The Laryngoscope
Lippincott Williams & Wilkins, Inc.
© 2006 The American Laryngological,
Rhinological and Otological Society, Inc.
A New Generation Videokymography for
Routine Clinical Vocal Fold Examination
Qingjun Qiu, PhD; Harm K. Schutte, MD, PhD
Objective: This study aims to introduce a new-
generation videokymographic system, which provides
simultaneous laryngoscopic and kymographic image,
for routine clinical vocal fold examination. Study De-
sign: The authors explored a new imaging method for
diagnosis and evaluation of voice disorders. Methods:
The new-generation videokymographic system in-
cludes two charge-coupled device image sensors, a
color area image sensor, and a monochromic high-
speed line-scan image sensor. The high-speed line-
scan image sensor is used to capture the kymogram,
and the color area image sensor is used to obtain the
laryngoscopic image. The two images can be dis-
played simultaneously on a video monitor or stored in
a standard video recorder. Three subjects with non-
pathologic voice were investigated in detail with the
new videokymographic system. Results: The high-
quality laryngoscopic image and kymogram can be
used directly for clinical purposes with no further
postprocessing. The scan position of the kymogram is
always indicated in the laryngoscopic image, which
provides feedback for the operator to easily locate the
expected scanning position. All varieties of vocal fold
vibration, including irregular vibrations, phonation
onset and offset, can be observed with the presented
method. The continuous kymogram of the vocal fold
vibration can be retrieved from a kymographic image
sequence for quantitative analysis. Conclusions: The
new-generation videokymography provides a simple,
quick means to investigate vocal fold vibration, espe-
cially for voice disorders. It can emerge as an impor-
tant tool for routine clinical vocal fold examination.
Key Words: Videokymography, vocal fold vibration,
From the Groningen Voice Research Lab, Department of Biomedical
Engineering, University Medical Center of Groningen, University of Gro-
ningen, Groningen, The Netherlands.
Editor’s Note: This manuscript was accepted for publication June 7,
2006.
The work was done in Groningen Voice Research Lab, the Depart-
ment of Biomedical Engineering, University Medical Center of Groningen,
University of Groningen, Groningen, The Netherlands.
This research was supported by the Technology Foundation STW,
the applied science division of NWO, and the technology programme of the
Ministry of Economic Affairs, The Netherlands, project No. G5973.
Send correspondence to Dr. Qingjun Qiu, BioMedical Department, Uni-
versity Medical Center of Groningen, University of Groningen, A. Deusing-
laan 1, NL 9713AV Groningen, The Netherlands. E-mail: q.qiu@med.umcg.nl
DOI: 10.1097/01.mlg.0000233552.58895.d0
Laryngoscope 116: October 2006
1824
laryngoscopy, voice disorders, routine clinical vocal
fold examination.
Laryngoscope, 116:1824 –1828, 2006
INTRODUCTION
The use of kymographic imaging as a method for visu-
alizing vocal fold vibration, especially for disordered vibra-
tion, has increased greatly since Gall and Hanson first in-
troduced it to register the motion of the vocal folds in 1971.1
In their research, a special photograph camera with a slit
shutter was used to expose the vocal fold movement onto the
film, a method that is known as photograph kymography.
This method is extremely time-consuming because the film
must still be developed with the result that photograph
kymography is not practical for routine clinical diagnosis.2
Fortunately, videokymography (VKG),3 in which the
kymographic image is encoded as a standard video signal,
can reveal the vocal fold kymogram directly on a standard
video monitor. Thus, the use of this real-time imaging tech-
nique spread rapidly into voice research and clinical prac-
tice. Schutte et al. reported the first clinical application of
VKG in 1998. In their study, more than 800 patients with
various functional and organic voice disorders were exam-
ined.4 Jiang et al. used VKG to quantify vocal fold mucosal
wave movements in canine larynges.5 Verdonck-de Leeuw
et al. combined videokymographic image sequences and
speech signals to evaluate the effect of irregular vocal fold
vibration on voice quality.6 A common conclusion from these
studies is that, with high spatial and temporal resolution,
VKG would emerge as a valuable method for voice disorder
diagnosis and a powerful tool for better understanding the
mechanism of the vocal fold vibration.
However, several drawbacks of the first-generation
VKG, which are illustrated in the “Discussion” section,
slowed the progress of its application during the last 5 years.
To overcome these obstacles, a new-generation videokymo-
graphic system has been developed that retains the advan-
tages of the first-generation VKG while resolving its prob-
lems. A preliminary clinical result is also presented,
illustrating what has been improved in the new system.
MATERIALS AND METHODS
The New-Generation Videokymography
The new-generation videokymographic system includes two
charge-coupled device (CCD) image sensors, a color area CCD,
Qiu and Schutte: A New Generation Clinical Videokymography
and a monochromic high-speed line-scan CCD. For the kymo-
graphic imaging, the high-speed line-scan CCD is used to capture
a selected line, which is usually aligned perpendicular to the
glottal axis of the vocal folds. The color area CCD sensor is used
to record the laryngoscopic image. A beam splitter optically di-
vides the image from the laryngoscope into two paths, one path
for the area CCD and the other for the line-scan CCD. The two
CCDs work simultaneously so that the laryngoscopic image and
kymographic image can be obtained at the same time. By means
of the beam splitter, the position of the linear CCD is fixed on the
reflective center of the area CCD, i.e., the kymogram taken from
the line-scan CCD shows the vocal fold vibration at the center line
of the laryngoscopic image.
The system is divided into two parts, a camera head and a
controller unit. The two parts connect with one another by a
high-performance video cable. The camera head houses only the
image sensors and the beam splitter, reducing weight and size for
easy handling. The main controller unit contains an embedded
microprocessor and a frame buffer memory, providing capability
for processing the video images in real time. The system has two
output interfaces, an analog and a digital. The analog video output
allows the two images to be displayed on a standard analog video
monitor, whose screen is vertically split into two equal parts with
the laryngoscopic image on the left and the kymogram on the right.
The digital output port allows the video data to be acquired by a
digital video frame-grabber. Custom-made software, which includes
a database system, was developed to capture, display, and store the
images.

