Good vocal health is a vital concern for those people who use the voice in a professional capacity, such as teachers, singers, actors, clergymen, and lawyers. Research in the area of vocal health reveals the need to determine if specific exercises are beneficial to the voice and if exercises used to train the singing voice might be beneficial to alleviate pathological and/or dysfunctional voice disorders. The purpose of this study was to describe the response of a variety of pathological voices to a selected set of singing exercises. Subjects were selected from the private practice of cooperating physicians who felt that the vocal instruction and exercise program might be helpful to the teachers, students, professional "pop" singers, and housewife-singers who were diagnosed to have muscle tension dysphonia, nodules, recurrent laryngeal nerve paralysis, or iatrogenic dysphonia. Instrumentation for assessing conditions before, during, and after exercise included a brief case history, subject interviews, attending physicians' medical charts, flexible fiberoptic video nasolaryngoscopy, video cassette recorder and video tape segments, three physician/observers, and a specific diagnostic procedure which provided a method of assessing organic, functional, and perceptual variables. For the exercise program the researcher chose seven vocalises from the routine designed by Allan R. Lindquest, whose techniques combined those of the Italian school with those of Swedish studios which produced such singers as Flagstad and Bjoerling. The seven vocalises included a warm up "massage" and exercises for separation and blending of the registers, vowel clarity and modification, tone focus, vocal attack, and flexibility. Since all the subjects showed improvement after exercise in the vocal conditions observed in this study, these vocalises and technique may be helpful to alleviate pathological conditions and/or dysfunctional behavior in other subjects. The researcher further suggests that the voice profession investigate the efficiency of other techniques, exercises, and musical vocalises which might bring about positive changes in vocal conditions and behavior.

A research report submitted in partial fulfilment of the requirements for the degree Master of Science in Medicine in the Field of Emergency Medicine in the Division of Emergency Medicine, University of the Witwatersrand / Introduction: Control over the patient bears time-critical importance in emergency medicine. In the entrapment situation after a Motor Vehicle Collision (MVC), emergency care including airway management may need to be initiated before extrication and thus with restricted access. Objective: This manikin study aimed at answering the question of which advanced airway device can be inserted the fastest and most reliably by paramedics in the simulated entrapped patient. Methods: Paramedics were asked to insert four airway devices (endotracheal tube with the Macintosh laryngoscope, endotracheal tube with the Airtraq® optical laryngoscope, Laryngeal Mask Airway - SupremeTM, and Laryngeal Tube Suction - DisposableTM) in randomised order into a manikin seated in the driver seat of a light motor vehicle. Time to first successful ventilation and number of attempts required for successful insertion were measured. Following each insertion, participants were asked by means of a questionnaire to rate the degree of insertion difficulty (scale 1 – 10) and provide reasons for this rating. Finally, participants were asked which device they preferred and why. Results: Prospectively collected data from 26 paramedics were analysed. The LMA-SupremeTM had the shortest mean time to first successful ventilation (16.7 seconds (CI [0.95]; 14.9 - 18.6)), followed by the LTS-DTM (19.4 seconds (CI [0.95]; 18.0 - 20.8)), ETI using the Macintosh laryngoscope (37.7 seconds (CI [0.95]; 31.8 - 43.5)) and ETI using the Airtraq® (41.2 seconds (CI [0.95]; 36.7 - 45.6)). Both face-to-face ETI with the Macintosh laryngoscope and the insertion of the LMA-SupremeTM had 100% first-attempt success. Five participants required a second attempt to successfully intubate the manikin using the Airtraq® and one participant had to re-insert the LTS-DTM for correct placement. In terms of insertion difficulty, the LMA-SupremeTM received the lowest mean score (1.7/10 (CI [0.95]; 1.2 - 2.1)) followed by the LTS-DTM (2.5/10 (CI [0.95]; 1.8 – 3.2)), face-to-face ETI using the Macintosh laryngoscope (3.7/10 (CI [0.95]; 2.9 - 4.5)), and ETI with the Airtraq® (4.5/10 (CI [0.95]; 3.7 - 5.3)). Most participants chose the Macintosh laryngoscope for ETI as their preferred device (10/26; 38%) followed closely by the LMA-SupremeTM (9/26; 35%). These participants stated clinical experience and ease of insertion respectively as the primary reasons for their preference. Conclusion: Besides ETI, Supraglottic Airway Devices are beneficial alternative airway devices to be considered by paramedics in the entrapped patient after a MVC. The LMA-SupremeTM was the fastest and least difficult airway device to insert. Face-to-face endotracheal intubation with the Macintosh laryngoscope remains an important definitive airway that was shown to be performed competently by participating paramedics. The Airtraq® can be used for face-to-face ETI and enables improved laryngoscopy.

