{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,16]],"date-time":"2026-05-16T00:55:03Z","timestamp":1778892903604,"version":"3.51.4"},"reference-count":21,"publisher":"Wiley","issue":"6","license":[{"start":{"date-parts":[[2020,12,31]],"date-time":"2020-12-31T00:00:00Z","timestamp":1609372800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["R01 DC009435"],"award-info":[{"award-number":["R01 DC009435"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["The Laryngoscope"],"published-print":{"date-parts":[[2021,6]]},"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>During vocal fold vibration, the medial surface of both folds forms a convergent shape during opening and a divergent shape during closing. A greater maximum divergence angle is associated with greater closing forces which will increase the closing speed of the glottis. An increased closing speed results in a greater acoustic intensity and greater vocal efficiency. Indentation testing showed that as the strain increases, the inferior aspect of the folds becomes stiffer than the superior aspect, resulting in the vertical stiffness gradient (VSG). We hypothesize that a reduction of the vertical stiffness gradient will reduce the maximum divergence angle.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Four excised canine larynges were tested. Stress\u2013strain curves of the superior and inferior aspects of the fold in the mid membranous plane of the baseline larynges were taken using the indentation method. Calcium hydroxylapatite (CaHA) crystals were then injected into the superior aspect of the fold. The stress\u2013strain tests were repeated. Particle imaging velocimetry (PIV) of the intraglottal velocity fields was performed in three larynges at different subglottal pressures in the mid coronal plane for the baseline and CaHA\u2010injected larynges.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>CaHA injection reduced the inferior\u2013superior stiffness gradient in all larynges. The maximal divergence angle was markedly reduced. In some cases, there was not a divergent angle.<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion<\/jats:title><jats:p>Marked reduction of the vertical stiffness gradient significantly reduces the maximum divergence angle. Clinical implications will be discussed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Level of Evidence<\/jats:title><jats:p>NA <jats:italic>Laryngoscope<\/jats:italic>, 131:E1934\u2013E1940, 2021<\/jats:p><\/jats:sec>","DOI":"10.1002\/lary.29345","type":"journal-article","created":{"date-parts":[[2020,12,31]],"date-time":"2020-12-31T11:17:44Z","timestamp":1609413464000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["Impact of Vertical Stiffness Gradient on the Maximum Divergence Angle"],"prefix":"10.1002","volume":"131","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9163-6922","authenticated-orcid":false,"given":"Charles","family":"Farbos de Luzan","sequence":"first","affiliation":[{"name":"Department of Otolaryngology\u2014Head and Neck Surgery University of Cincinnati Medical Center  Cincinnati Ohio U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexandra","family":"Maddox","sequence":"additional","affiliation":[{"name":"Department of Aerospace Engineering and Engineering Mechanics University of Cincinnati  Cincinnati Ohio U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3232-6799","authenticated-orcid":false,"given":"Liran","family":"Oren","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2014Head and Neck Surgery University of Cincinnati Medical Center  Cincinnati Ohio U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ephraim","family":"Gutmark","sequence":"additional","affiliation":[{"name":"Department of Aerospace Engineering and Engineering Mechanics University of Cincinnati  Cincinnati Ohio U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5503-0325","authenticated-orcid":false,"given":"Rebecca 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