title: Does hyaluronic acid distribution in the larynx relate to the newborn's capacity for crying?
abstract: OBJECTIVE
  The newborn is heavily dependent on voice communication and therefore has relatively higher vocal demands and expenditures than the adult, the loudness output per mass performance exceeds that of the adult, and the newborn larynx exhibits significant histological and biochemical differences. The neonatal larynx is capable of sustaining relatively greater pitch and loudness than the adult over longer periods of time. This ability may be related to a more compact arrangement of collagen within the lamina propria, less interstitial space, and a uniform distribution of hyaluronic acid (HA). As HA is the primary determinant of vocal fold viscosity and water content, the distribution of HA in the superficial portion of the neonatal vocal fold is hypothesized to be related to newborn crying endurance. Our objective was to examine the histological structure and the quantity and arrangement of HA within the lamina propria of the pediatric larynx and review the relevant physiology of hyaluronic acid and its impact on voice production.
  
  
  METHODS
  Histological and digital subtraction analysis.
  
  
  METHODS
  Intact, neonatal larynges were sourced from fresh cadaveric specimens. Trichrome stain was used to assess the collagen content and location in the tissues. HA was stained using a colloidal iron staining technique with and without incubation with bovine testicular hyaluronidase. Average optical density was calculated in tissue before and after treatment with hyaluronidase, and the stain intensity ratio was calculated.
  
  
  RESULTS
  A total of 14 larynges were suitable for examination, eight males and six females. Histological examination revealed a uniform appearance of the vocal fold without evidence of a distinct vocal ligament or layered structure. Colloidal iron staining revealed an even distribution of HA throughout the vocal fold with no significant difference between quadrants. Images of the colloidal iron-stained tissue had a mean pixel intensity of 82 of 255. Slides of vocal fold tissue treated with hyaluronidase revealed a pixel intensity of 106 of 255 for a 22% mean difference in stain intensity (P < .01).
  
  
  CONCLUSIONS
  The identification of the layered structure of the adult lamina propria has raised a number of questions as to the development and purpose of the human larynx. Based on histological observations from the current study, possible explanations for the physiological differences include differences in the distribution and tissue concentration of HA and consequently dynamic viscosity, oncotic affinity for water, and less intercellular space in the superficial lamina propria.
authors.affiliation: Department of Otolaryngology, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA. jschweinfurth@ent.umsmed.edu
authors.forename: John M
authors.initials: JM
authors.lastname: Schweinfurth
authors.forename: Susan L
authors.initials: SL
authors.lastname: Thibeault
mesh_terms: D002102:Cadaver; D003448:Crying / Q000502:physiology*; D005260:Female; D005865:Gestational Age; D006801:Humans; D006820:Hyaluronic Acid / Q000032:analysis*; D007231:Infant, Newborn; D007830:Larynx / Q000737:chemistry* / Q000166:cytology; D008297:Male; D014827:Vocal Cords / Q000737:chemistry / Q000166:cytology
chemical_list: D006820:Hyaluronic Acid