intrODuCtiOn

fasting is defined as abstinence from water and food in-take from sunrise to sunset. it is commonly practiced byMoslems in the month of ramadan as one of the rituals ofislam. the intermittent intake of water and food has severaleffects on the body and the vocal apparatus [1-3]. previousstudies have clearly illustrated that there are metabolicchanges more often than not accompanied by sleep depriva-tion and circadian rhythm alterations [4,5]. the metabolicchanges have been described as hypoglycemia, hyperlip-idemia, increase in uric acid and disturbances in electrolytes.the fluctuation in the lipid profile and many of the blood pa-rameters has been attributed to the alteration in the lifestyleoften experienced by the fasting subjects [6,7]. Most Mus-lims in order to compensate for the water and food depri-vation that occurs during the day increase their alimentaryintake during the night between sunset and sunrise.

As a result, to this behavioral change, metabolic altera-tions do occur with weight loss and dehydration being themost common. the weight loss has been reported to varybetwen 0.1-1.4 kg and signs of dehydration are invariablyencountered. As a result, cardiovascular, respiratory, uri-nary, ocular and, last but not least, phonatory health prob-lems may occur [2-3,8-9].

the authors of this manuscript have previously re-ported on the effect of fasting on voice in both females

and males using a questionnaire, acoustic analysis andlaryngeal video-endostroboscopic examination [2,3]. ina prospective study on 28 female subjects, vocal fatiguewas reported in almost 53% of the cases and phonatoryeffort had increased in 23 out of the 28 cases. thesesymptoms were coupled by a significant decrease in themaximum phonation time and no changes in the remain-ing acoustic parameters. likewise, in the male group, theincidence of vocal fatigue was higher while fasting com-pared to non fasting and 50% of the 26 subjects had anincrease in their phonatory effort. in both studies, thelaryngeal video-endostroboscopic findings were clini-cally irrelevant. hence, the explanation for the increasedphonatory effort and fatigue was based hypothetically onthe systemic effects of fasting namely dehydration, neu-romuscular fatigability and metabolic changes.

the purpose of this study is to examine further the vo-cal mechanism while fasting. is the increase in phonatoryeffort and or vocal fatigue experienced by fasting sub-jects accompanied by changes in the glottic closure time,namely in the ratio of the closing and opening phase?previous reports have indicated the presence of vocal foldedema, anterior glottal gap, and spindle shaped opening orincomplete glottic closure with vocal fatigue followingspecific phonatory tasks [10-14]. however, no previousstudies have examined glottic closure in fasting subjectsusing frame by frame analysis.

ARTICLE ORIGINAL / ORIGINAL ARTICLEFRAME By FRAME AnALySiS oF GLoTTiC CLoSuRE in FASTinG SuBjECTShttp://www.lebanesemedicaljournal.org/articles/66-1/original3.pdf

Abdul-latif hAMDAn1*, Georges ziADe1, Jihad nASSAr1, Alexander DOwli2

zaid Al zAGhAl1, Abla SiBAi3

hamdan Al, ziade G, nassar J, Dowli A, Al zaghal z, Sibai A.frame by frame analysis of glottic closure in fasting subjects.J Med liban 2018 ; 66 (1) : 16-20.

hamdan Al, ziade G, nassar J, Dowli A, Al zaghal z, Sibai A.une analyse image par image de la fermeture vocale de sujetsjeûnant. J Med liban 2018 ; 66 (1) : 16-20.

ABSTRACT • Objective : The purpose of the study is toexamine vocal fold closure in fasting subjects using frameby frame analysis. Subjects and Methods : Twenty-twomale subjects were recruited for this study. All subjectswere evaluated while fasting and non fasting. Frame byframe analysis of at least three glottic cycles was per-formed and reported as a mean closed quotient. The de-gree of phonatory effort and vocal fatigue was also report-ed. Results : The mean closed quotient for all subjectswhile non fasting was 0.427 ± 0.098 and while fasting0.441 ± 0.073, with no significant difference between thetwo (p value 0.417). There was a significant increase in thephonatory effort while fasting (0.23 non fasting vs. 0.77fasting, p value 0.036). Conclusion: There is no changein the mean closed quotient in male subjects while fasting.However, most subjects exhibit a significant increase inphonatory effort.