Na primeira parte deste estudo, foram dissecados 30 polos superiores tireoideanos, de 15 cadáveres frescos, com o intuito de se identificar o ramo externo do nervo laríngeo superior (RELS) e analisar as suas relações anatômicas com o pedículo superior da glândula tireóide. Obedecendo a uma classificação eminentemente anátomo-cirúrgica, 1 nervo (3%) não foi localizado, 18 (60%) eram do Tipo 1 (cruzando os vasos tireoideanos superiores acima de 1 cm de um plano horizontal que passava pela borda do polo superior tireoideano), 5 (17%) eram do Tipo 2a (nervo a menos de 1 cm acima do plano acima descrito) e 6 (20%) eram do tipo 2b (nervo abaixo do plano). Esta última configuração anatômica foi considerada de alto risco de lesão iatrogênica durante uma hipotética tireoidectomia. A seguir, foi executado um estudo clínico, prospectivo e randomizado. Setenta e seis doentes, após uma avaliação fonoaudiológica completa pré-operatória, foram divididos em tres grupos. No Grupo 1, o polo superior foi dissecado pelo Autor com lupa, pesquisando-se o RELS, após a secção dos músculos pré-tireoideanos, por meio de um neuro-estimulador e observando-se a consequente contração do músculo crico-tireoídeo (MCf) no próprio campo operatório. No Grupo 2, o polo superior tireoideano foi dissecado por Médicos-Residentes de 20. Ano de Cirurgia Geral, estagiando na Disciplina de Cirurgia de Cabeça e Pescoço do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (DCCP-HC FMUSP), sem qualquer tentativa para se individualizar o RELS. Os indivíduos do Grupo 3 foram operados obedecendo à mesma técnica descrita no grupo anterior, pelo Autor. No período pós-operatório, foi repetida a avaliação fonoaudiológica e realizada uma eletromiografia de ambos os MCT. Os doentes que tiveram uma lesão completa do RELS, comprovada pela ausência de atividade elétrica do MCT, sofreram novas avaliações fonoaudiológica e eletromiográfica tardias, 6 meses após a cirurgia. Nenhum caso do Grupo 1 apresentou lesão completa do RELS. No Grupo 2, 28% dos pacientes exibiram esta lesão, que foi definitiva em 57%. No Grupo 3, constataram-se lesões totais em 12% dos doentes; nenhuma das lesões analisadas tardiamente neste grupo foi definitiva. Quando comparados com os nervos não dissecados, houve um aumento estatisticamente significativo de lesões completas nos Grupos 2 (p=O,0002776) e 3 (p=O,0346393), enquanto que não houve diferença nos doentes do Grupo 1. A avaliação fonoaudiológica revelou uma melhora nos parâmetros dos casos do Grupo 1, mormente aqueles relacionados com a respiração. Observou-se uma deterioração da performance vocal nos doentes do Grupo 2, que persistiu, em parte, na avaliação fonoaudiológica tardia. Já no Grupo 3 foi marcante uma piora estatisticamente significativa nas frequências mais altas e uma redução acentuada na extensão vocal, que foram atribuídas a lesões parciais do RELS, não detectadas pela avaliação eletromiográfica. Concluiu-se que a única forma eficaz de se prevenir uma lesão iatrogênica do RELS durante uma tireoidectomia foi a sua pesquisa sistemática e objetiva na região do polo superior, com O auxílio de um neuro-estimulador. / In the first part of this study, the external branch of the superior laryngeal nerve (RELS) was dissected in the region of 30 superior thyroid poles, in 15 fresh cadavers, with special attention for its anatomical relationship with the superior thyroid vessels. Four different kinds of nerves were found: Not localized - 1 (3%) nerve; Type 1 (crossing the superior thyroid vessels more than 1cm above a horizontal plane located at the upper limit of the superior thyroid pole) - 18 (60%); Type 2a (nerve situated less than 1 cm above the plane) - 5 (17%); Type 2b (nerve below the plane) - 6 (20%). This last relationship was considered to be \"high risk\", regarding an iatrogenic lesion during a hypothetical thyroidectomy. Then, a prospective randomized clinical study was undertaken. Seventy-six patients, after being submitted to a complete phonoaudiological evaluation, were divided in three groups. In Group 1, the superior thyroid pole was dissected by the Author with a loupe, searching the RELS with a nerve stimulator, after dividing the strap muscles to gain better exposure. The identification of the nerve was considered to be positive when a contraction of the cricothyroid muscle (MCT) was obtained. In Group 2, the superior thyroid pole was operated on by 2nd Year General Surgery Residents, training during a I-rnonth period at the Department of Head and Neck Surgery of Hospital das Clínicas of the University of São Paulo Medical School (DCCP-HC FMUSP), without any attempt to identify the RELS. In Group 3, the patients were operated on by the Author, according to the same technique described for the Group 2. In the postoperative period, the complete phonoaudiological evaluation was repeated and an electromiography of both MCTs was performed. Those cases who showed a complete lesion of the RELS, which was evident by the absence of any electrical activity of the MCT, underwent again both phonoaudiological and electromiographic evaluations, 6 months after the surgery. No patient in Group 1 showed any complete lesion of the RELS. In Group 2, 28% of the cases suffered