al., 1991b; Bassiouny, 1998). The Accent Method was presented in a comprehensive manner, in book form (Kotby, 1995), and as a summary, in the form of an article (Kotby & Fex, 1998). We carried out an attempt to study the mechanism of action of the accent exercises in improvement of the vocal function (Kotby et al., 1993b).
We also worked in the area of the singing voice. These concentrated on the traditional singing of the country (Kotby et al., 1992d; Kotby et al., 1995b).
After 33 years we have reached the stage that people with communication disorders (including voice disorders) are well-recognized and their needs are fulfilled as much as a developing economy and community can supply. Self-control, patience, endurance, persistence, perseverance, and tenacity are the attitudes that continue to guide our work.
M. Nasser Kotby , professor at Ain Shams University, established the specialty of Phoniatrics and Logopedics (medical and non-medical speech pathology) at Ain Shams University and Egypt in 1974 and chaired the unit until 1998. He is president of The Egyptian Association of Phoniatrics and Logopedics. Contact him at nkotby@cng.com.eg.
|