Keywords : fasting; glottis; larynx; voice

RÉSUMÉ • Objectif : Le but de l’étude est d’examiner la ferme-ture vocale de sujets jeûnant en utilisant une analyse image parimage. Sujets et méthodes : Vingt-deux sujets de sexe mas-culin ont été recrutés pour cette étude. Tous les sujets ont étéévalués pendant deux périodes : jeûne et non-jeûne. L’analyseimage par image d’au moins trois cycles glottiques a été effec-tuée et rapportée comme un quotient fermé moyen (QFM). Ledegré d’effort phonatoire et la fatigue vocale ont également étéévalués. Résultats: Pour tous les sujets le QFM non-jeûne était0,427 ± 0,098 et le QFM jeûne 0,441 ± 0,073, sans différencesignificative entre les deux quotients (p = 0,417). Il y avait uneaugmentation significative de l’effort pulmonaire pendant lejeûne 0,77 vs 0,23 pendant le non-jeûne (p = 0,036).Conclusion : Il n’y a pas de changement significatif dans lequotient fermé moyen chez les sujets masculins pendant lejeûne. Cependant, la plupart des sujets présentent une aug-mentation significative de l’effort phonatoire.

Mots-clés : jeûne; glotte; larynx; voix

1 Department of Otolaryngology, head and neck Surgery, 2 research assistant, 3 Department of health, American university of Beirut Medical Center, lebanon. *Corresponding author : Abdul-Latif Hamdan, MD e-mail: ah77@aub.edu.lb

Absence of changes in the closed glottic quotientwhile fasting should allude to other causes for the in-crease in phonatory effort and fatigue such as respiratorymuscle fatigue or increased vocal fold viscosity.

MAteriAlS AnD MethODS

A total of twenty-two male subjects have been recruitedfor this study. All participants have signed the informedconsent that was approved by the institution reviewBoard and the work was performed in accordance withthe principles of the 1983 Declaration of helsinki. Sub-jects with vocal fold pathologies, recent history of upperrespiratory tract infection or laryngeal manipulation wereexcluded from the study. Demographic data included age,weight, and history of smoking.

All subjects were evaluated while fasting and nonfasting. the authors have made sure that the number offasting hours exceeded 12 hours in all subjects. the eval-uation consisted of self-reporting degree of phonatoryeffort and vocal fatigue in addition to frame by frameanalysis of at least three glottic cycles using laryngealvideo-endostroboscopic recording.

the degree of phonatory effort and vocal fatigue wasgraded from 0 to 3 where 0 indicates absence, 1 mild, 2moderate, and 3 severe.

the subjects underwent laryngeal video-endostrobo-scopy using the 70-degree rigid telescope coupled to theDigital rhino-laryngeal-Strobe model 9100S. frame byframe Analysis (fBfA) technique was used to evaluate atleast three glottic cycles per subject. Count of the openframes was defined as the number of frames starting withthe first evidence of mid-membranous vocal fold openingand ending with the frame before the first evidence of mid-membranous vocal fold closure. the count of closed phasewas considered as the number of frames starting with thefirst evidence of mid-membranous vocal fold closure andending with the frame before the first evidence of mid-membranous vocal fold opening. See figure 1.

the percentage of closure duration was measured bycomputing the ratio of closed frames over the total num-ber of frames, i.e. open plus closed.

frequencies and means (± SD) were used to describethe sample, for categorical and continuous variablesrespectively. for each subject, the parameters were col-lected before and after fasting, and the appropriate statis-tical analysis for small-size samples (wilcoxon non-parametric paired test) was conducted. the analysis tookinto consideration the design (before and after) andmodality of data collection (paired data).

Differences were considered significant for p < 0.05.All analysis was conducted using SpSS software.

Figure 1. Frame by frame analysis of a glottic cycle. Note the mid membranous vocal fold opening on the third frame and beginning of mid membranous vocal fold closure on frame number eight, indicating a closed quotient of 0.5.

A-L. HAMDAN et al – Glottic closure in fasting subjects Lebanese Medical Journal 2018 • Volume 66 (1) 17

reSultS

Demographic datatwenty-two healthy male subjects were recruited for thisstudy. Age ranged between 20 to 48 years with a mean of30.23 + 8.38 years. forty-five percent of the subjectswere smokers. while non fasting, the mean weight was78.65 kg ± 13.40 kg. while fasting, the mean weight was77.46 kg ± 13.29 kg. it is worth noting that the decreasein weight while fasting ranged between 0.5-3.30 kg andclose to 81% of the subjects had a decrease in weight.See table i.

Phonatory effort and vocal fatigue there was a significant increase in the phonatory effortwhile fasting compared to non fasting (0.23 non fasting vs.0.77 fasting, p value 0.036). forty percent of the subjectshad an increase in the phonatory effort while fasting and in22.7% the increase was by two points. As for the vocalfatigue, there was an increase while fasting in the overallmean by 0.32; however the increase was not statisticallysignificant (p value 0.07). this was accompanied by a sig-nificant decrease in weight (p value 0.00). See table ii.

Frame by frame analysisfor the frame by frame analysis, the mean closed quo-tient for all subjects while non fasting was 0.427 ± 0.098and while fasting 0.441 ± 0.0734, with no significant dif-ference between the two (p value 0.417). it is worth not-ing that 13 subjects out of the 22 had no change in theclosed quotient while fasting and non fasting. in the nineremaining subjects 5 had an increase and 4 had a decreasein the closed quotient while fasting. See table iii.