this lesion, which was definitive in 57%. In Group 3, 12% of the patients had a complete paralysis of the nerve; none of the two lesions analyzed after 6 months (67%) proved to be definitive. A comparison of the three groups was established with the non-dissected nerves. A significant statistical difference was obtained in the Groups 2 (p=0.0002776) and 3 (p=0.00346393), clearly demonstrating an increased risk of lesion in these groups. No difference was observed between Group 1 and the non-dissected nerves group. An actual improvement in the vocal performance was noted in Goup 1, especially regarding respiratory characteristics. On the other hand, the vocal performance worsened in Group 2 patients, and this deterioration persisted, in part, also during the late evaluations. ln Group 3, there was a marked lowering of the highest frequencies, associated with a profound reduction in the vocal extension. These features were attributed to partial RELS lesions, which could not be detected by the electromiography. ln conclusion, the only effective way to prevent an iatrogenic lesion of the RELS during a thyroidectomy was, in this study, an objective and meticulous search of the nerve near the superior thyroid pole, using a nerve stimulator.

Na primeira parte deste estudo, foram dissecados 30 polos superiores tireoideanos, de 15 cadáveres frescos, com o intuito de se identificar o ramo externo do nervo laríngeo superior (RELS) e analisar as suas relações anatômicas com o pedículo superior da glândula tireóide. Obedecendo a uma classificação eminentemente anátomo-cirúrgica, 1 nervo (3%) não foi localizado, 18 (60%) eram do Tipo 1 (cruzando os vasos tireoideanos superiores acima de 1 cm de um plano horizontal que passava pela borda do polo superior tireoideano), 5 (17%) eram do Tipo 2a (nervo a menos de 1 cm acima do plano acima descrito) e 6 (20%) eram do tipo 2b (nervo abaixo do plano). Esta última configuração anatômica foi considerada de alto risco de lesão iatrogênica durante uma hipotética tireoidectomia. A seguir, foi executado um estudo clínico, prospectivo e randomizado. Setenta e seis doentes, após uma avaliação fonoaudiológica completa pré-operatória, foram divididos em tres grupos. No Grupo 1, o polo superior foi dissecado pelo Autor com lupa, pesquisando-se o RELS, após a secção dos músculos pré-tireoideanos, por meio de um neuro-estimulador e observando-se a consequente contração do músculo crico-tireoídeo (MCf) no próprio campo operatório. No Grupo 2, o polo superior tireoideano foi dissecado por Médicos-Residentes de 20. Ano de Cirurgia Geral, estagiando na Disciplina de Cirurgia de Cabeça e Pescoço do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (DCCP-HC FMUSP), sem qualquer tentativa para se individualizar o RELS. Os indivíduos do Grupo 3 foram operados obedecendo à mesma técnica descrita no grupo anterior, pelo Autor. No período pós-operatório, foi repetida a avaliação fonoaudiológica e realizada uma eletromiografia de ambos os MCT. Os doentes que tiveram uma lesão completa do RELS, comprovada pela ausência de atividade elétrica do MCT, sofreram novas avaliações fonoaudiológica e eletromiográfica tardias, 6 meses após a cirurgia. Nenhum caso do Grupo 1 apresentou lesão completa do RELS. No Grupo 2, 28% dos pacientes exibiram esta lesão, que foi definitiva em 57%. No Grupo 3, constataram-se lesões totais em 12% dos doentes; nenhuma das lesões analisadas tardiamente neste grupo foi definitiva. Quando comparados com os nervos não dissecados, houve um aumento estatisticamente significativo de lesões completas nos Grupos 2 (p=O,0002776) e 3 (p=O,0346393), enquanto que não houve diferença nos doentes do Grupo 1. A avaliação fonoaudiológica revelou uma melhora nos parâmetros dos casos do Grupo 1, mormente aqueles relacionados com a respiração. Observou-se uma deterioração da performance vocal nos doentes do Grupo 2, que persistiu, em parte, na avaliação fonoaudiológica tardia. Já no Grupo 3 foi marcante uma piora estatisticamente significativa nas frequências mais altas e uma redução acentuada na extensão vocal, que foram atribuídas a lesões parciais do RELS, não detectadas pela avaliação eletromiográfica. Concluiu-se que a única forma eficaz de se prevenir uma lesão iatrogênica do RELS durante uma tireoidectomia foi a sua pesquisa sistemática e objetiva na região do polo superior, com O auxílio de um neuro-estimulador. / In the first part of this study, the external branch of the superior laryngeal nerve (RELS) was dissected in the region of 30 superior thyroid poles, in 15 fresh cadavers, with special attention for its anatomical relationship with the superior thyroid vessels. Four different kinds of nerves were found: Not localized - 1 (3%) nerve; Type 1 (crossing the superior thyroid vessels more than 1cm above a horizontal plane located at the upper limit of the superior thyroid pole) - 18 (60%); Type 2a (nerve situated less than 1 cm above the plane) - 5 (17%); Type 2b (nerve below the plane) - 6 (20%). This last relationship was considered to be \"high risk\", regarding an iatrogenic lesion during a hypothetical thyroidectomy. Then, a prospective randomized clinical study was undertaken. Seventy-six patients, after being submitted to a complete