The Instruments and Subjects

The new-generation videokymographic system was used for
gathering kymographic data of the present study. The images
were obtained with a 90° rigid laryngoscope (Richard Wolf
4450.57, Germany) together with a C-mount optical adapter
(Richard Wolf 5261.27, f ⫽ 32 mm, Germany) The vocal folds were
illuminated by the light from a 300-W xenon light source (Kay
Elemetrics 7150), which is transmitted to the tip of the endoscope
using a bunch of optical fibers. For digital recording, a 16-bit
parallel digital frame-grabber (National Instruments PCI-1422)
was used to directly obtain the images from the digital port of the Fig. 1. The new kymographic images from subject no. 1. The upper
new system. For analog video recording, an s-VHS video recorder one was captured during a sustained vowel /i/. The lower images
(Panasonic AG-7355; Panasonic-Matsushita Electric Industrial show irregular vocal fold vibration when the subject intentionally
Co., Ltd., Japan) was used. The analog video recording was then produced a hoarse voice. Each image is vertically split into two
digitized by a video frame-grabber (National Instruments PCI- parts. The left part shows the laryngoscopic image and the right part
1411). For comparison purposes, the first-generation videokymo- shows the kymographic one. The white line in the laryngoscopic
image indicates the scanning position of the kymogram. “A” points
graphic system (Lambert Instruments, BV, Leutingewolde, The
out a blood vessel on the vocal folds. “B” and “C” indicate vibratory
Netherlands) was also used in the experiment. cycles, respectively, with and without closed phase. “L” and “R”
Three subjects with nonpathologic voices were investigated in indicate left and right sides, respectively.
detail in the Groningen Voice Research Lab in The Netherlands.

RESULTS graphic image contains approximately seven vibratory cy-

The upper part of Figure 1 was captured by the new
system while subject no. 1 was sustaining the vowel /i/. The
laryngoscopic and kymographic images are shown on the left
and the right, respectively. The white line in the laryngo-
scopic image indicates the scan position for the kymogram.
The vocal folds in the laryngoscopic image appear blurred
because the area CCD is not fast enough to follow the vibra-
tion of the vocal folds (25 frames per second); the high-speed
kymographic image, however, clearly displays the vibrations
(7200 lines per second). Each frame contains 40 millisecond
of vibratory history of the vocal folds. Thus, the fundamental
frequency of the regular vocal fold vibration can easily be
estimated by counting the number of vibratory periods in the
kymographic image. In this particular frame, the kymo-
cles, implying that the fundamental frequency is approxi-
mately 175 Hz for this phonation. Other quantitative
parameters such as closed quotient can be calculated by
postprocessing software.
The lower part of Figure 1 shows an irregular vocal
fold vibration when the subject intentionally produced a
hoarse voice. Like in the upper half of the figure, the
laryngoscopic image is also blurred. The kymographic im-
age, however, shows a complex disordered vibration pat-
tern. The closed phase is much shorter than in a regular
vibration (as indicated in B), and several of these cycles
have no closed phase (as indicated in C).
Onset and offset are particularly revealing phases of
phonation. In clinical practice, the assessment of a pho-