DiSCuSSiOn

Several measures have been used to assess glottic closureduring phonation. these include subjective measures likeperceptual evaluation using the GrBAS (grade, roughness,breathiness, asthenia, strain) classification and the Voicehandicap index, and objective ones such as spectroacousticanalysis, airflow measurements and laryngeal video-strobo-scopy [15-17]. the latter has also been used to assess theextent of mucosal waves which is a reflection of vocal foldcontact and malleability [18]. Other parameters reported instroboscopy are closure pattern, symmetry and periodicityof closure. Despite the fact that stroboscopy is an illusionaryrepresentation of the glottic behavior, various phases of aglottic cycle is often described. these are the opening phase,open phase, closing phase and then closed phase.

frame by frame analysis is a technique used to evaluatethe glottic cycle recorded by laryngeal stroboscopy. the per-centage of closure duration is usually measured by comput-ing the ratio of closed frames over the total number offrames, i.e. open plus closed. Subjects with normal vocalfolds phonating at a modal register will have 50% of theirglottal cycle in an open phase [19]. this finding has beensubstantiated by many authors further documenting that the

ratio of closed frames to rest of cycle is one to two [20].A decrease in the glottic closure is a sign of glottic insuf-

ficiency whereas an increase is probably indicative of hyper-functional behavior or excessive closure as in patients withhyperadduction of the vocal folds. Glottic insufficiency isdefined as unintentional escape of air from the glottis duringphonation. it is primarily due to paresis or paralysis of thevocal fold. Carroll et al. have shown that patients with atro-phy or paresis of the vocal folds experience a reduction inthe average closure duration to 32-38% compared to 50% innormal subjects [21]. Other causes of glottic insufficiencyinclude hypoadduction as in patients with parkinson’s dis-ease, bowing of the vocal folds secondary to aging, scarringfollowing phonosurgery and others. the clinical presenta-tion of glottic insufficiency is a constellation of symptomslike breathiness, loss of range, loss of power, and aspiration.Among these symptoms is vocal fatigue and increase invocal effort.

the authors of this manuscript have hypothesized thatvocal fatigue and increase in phonatory effort could be asso-ciated with a change in the ratio of open to closed frameswithin a glottic cycle, either a decrease suggestive of glotticinsufficiency or an increase suggestive of hyperfunction. Adecrease in closed quotient could be hypothetically second-ary to thinning of the vocal folds with the weight loss whilefasting or secondary to bowing of the vocal folds with theadductor muscle fatigue. On the other hand, an increase inthe closed quotient could be due to a hyperfunctional glottic

18 Lebanese Medical Journal 2018 • Volume 66 (1) A-L. HAMDAN et al – Glottic closure in fasting subjects

TABlEAU IDEMOGRAPHIC DATA

Age 30.23 ± 8.38Gender MaleSmoking 45.50%Mean weight

While fasting 77.46 kg ± 13.29 kgWhile non fasting 78.65 kg ± 13.40 kg

TABlEAU IIICLOSED QUOTIENT USING FRAME By FRAME ANALySIS

Fasting Non-fasting

Mean ClosedQuotient ± SD 0.441 ± 0.0734 0.427 ± 0.0985

Range 0.3 - 0.6 0.3 - 0.6p value 0.417

TABlEAU IIDEGREE OF PHONATORy EFFORT, VOCAL FATIGUE

ON A SCALE OF 0 TO 3

Mean pNon-fasting Fasting

Phonatory effort 0.23 0.77 0.036

Vocal fatigue 0.36 0.68 0.071

behavior as a manifestation of the increase in phonatoryeffort and fatigability. the results of our study show that theincrease in vocal fatigue and phonatory effort while fastingdid not affect the mean closed quotient indicating that theclosure pattern was not affected by either glottic insufficien-cy or hyperfunction. in our study the mean closed quotientwas close to 50% (0.42 while non fasting and 0.44 whilefasting) indicating that there was no glottic insufficiency inour subjects. More so there was no significant change in themean closed quotient of the overall group in fasting com-pared to non fasting. As a matter of fact, 60% of the subjectshad the same closed quotient while fasting and non fasting.

that being stated, possible explanations for the increasein phonatory effort and fatigue are many. the underlyingmechanisms include neuromuscular fatigue, increased vocalfold viscosity, reduced blood circulation, neuromuscular tis-sue strain and respiratory muscle fatigue [22]. Among theseare dehydration and or alterations in respiratory function.fasting subjects are estimated to lose weight between 0.1 kgto 1.4 kg, most of which is water. in our study, 81 had adecrease in weight that varied between 0.5 kg to 3.3 kg witha mean of 1.29 kg. the decrease in weight while fasting ismostly water as evidenced by an increase in serum electro-lytes and proteins [4]. Dehydration whether systemic or localcan affect the vibratory behavior of the vocal folds by induc-ing rheologic changes that in turn can affect the viscoelas-tic properties of the vocal fold [23,24]. Adults subjected tosystemic dehydration experience an increase in the phona-tory effort that is reversed with hydration [17]. Similarly,Solomon et al. have demonstrated that the increase inphonatory threshold pressure witnessed after vocal loadingcan be attenuated by drinking water in three out of fourfemale subjects [13]. hence dehydration during fasting canexplain the increase in phonatory effort and vocal fatigue.