phonoaudiological evaluation, were divided in three groups. In Group 1, the superior thyroid pole was dissected by the Author with a loupe, searching the RELS with a nerve stimulator, after dividing the strap muscles to gain better exposure. The identification of the nerve was considered to be positive when a contraction of the cricothyroid muscle (MCT) was obtained. In Group 2, the superior thyroid pole was operated on by 2nd Year General Surgery Residents, training during a I-rnonth period at the Department of Head and Neck Surgery of Hospital das Clínicas of the University of São Paulo Medical School (DCCP-HC FMUSP), without any attempt to identify the RELS. In Group 3, the patients were operated on by the Author, according to the same technique described for the Group 2. In the postoperative period, the complete phonoaudiological evaluation was repeated and an electromiography of both MCTs was performed. Those cases who showed a complete lesion of the RELS, which was evident by the absence of any electrical activity of the MCT, underwent again both phonoaudiological and electromiographic evaluations, 6 months after the surgery. No patient in Group 1 showed any complete lesion of the RELS. In Group 2, 28% of the cases suffered this lesion, which was definitive in 57%. In Group 3, 12% of the patients had a complete paralysis of the nerve; none of the two lesions analyzed after 6 months (67%) proved to be definitive. A comparison of the three groups was established with the non-dissected nerves. A significant statistical difference was obtained in the Groups 2 (p=0.0002776) and 3 (p=0.00346393), clearly demonstrating an increased risk of lesion in these groups. No difference was observed between Group 1 and the non-dissected nerves group. An actual improvement in the vocal performance was noted in Goup 1, especially regarding respiratory characteristics. On the other hand, the vocal performance worsened in Group 2 patients, and this deterioration persisted, in part, also during the late evaluations. ln Group 3, there was a marked lowering of the highest frequencies, associated with a profound reduction in the vocal extension. These features were attributed to partial RELS lesions, which could not be detected by the electromiography. ln conclusion, the only effective way to prevent an iatrogenic lesion of the RELS during a thyroidectomy was, in this study, an objective and meticulous search of the nerve near the superior thyroid pole, using a nerve stimulator.

Deterioration in voice quality following radiation therapy for the treatment of laryngeal cancers (LC) is well documented in literature. The majority of studies show that these voice problems are long term and in some cases permanent. Deterioration in voice quality, especially over a period of time could lead to significant communication difficulties in daily life or in some cases could even result in loss of profession. Despite the negative effects of radiation therapy on voice quality being well documented, few studies have focused on the efficacy of voice therapy in the irradiated LC population. The purpose of this study was to investigate the efficacy of a well researched, evidence based voice therapy approach, known as Vocal Function Exercises (VFEs) in improving vocal function in patients who have been irradiated for LCs. The present study conducted in three systematic stages with distinct and related study aims. The first involved characterizing the head and neck cancer treatment seeking population at the University of Kentucky (UK). Stage 2 involved characterizing vocal function following irradiation for LC using a multidimensional assessment approach. Stage 3 was a phase 2 clinical trial aimed at treating these deficits in vocal function identified through stage 2 using a systematic evidence based voice therapy approach, Vocal Function Exercises. For the phase 2 clinical trial, the comparison group received vocal hygiene (VH) counseling. Observations from stage 1 showed that majority of patients from the treatment seeking population at UK between a 3 year time period from 2008 to 2010 were diagnosed with laryngeal cancers and were treated with chemoradiation therapy. Stage 2 demonstrated a multidimensional deterioration in vocal function following radiation therapy for laryngeal cancers. Stage 3 demonstrated a significant improvement in vocal function across the primary outcome measure (Voice Handicap Index) as a result of VFE+VH. Improvements were also seen in select parameters across the five domains of voice assessment in the VFE group. No significant improvements were observed in the vocal hygiene group in any parameters in each domain of voice assessment. Our study demonstrated adults irradiated for laryngeal cancers demonstrated a multi-dimensional deterioration of vocal function. These changes were long term since study participants were 2- 7 years post radiation therapy. Implementation of VFE+VH demonstrated a significant improvement in voice related quality of life and select parameters across the five domains of voice assessment. The present study demonstrated promising preliminary evidence for the use of VFE+VH to improve vocal function in patients irradiated for laryngeal cancers.

