1
|
Gartling G, Balou M, Amin M, Molfenter S, Jones-Rastelli B, Ezeh UC, Achlatis S, Johnson A, Gherson S, Chiappetta N, Barkmeier-Kraemer J, Branski RC. The Impact of Vocal Tremor on Deglutition: A Pilot Study. Laryngoscope 2024. [PMID: 38963230 DOI: 10.1002/lary.31581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/20/2024] [Accepted: 05/31/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE Vocal tremor (VT) poses treatment challenges due to uncertain pathophysiology. VT is typically classified into two phenotypes: isolated vocal tremor (iVT) and essential tremor-related voice tremor (ETvt). The impact of phenotypes on upper aerodigestive tract physiology during swallowing remains unclear. Qualitative and quantitative measures were employed to characterize tremor phenotypes and investigate the effects on swallowing physiology. METHODS Eleven ETvt participants (1 Male, 10 Female; x̄ age = 74) and 8 iVT participants (1 Male, 7 Female; x̄ age = 71) swallowed 20 mL boluses in cued and uncued conditions under standardized fluoroscopic visualization. Sustained/a/productions were captured to assess the rate and extent of fundamental frequency (F0) modulation. Penetration and Aspiration Scale (PAS) scores were obtained and swallowing biomechanics were captured using Swallowtail™ software. Participants also completed the Swallowing Quality of Life (SWAL-QOL) questionnaire. RESULTS Hypopharyngeal transit was faster in both VT phenotypes compared with Swallowtail™ normative reference data. Total pharyngeal transit times, however, were only faster in patients with iVT, relative to reference data. No significant differences were observed on the SWAL-QOL or PAS between tremor phenotypes. SWAL-QOL scores revealed that these patients rarely reported dysphagia symptoms. CONCLUSIONS Subtle differences in swallowing patterns were observed across VT phenotypes, possibly related to adaptive mechanisms resulting in quicker pharyngeal bolus transit. Most patients did not report swallowing issues or dysphagia symptoms. This study is foundational for larger studies on this challenging population. LEVEL OF EVIDENCE 4 Laryngoscope, 2024.
Collapse
Affiliation(s)
- Gary Gartling
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
| | - Matina Balou
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
| | - Milan Amin
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
| | - Sonja Molfenter
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
- Communicative Sciences and Disorders, Steinhardt School of Culture, Education, and Human Development, New York University, New York, New York, U.S.A
| | - Brynn Jones-Rastelli
- Communicative Sciences and Disorders, Steinhardt School of Culture, Education, and Human Development, New York University, New York, New York, U.S.A
| | - Uche C Ezeh
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
- Miller School of Medicine, University of Miami, Miami, Florida, U.S.A
| | - Stratos Achlatis
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
| | - Aaron Johnson
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
- Communicative Sciences and Disorders, Steinhardt School of Culture, Education, and Human Development, New York University, New York, New York, U.S.A
| | - Shirley Gherson
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
| | - Natalie Chiappetta
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
| | - Julie Barkmeier-Kraemer
- Otolaryngology-Head & Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A
- Communication Sciences & Disorders, University of Utah, Salt Lake City, Utah, U.S.A
| | - Ryan C Branski
- Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, New York, U.S.A
- Communicative Sciences and Disorders, Steinhardt School of Culture, Education, and Human Development, New York University, New York, New York, U.S.A
| |
Collapse
|
2
|
Patel R, Burroughs L, Higgins A, Zauber SE, Isbaine F, Schneider D, Hohman R, Gupta K. Bilateral Deep Brain Stimulation of the Ventral Intermediate Nucleus of the Thalamus Improves Objective Acoustic Measures of Essential Vocal Tremor. Neurosurgery 2024:00006123-990000000-01134. [PMID: 38787392 DOI: 10.1227/neu.0000000000002955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/28/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Deep brain stimulation of the ventral intermediate nucleus of the thalamus (VIM-DBS) is an established treatment for medically refractory essential tremor. However, the effect of VIM-DBS on vocal tremor remains poorly understood, with results varying by method of vocal tremor assessment and stimulation laterality. This single-center study measures the effect of bilateral VIM-DBS on essential vocal tremor using blinded objective acoustic voice analysis. METHODS Ten patients with consecutive essential tremor with comorbid vocal tremor receiving bilateral VIM-DBS underwent voice testing before and after implantation of DBS in this prospective cohort study. Objective acoustic measures were extracted from the middle one second of steady-state phonation including cepstral peak prominence, signal-to-noise