Laryngoscope 116: October 2006 Qiu and Schutte: A New Generation Clinical Videokymography
1825
 Fig. 3. Two kymographic images from subject no. 3. The left image
was taken with the old videokymographic system and the right one
with the new system. The subject was instructed to maintain the
same pitch and loudness. “L” and “R” indicate left and right sides,
respectively.

sired scanning position, a general operational rule must be

Fig. 2. A kymographic image sequence from subject no. 2. The
images were taken during a very brief phonation of vowel /i/, doc-
umenting voice onset and offset. The phonation continues without
interruption from the left segment through the right. “L” and “R”
indicate left and right sides, respectively.
observed. First, the normal mode is used to locate the vocal
folds in the laryngoscopic image. The desired scanning posi-
tion must be kept at the top of the laryngoscopic image,
because only the top line will be scanned in the kymographic
mode (Fig. 4A). Then the kymographic mode is activated to

nation onset can be used as a tool to diagnose vocal dys-

functions. To show the capability of revealing phonation
onset and offset with the new system, Figure 2 illustrates
a complete short phonation, including the phonation onset
and offset period. The image was obtained when subject
no. 2 produced a very short vowel /i/. In this case, during
the onset period, the two vocal folds are synchronized.
However, the right vocal fold is ahead of the left vocal fold
during the offset period.
For comparison purposes, subject no. 3 was examined
with both the new- and the old-generation videokymo-
graphic systems. The subject was instructed to keep the
pitch and loudness constant for both examinations. Figure 3
shows the result. The left image was taken with the old
videokymographic system and the right with the new one.

DISCUSSION
The simultaneous laryngoscopic and kymographic im-
aging in the new system dispenses with the complicated
operational procedure of kymogram acquisition used in the
old-generation VKG system, illustrated in Figure 4. The old
system provides two working modes, normal mode and ky-
mographic mode. In the normal mode, laryngoscopic images
are obtained. The kymographic mode produces the high-
speed kymogram. A footswitch controls the working mode.
However, the two working modes are mutually exclusive,
preventing the operator from seeing the scan position while
using the kymographic mode. Therefore, to obtain the de-
Fig. 4. A general procedure for acquiring a kymographic image with
the old-generation videokymograph. The videokymograph has two
working modes, a (A) normal mode and a (B) kymographic mode.
The normal mode is first used to locate the desired scanning posi-
tion on the top line of the laryngoscopic image. Then one shifts to
the kymographic mode, and the kymogram of the top line in the
laryngoscopic image is revealed on the screen (B). The interlaced
kymogram makes the images not directly observable from the
screen. As a result, postprocessing is necessary to retrieve the
kymogram, which will always lack the information during the vertical
blanking period (C).