A second possible explanation for the phonatory symp-toms in fasting subjects is the alterations in respiratoryfunction in fasting subjects. in a study by Duncan et al.there was a reduction in pulmonary expiratory flow and theratio of dead space to tidal volume [25]. in a similar studySubhan et al. have reported an increase in the expiratoryflow rates post ramadan relative to ramadan [26]. thedifferences in body mass and forced expiratory flow (fef75) in ramadan and post ramadan showed a significantcorrelation [26]. As breathing is a major component forvoice production, the aforementioned changes in respirato-ry function can affect phonation.

A third important confounding factor that might have hadan impact on the higher prevalence of vocal fatigue and in-creased phonatory effort while fasting is laryngo-pharyngealreflux disease. the changes in the eating habits and behav-ior during the month of ramadan submit the fasting subjectto chronological and physiological changes [27-30]. therehave been conflicting reports in the literature on the inci-dence of ulcer disease and gastro-intestinal bleeding in fast-ing subjects compared to non-fasting with no clear consen-sus [31,32]. Both acid and pepsin levels have been reportedto increase during ramadan, secondary to the aforemen-tioned behavioral changes in relation to food intake [33,34].

the impact of the alteration in gastric secretions on thelaryngopharyngeal complex is hard to measure in this studydue to the lack of ph monitoring and or impedance mea-surements. nevertheless, reflux remains hypothetically apossible coexisting confounding factor.

last but not least is the possible correlation between reli-giosity and vocal symptoms. there are numerous reports inthe literature suggesting that religion plays an importantdetermining factor in mental health, cancer, cardiac disease,depression, psychopathology, oral health and health out-comes in general [35-40]. A comprehensive literature searchon the impact of religious intervention on health outcomesrevealed that acts such as prayer may decrease hospital stay,duration of disease, adverse outcomes of cardiac diseasesand many other medical conditions. As such, and becausereligiosity emphasizes the supreme value of life and isregarded by many as an example of psychosocial healthdeterminant, fasting subjects may either exaggerate or sup-press the voicing of their phonatory complaints in view oftheir religious beliefs. this fact needs to be taken into con-sideration in the interpretation of our findings. A future studyon the correlation between religiosity and vocal health mayshed information on this topic.

Our study has three limitations. One is the lack of respi-ratory function tests as outcome measurement tools for bet-ter understanding of the phonatory symptoms. Second is thesmall sample size. last but not least is the lack of a controlgroup given the known variations in phonatory effort in rela-tion to vocal loading, sleeping pattern and dietary factors. tothat end, fasting by itself may not be the sole culprit for theincreased phonatory effort and vocal fatigue, as the changein lifestyle often witnessed in non-fasting subjects with dualjobs and altered sleep patterns may also be responsible forthese phonatory symptoms. this has been reiterated upon inthe explanation of phonatory effort and vocal fatigue in thecontext of neuromuscular and respiratory fatigue. unfortu-nately, a control group is missing in this study in view of theextreme hardship in recruiting subjects that match the fast-ing group in terms of the aforementioned factors. fasting byitself may not be the sole culprit for the increased phonato-ry effort and vocal fatigue, as the change in lifestyle oftenwitnessed in subjects with dual jobs and altered sleep pat-terns may also be responsible for these phonatory symp-toms. nevertheless, this study casts more light on the inter-play between phonatory effort, vocal fatigue and fasting.looking at the phonatory threshold pressure should be thesubject of a future investigation.

COnCluSiOn

fasting subjects have increased vocal effort and fatigue.these phonatory symptoms are accompanied by weightloss and dehydration in the majority of the cases. frameby frame analysis failed to reveal any changes in the clos-ing phase of the glottic cycle to indicate glottic insufi-ciency or hyperkinetic behavior. future studies on vocalfold viscosity and respiration are needed to unveil thecause of increased effort and fatigability while fasting.

A-L. HAMDAN et al – Glottic closure in fasting subjects Lebanese Medical Journal 2018 • Volume 66 (1) 19

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20 Lebanese Medical Journal 2018 • Volume 66 (1) A-L. HAMDAN et al – Glottic closure in fasting subjects