Orientador: Regina Helena Garcia Martins / Resumo: Mercuri G. Incidência e Prevalência da Papilomatose Laríngea no Estado de São Paulo [dissertação]. Botucatu, SP: Faculdade de Medicina de Botucatu, Universidade Estadual Paulista; 2019. Introdução: A papilomatose respiratória recorrente ou papilomatose laríngea recorrente é a neoplasia benigna da laringe causada pelo Papiloma Vírus Humano, caracterizando-se pela presença de lesões proliferativas exofíticas recorrentes. A ausência de tratamento curativo, os custos relacionados ao diagnóstico, prevenção e tratamento das doenças causadas pelo HPV apresentam importante impacto econômico em todo mundo. No entanto, a falta de dados epidemiológicos nacionais, quanto à incidência e prevalência da papilomatose laríngea no Brasil não nos permite analisar o comportamento da doença em nossa população, bem como os benefícios da vacinação. Objetivo: Estimar a incidência e a prevalência da Papilomatose Laríngea no Estado de São Paulo. Métodos: Estudo populacional que objetivou levantar todos os casos diagnosticados de Papilomatose Laríngea do Estado de São Paulo, considerando os principais centros de diagnóstico desta enfermidade. Foram mapeados e selecionados os principais serviços de residência e especialização em Otorrinolaringologia do Estado de São Paulo, a partir dos dados fornecidos pela Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial (ABORL-CCF). Através do preenchimento de um questionário obtivemos os dados para estimar a prevalência e a incidência mínimas p... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Mercuri G. Incidence and Prevalence of Laryngeal Papillomatosis in São Paulo State [thesis]. Botucatu, SP: Faculty of Medicine of Botucatu, Universidade Estadual Paulista; 2019. Introduction: Recurrent respiratory papillomatosis or recurrent laryngeal papillomatosis is a benign laryngeal neoplasm caused by Human Papilloma Virus, characterized by the presence of recurrent exophytic proliferative lesions. Without curative treatment, costs related to the diagnosis, prevention, and treatment of HPV-related diseases have a significant economic impact worldwide. However, the lack of national epidemiological data on the incidence and prevalence of laryngeal papillomatosis in Brazil does not allow us to analyze the behavior of the disease in our population, as well as the benefits of vaccination. Objective: To estimate the incidence and prevalence of Laryngeal Papillomatosis in the State of São Paulo. Methods: A population study was conducted aiming to raise all the diagnosed cases of Laryngeal Papillomatosis of the State of São Paulo, considering the main centers of diagnosis of this disease. The main services of residence and specialization in Otorhinolaryngology of the State of São Paulo were mapped and selected, based on the data provided by the Brazilian Association of Otorhinolaryngology and Cervical-Facial Surgery (ABORL-CCF). By completing a questionnaire we obtained the data to estimate the minimum prevalence and incidence for the State in 2017. Results: The questionnaire wa... (Complete abstract click electronic access below) / Mestre

A fisiopatologia do edema de Reinke ainda permanece desconhecida e poucos estudos abordam sobre as alterações das proteínas fibrosas, colágeno e elastina, na matriz extracelular da prega vocal com edema de Reinke. Por isso, este estudo foi idealizado para descrever a distribuição das fibras colágenas e do sistema de fibras elásticas do espaço de Reinke com edema de Reinke comparando com a prega vocal normal e com a severidade do edema. Foram obtidas 20 amostras de pregas vocais de indivíduos com edema de Reinke, sendo nove casos com edema de Reinke grau II e 11 casos grau III. Dezessete indivíduos eram do sexo feminino e três do sexo masculino, com idade variando de 47 a 62 anos (55 ± 4,4 anos). Quinze pacientes eram tabagistas e cinco ex-tabagistas, média e desvio padrão de 22 ± 10,7 maço/ano. O tempo de disfonia apresentou média e desvio padrão de 36 ± 16,6 meses. Dez pregas vocais normais de laringes humanas excisadas foram utilizadas como controles. Os métodos da Picrossírius-polarização e da Resorcina-fucsina de Weigert com oxidação prévia pelo oxone 10% foram empregados para visualização das fibras colágenas e do sistema de fibras elásticas, respectivamente. Uma avaliação semiquantitativa foi utilizada para categorizar os resultados histológicos que foram correlacionados com a idade, consumo de cigarro, tempo de disfonia e com a severidade do edema. Evidenciou-se que o arranjo entrelaçado das fibras colágenas semelhante a uma cesta de vime observado em pregas vocais normais estava desestruturado no edema de Reinke. A desestruturação foi caracterizada por um afastamento das fibras, fragmentação, formando áreas esparsas e tomadas por um estroma mixóide de quantidade variável. Todos os casos de edema de Reinke mostraram uma