Laryngoscope 116: October 2006 Qiu and Schutte: A New Generation Clinical Videokymography
1826
obtain the kymogram. However, if there is subsequently a
slight relative movement between the endoscope and the
vocal folds, the kymogram will represent the vibrations at a
position other than the intended one. The error can be more
serious if the operator does not notice that discrepancy, pos-
sibly resulting in an incorrect clinical diagnosis. Fortunately,
the new VKG system presents the laryngoscopic and kymo-
graphic images simultaneously with the scan position of the
kymogram always indicated on the laryngoscopic image.
Even a slight relative movement between the vocal folds and
the endoscope would be revealed in the laryngoscopic image.
In this way, the simultaneous imaging greatly facilitates
finding the desired position for the kymogram along the
glottis.
The new imaging system also provides an uninter-
rupted kymogram, which was not possible in the old system.
The old VKG is a species of television standard video camera
(PAL standard is used in this article) in which each half
frame of 20 milliseconds, called a field, contains an active
time and a vertical blanking time. The video image can only
be shown during the active time of 18.4 milliseconds. As a
result, during the vertical blanking period, the kymographic
information is missing (Fig. 4C). However, in the new sys-
tem, this problem is solved by buffering the kymographic
image. During vertical blanking, the line-scan CCD still
captures kymographic images, which cannot be displayed
but can be stored in the buffer memory of the controlling
system. When the video is activated, these images will be
displayed. This makes possible the construction of a contin-
uous kymogram, like in Figure 2.
For the clinical application, it is very important to
keep examination time brief. The real-time laryngoscopic
and kymographic imaging of the new system greatly
speeds the process. Examination time using the first-
generation VKG is relatively short, but some postprocess-
ing is always necessary to obtain satisfactory images. In
that system, there are two problems with the raw kymo-
graphic image, which is displayed on the video screen in
real time (see Fig. 4). First, every second line is black,
interrupting the continuity of information. Second, in nor-
mal video, each frame is made up of two interlaced fields,
an odd and an even. Without postprocessing, the display of
these interlaced kymograms is difficult to read. Figures
4B and 4C show kymograms before and after postprocess-
ing. Both problems are caused by the TV standard used in
the old system. However, in the new system, the digital
signal processor reformats output video data so that these
problems are eliminated, and the images can be used
directly for clinical purposes. If desired, postprocessing
can be implemented for extracting quantities such as fun-
damental frequency and closed quotient.
The new videokymophic system has both analog and
digital video outputs. Using the PAL standard, the images
from the analog output can be shown on a standard video
monitor, stored in a standard video recorder, or printed by
a video image printer. However, the maximal spatial res-
olution is also limited by the PAL standard of 720 ⫻ 576
pixels. The laryngoscopic and kymographic images each
occupy half of the frame, having a maximal spatial reso-
lution of 360 ⫻ 576 pixels. This limitation is overruled in
the digital video output, which is based on a nonstandard
Laryngoscope 116: October 2006
parallel digital interface. The resolution of laryngoscopic
image is 720 ⫻ 576 pixels in one frame with 25 frames per
second. The resolution of kymographic image is 625 pixels
per line with 7,200 lines per second. A further advantage
of using the digital port is that the speed of the digital port
is high enough to transfer the raw image in real time
without any loss through compression. Thus, the quality
of the images from the digital port is superior to that from
the analog port. Nevertheless, both the analog port and
the digital port provide noninterrupted vibratory informa-
tion of the vocal folds, which can be digitized or acquired
by a computer, quantified by analysis software, and stored
in a database system.
The CCD used to record the kymographic image has
a particularly high sensitivity, resulting in two major ad-
vantages of the new system. First, the high-sensitivity
imaging reduces the requirement for the light source. A
standard 250-W or 300-W xenon light source is sufficient
to obtain good-quality images. A 180-W xenon light source
is even adequate if a rigid laryngoscope with direct optical
fiber connection is used, that is, the optical fiber is an inte-
gral part of the laryngoscope. Second, the high-sensitivity
feature gives it a marked advantage in image quality over
other commercially available kymographic systems. Figure 3
shows the obvious difference in image quality between the
old videokymographic system and the new one. In the noise-
free image of the new system, even the blood vessels on the
vocal folds are recognizable (Fig. 3).
The advances in image quality also provide a promising
impression of three-dimensional vocal fold movement. In
comparison to the upper part of Figure 1, the three-
dimensional vibration of the whole vocal folds is more sa-
liently recognizable in the kymographic image of the lower
part of Figure 1. The chief explanation of the high-amplitude
vocal fold movement is that the vocal folds are less coupled to
the airflow in this specific irregular phonation with a high
mean airflow. A similar phenomenon can be seen in vocal
fold vibration in a unilateral laryngeal paralysis.4 Evidence
of such a three-dimensional movement pattern might help to
interpret the cause of an existing vocal fold disorder.
The three-dimensional vocal fold movement can also
be revealed with stroboscopy. However, stroboscopy has a
serious limitation in that it works only with periodic vi-
bration.7 To observe aperiodic vibration, VKG or a full
high-speed camera is the proper choice.
Several earlier papers have compared the old system
of VKG and the full high-speed camera with respect to
their various advantages,8,9 and we do not repeat that
comparison here. The new system, however, adds major
improvements, discussed previously, to the advantages of
the old VKG. The most important of these advantages is
its high image quality, which includes high spatial reso-
lution, high temporal resolution, and a high signal-to-
noise-ratio. Another important advantage is lower data
volume, allowing the kymographic image to be captured in
real time without the time constraint that pertains to the
full high-speed camera.
The audio and the electroglottograph signals also play
an important role in voice research. The system provides a
synchronization mechanism to align the audio signal and
Qiu and Schutte: A New Generation Clinical Videokymography
1827
electroglottogram. This is beyond the scope of the present
study and will be addressed in a forthcoming paper.
CONCLUSION
Our results show that the new-generation videokymo-
graphic system provides high-quality laryngoscopic and ky-
mographic images simultaneously. For the first time, the
kymographic image can be visualized directly on a video
monitor or stored in a standard video recorder without any
waiting time for postprocessing, remarkably reducing exam-
ination time. A continuous kymogram of the vocal fold vibra-
tion can be retrieved from a kymographic image sequence
without interruption of vertical blanking. This gives the new
VKG system important advantages not only for clinical pur-
poses, but also for voice quantitative research. In summary,
the new-generation VKG provides a simple and fast way to
study vocal fold vibration, especially when this is irregular.
It will be an important tool for routine clinical vocal fold
examination as well as for detailed research.
Acknowledgments
The authors gratefully acknowledge D. G. Miller for
help with the English version of the article. The authors also
Laryngoscope 116: October 2006
1828
appreciate the comments of J. G. Švec and N. A. George in
reviewing the manuscript.
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Qiu and Schutte: A New Generation Clinical Videokymography