maior preservação do arranjo das fibras colágenas próximo ao epitélio da prega comparada com as fibras da camada mais profunda do espaço de Reinke. O arranjo do sistema de fibras elásticas formado por fibras finas e onduladas paralelas à membrana basal do epitélio e uma rede de fibras mais finas, logo abaixo da membrana basal do epitélio observado em pregas vocais normais estava desestruturado no edema de Reinke. Na avaliação semiquantitativa observou-se que moderada e intensa desestruturação ocorreram em 90% dos casos com relação às fibras colágenas e em todos os casos para o sistema de fibras elásticas. Houve uma correlação estatisticamente significante entre a idade e o grau de desestruturação das fibras colágenas (r=0,47, p=0,037). Houve diferenças estatisticamente significantes entre os edemas grau II e III quanto à desestruturação das fibras colágenas (p=0,007) e quanto à idade (p=0,036). Observamos com este estudo que as alterações nas proteínas fibrosas presentes no edema de Reinke podem contribuir com a deformidade da prega vocal / The physiopathological mechanisms underlying Reinkes edema are still unknown and few studies addressed alterations in the fibrillar proteins, collagen and elastin, in extracellular matrix with Reinkes edema. This study was idealized to describe the distribution of collagen fibers and elastic system fibers in Reinkes space with Reinkes edema, comparing with normal vocal fold and with the severity of Reinkes edema. Twenty surgical vocal fold specimens were obtained from patients with Reinkes edema, nine cases presented grade II severity and 11 cases grade III. Seventeen subjects were females and three were males, ranging in age from 47 to 62 years (mean±SD 55 ± 4.4 years). Fifteen patients were smokers and five ex-smokers, mean±SD of 22 ± 10.7 pack-years. The duration of dysphonia ranged from 6 to 60 months (mean of 36 ± 16.6 months). Ten vocal folds from human larynges of nonsmokers cadavers were used as normal controls. The Picrosirius polarization method and the Weigerts resorcin-fuchsin stain after oxidation with 10% aqueous oxone were used for visualization of collagen fibers and the elastic system fibers, respectively. Findings were categorized semiquantitatively and correlated with age, cigarette smoking, duration of dysphonia and Reinkes edema severity. The intertwined network of collagen fibers resembling a wicker-basket found in normal vocal folds was disarranged in Reinkes edema. Disarrangement of collagen fibers was characterized by loosely arranged and fragmented fibers intermixed with varying amounts of myxoid stroma. All cases showed a better preservation of collagen fibers arrangement closer to the epithelium compared to fibers of the deeper of the Reinkes space. The elastic system fibers arrangement formed by a delicate network of thin and undulated fibers arranged in parallel to the epithelial basement membrane and a network of thinner fibers immediately below the basement membrane was disarranged. The semiquantitatively analysis showed that moderate and large areas of disarrangement of collagen fibers were found in 90% of cases and in all cases for elastic fibers. Age was significantly correlated with collagen fiber disarrangement (r=0.47, p=0.037). There was a statistical difference in collagen disarrangement (p = 0,007) and age (p=0,036) between grade II and grade III severity. In our study, the alterations in the fibrillar proteins observed in Reinkes edema may contribute to the vocal fold deformity

Bakgrund Ambulanssjuksköterskans hantering av luftvägen och ventilering vid hjärtstopp är av stor vikt för att en patient ska kunna återupplivas. Många hjälpmedel finns för att underlätta detta arbete, men prehospitalt finns det åtskilliga faktorer att ta hänsyn till som inte existerar på sjukhus och som kan inverka på ambulanssjuksköterskans val av metod för ventilering. Syfte Att undersöka vilka faktorer som påverkar ambulanssjuksköterskans val av metod för ventilering vid hjärtstopp. Metod En kvalitativ design användes med semistrukturerade intervjuer. Åtta intervjuer med specialistsjuksköterskor inom intensivvård och ambulanssjukvård genomfördes. Kvalitativ innehållsanalys användes för att analysera materialet.  Resultat Dataanalysen resulterade i fyra kategorier med tillhörande underkategorier. I kategorin Tiden prioriterades snabb ventilering för patienten samtidigt som avståndet till sjukhus också påverkade val av metod. Patienten och dennes förutsättningar är en kategori där bakomliggande orsaker till hjärtstoppet, patientens anatomiska förutsättningar samt om hjärtstoppet avslutades på plats eller inte påverkade ambulanssjuksköterskans metodval. Tredje kategorin var resurser som påverkade metodvalet genom att antalet enheter på plats och deras kompetens och erfarenhet hade en inverkan på metodval. Den fjärde kategorin användarvänlighet handlar om miljöfaktorer som påverkade metodvalet samt transport av patienten där avancerade metoder föredrogs för att underlätta förflyttningen. Slutsats Många av dessa faktorer är sådant som inte är något problem på sjukhus men som ambulanssjuksköterskan behöver vara medveten om. Vissa av faktorerna kan avhjälpas av verksamheten med ökad utbildning och modern utrustning men andra faktorer är sådant som ambulanssjuksköterskan behöver vara redo för att hantera. / Background Airway management is of great importance to the resuscitation in patients with cardiac arrest. There are a lot of tools to alleviate this task, but there are several factors to consider in out-of-hospital cardiac arrest, that doesn't exists within the hospital walls, that may influence the ambulance nurse method for managing the ventilation. Aim To study witch factors that influence the ambulance nurse choice of method to ventilate an out-of-hospital cardiac arrest. Methods A qualitative design was used with semi-structured interviews. Eight interviews were conducted with nursing specialists within intensive- and prehospital care. Qualitative content analysis was used to analyze the collected data. Results Data analysis resulted in four categories with associated under-categories. In the category Time distance to hospital had an effect on the choice of ventilation and fast ventilation was prioritized. The Patient was a category where the cause of the cardiac arrest, the patient anatomy and if the resuscitation was terminated on the spot or not was identified to have an impact on the method of airway management. The third category was Resources that influenced the airway approach was the amount of units on the scene and their competence and experience. The fourth category was ease-of-use where environment had an influence on airway management as well as the transportation of the patient. Conclusion Even though these factors often are a none-issue in the hospital it's vital to the ambulance nurse to be aware of these. Some factors can be alleviated by the agency with increased education and modern equipment but other factors are just something the ambulance nurse needs to be aware of and able to handle.

INTRODUÇÃO: O carcinoma papilífero da glândula tireoide é a neoplasia maligna endócrina mais prevalente com incidência em torno de 95%. Apresenta alto índice de disseminação linfática cervical, principalmente para os linfonodos do compartimento central ipsilateral, no nível VI, sendo os paratraqueais e os pré-traqueais os mais acometidos. Porém, existe uma área específica, não descrita nos compêndios anatômicos, que também é sede de metástase e de recidiva tumoral e está localizada entre o nervo laríngeo recorrente direito e as artérias carótida comum direita e tireóidea inferior direita. Uma abordagem cirúrgica nessa área causa maior morbidade devido à anatomia topográfica entre essas estruturas e os linfonodos ali localizados. Dessa forma, essa área pouco explorada é objetivo desse estudo, que pretende comparar dados antropométricos e demográficos com a presença ou não de linfonodos. MÉTODOS: Estudo anatômico transversal, com dissecção de 32 cadáveres não formalizados do Serviço de Verificação de Óbitos da Capital, onde se dissecou a região cervical à direita até a exposição da região localizada entre o nervo laríngeo recorrente direito e as artérias carótida comum direita e tireóidea inferior direita, com subsequente ressecção em bloco do tecido fibrogorduroso dessa região para análise dos linfonodos após preparação específica para esse fim. RESULTADOS: As características demográficas da população estudada foram as seguintes: Idade(anos): 66,75 ± 13,89; Sexo: masculino 20/32 (62,5%) e feminino 12/32 (37,5%); Peso (Kg): 63,1 ± 12,36; Altura (metros): 1,66 ± 0,09; IMC (Kg/m2): abaixo do peso 5/32 (15,6%), normal: 20/32 (62,5%), obeso: 3/32 (9,4%), obesidade mórbida: 4/32 (12,5%); Raça: branca 21/32 (65,62%), negra 10/32 (31,25%), amarela 1/32 (3,12%); Dados antropométricos: brevilineo 8/32 (25%), normolíneo 15/32 (46,88%), longilíneo 9/32 (28,12%). A presença de linfonodos em 22/32 (68,75%), IC 95%, nos casos em que se encontraram linfonodos, a média foi de 1,65 ± 0,29 linfonodos por cadáver. Presença de linfonodos em cadáveres classificados como normolíneos, pelo teste exato de Fischer (p=0,03) e da raça branca, pelo teste exato de Fischer (p=0,04). Não se observou relação entre IMC e a presença de linfonodos, pelo teste de Sperman (p=0,461). CONCLUSÕES: A presença de linfonodos foi confirmada em 22/32 das espécimes estudadas (68,75%); Quanto às características dos linfonodos encontrados, o número variou de zero a 6 e, contando somente os casos em que os linfonodos foram achados, a média foi de 1,65 ± 0,29 linfonodos por cadáver. O tamanho variou de 0,9 a 5,39 mm no diâmetro transverso e de 1,36 a 11,64 mm no diâmetro longitudinal. Houve correlação antropométrica com presença de linfonodos nos cadáveres considerados normolíneos (p=0,03) e da raça branca (p=0,04) / INTRODUCTION: The papillary carcinoma of thyroid gland is the most prevalent endocrin malignant neoplasm, whose incidence is around 95%. This type of cancer causes increased likelihood of lymphatic spread in neck region, mainly to lymph nodes of the ipsilateral central compartiment, in level VI, such as the paratraqueal and the pretraqueal lymph nodes. However, there is a specific area, not described in the anatomic literature, that is receptor of metastasis and of tumor recurrences and is located among the right recurrent laryngeal nerve and the right common carotid and right inferior thyroid arteries. A surgical approach in this area causes more morbidity because of the topographic anatomy among those structures and the lymph nodes located there. Thus, this unexplored area is objective of this scientific study, which pretends to compare anthropometric and demographic data with the lymph nodes presence or absence. METHODS: Cross-sectional anatomic study, with dissection of 32 non-preserved corpses from the Serviço de Verificação de Óbitos da Capital, this study there had happened dissection of the right neck region until the exposition of the region located among the right recurrent laryngeal nerve and the right common carotid and right inferior thyroid arteries. Moreover, there was made resection in block of fibroadipose tissue of this region to analyse the lymph nodes after being prepared with specific material for this goal. RESULTS: Those are the demographic characteristics of this studied population: Age (in years): 66,75 ±13,89; Gender: male 20/32 (62,5%) and female 12/32 ( 37,5%); Weight(Kg): 63,1 ± 12,36; Height(meters): 1,66 ± 0,09; BMI (body mass index) (Kg/m2): underweight 5/32 (15,6%), normal: 20/32 (62,5%); obese: 3/32 (9,4%); morbid obesity: 4/32 (12,5%); Race: caucasian 21/32 (65,62%), afrodescendants 10/32(31,25%), asian 1/32 (3,12%); anthropometric data: brevilineo 8/32 (25%), normolineo 15/32 (46,88%), longilineo 9/32 (28,12%). There are lymph nodes in 22/32 (68,75%); Confidence Interval 95%, in the cases that lymph nodes were found, the average was 1,65 ± 0,29 lymph nodes for each corpse. There are lymph nodes in corpses classified as normolineos by accurate Ficher\'s Test(p= 0,03) and of the white race by accurate Ficher\'s Test(p=0,04). There is no observed correlation between BMI and lymph nodes found, by Spearman\'s correlation test( p=0,461). CONCLUSIONS: lymph nodes were found in 22/32 studied corpses (68,75%). 0 to 6 is the gap of the number of lymph nodes found in the same body. In those bodies which lymph nodes were found, the average is 1,65 ± 0,29 lymph nodes for each body. Their size varies from 0,9 to 5,39 mm in the transversal diameter and from 1,36 to 11,64 mm in the longitudinal diameter. There is a anthropometric correlation with lymph nodes presence in corpses considered as normolineos(p=0.03) and of the white race (p=0,04)

O presente trabalho de doutorado tem por objetivo a criação de uma nova família de filtros digitais específica para o processo de classificação de dados, particularmente aplicada ao pré-diagnóstico de patologias na laringe. Antes de explicar a criação dessa nova família de filtros, foi apresentada uma breve revisão bibliográfica sobre o funcionamento do aparelho fonador humano, sobre o processo de diagnóstico de patologias e sobre a transformada discreta Wavelet, que serviu de base para a construção dos filtros propostos. Em seguida, é descrita a tecnologia proposta para a criação da nova família de filtros, que é baseada na construção da Transformada Wavelet de Daubechies, além disso, apresenta-se uma breve comparação com outras técnicas já descritas na literatura para a mesma finalidade. Posteriormente, são apresentados os resultados obtidos com base na técnica proposta, verificando-se uma taxa de acerto na classificação de vozes normais de 100% e uma taxa de acerto de 95,52% para vozes patológicas. / The main purpose of this thesis is the development of a new family of digital filters used for data classification, particularly applied to the pre-diagnosis of pathologies in the larynx. A brief bibliographical review, that concentrates on the functioning of the human vocal tract, on the process of disease diagnosis, and on the discrete wavelet transform, which formed the basis for the construction of the proposed filters, is presented. The technology used to develop these new families of filters, that is based on the Daubechies Wavelet Transform, is also described, moreover, a comparison with other techniques described in the specialized literature for the same purpose is also presented. The investigation shows the results obtained with the proposed technique, in which the accuracy of 100% in normal voice classifications and of 95,52% in pathological voice classifications, was obtained.