ratio, percentage voicing, tremor rate, extent of fundamental frequency modulation, and extent of intensity modulation. DBS surgery was performed awake with microelectrode recording and intraoperative testing. Postoperative voice testing was performed after stable programming. RESULTS Patients included 6 female and 4 male, with a mean age of 67 ± 6.7 years. The VIM was targeted with the following coordinates relative to the mid-anterior commissure:posterior commissure point: 13.2 ± 0.6 mm lateral, 6.2 ± 0.7 mm posterior, and 0.0 mm below. Mean programming parameters were amplitude 1.72.0 ± 0.6 mA, pulse width 63.0 ± 12.7 µs, and rate 130.6 ± 0.0 Hz. VIM-DBS significantly improved tremor rate from 4.43 ± 0.8 Hz to 3.2 ± 0.8 Hz (P = .001) CI (0.546, 1.895), jitter from 1 ± 0.94 to 0.53 ± 0.219 (P = .02) CI (-0.124, 1.038), cepstral peak prominence from 13.6 ± 3.9 to 18.8 ± 2.9 (P = .016) CI (-4.100, -0.235), signal-to-noise ratio from 15.7 ± 3.9 to 18.5 ± 3.7 (P = .02) CI (-5.598, -0.037), and articulation rate from 0.77 ± 0.2 to 0.82 ± .14 (P = .04) CI (-0.097, 0.008). There were no major complications in this series. CONCLUSION Objective acoustic voice analyses suggest that bilateral VIM-DBS effectively reduces vocal tremor rate and improves voicing. Further studies using objective acoustic analyses and laryngeal imaging may help refine surgical and stimulation techniques and evaluate the effect of laterality on vocal tremor.
Collapse
Affiliation(s)
- Rita Patel
- Department of Otolaryngology Head & Neck Surgery, Indiana University School of Medicine, Indianapolis/Indiana University Bloomington, Bloomington, Indiana, USA
| | - Leah Burroughs
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexis Higgins
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - S Elizabeth Zauber
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Faical Isbaine
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Dylan Schneider
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ryane Hohman
- Department of Speech, Language and Hearing Sciences, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Kunal Gupta
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
3
|
Lester-Smith RA, Jebaily CG, Story BH. The Effects of Remote Signal Transmission and Recording on Acoustical Measures of Simulated Essential Vocal Tremor: Considerations for Remote Treatment Research and Telepractice. J Voice 2024; 38:325-336. [PMID: 34702610 PMCID: PMC9033886 DOI: 10.1016/j.jvoice.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Studies on medical and behavioral interventions for essential vocal tremor (EVT) have shown inconsistent effects on acoustical and perceptual outcome measures across studies and across participants. Remote acoustical and perceptual assessments might facilitate studies with larger samples of participants and repeated measures that could clarify treatment effects and identify optimal treatment candidates. Furthermore, remote acoustical and perceptual assessment might allow clinicians to monitor clients' treatment responses and optimize treatment approaches during telepractice. Thus, the purpose of this study was to evaluate the accuracy of remote signal transmission and recording for acoustical and perceptual assessment of EVT. METHOD Simulations of EVT were produced using a computational model and were recorded using local and remote procedures to represent client- and clinician-end recordings respectively. Acoustical analyses measured the extent and rate of fundamental frequency (fo) and intensity modulation to represent vocal tremor severity and the cepstral peak prominence (CPPS) to represent voice quality. The data were analyzed using repeated measures analysis of variance (ANOVA) with recording as the within-subjects factor and sex of the computational model as the between-subjects factor. RESULTS There was a significant main effect of recording on the rate of fo modulation and significant interactions of recording and sex for the extent of intensity modulation, rate of intensity modulation, and CPPS. Posthoc pairwise comparisons and analysis of effect size indicated that recording procedures had the largest effect on the extent of intensity modulation for male simulations, the rate of intensity modulation for male and female simulations, and the CPPS for male and female simulations. Despite having disabled all known software and computer audio enhancing options and having stable ethernet connections, there was inconsistent attenuation of signal amplitude in remote recordings that was most problematic for samples with a breathy voice quality but also affected samples with typical and pressed voice qualities. CONCLUSIONS Acoustical measures that correlate to perception of vocal tremor and voice quality were altered by remote signal transmission and recording. In particular, signal transmission and recording in Zoom altered time-based estimates of intensity modulation and CPPS with male and female simulations of EVT and magnitude-based estimates of intensity modulation with male simulations of EVT. In contrast, signal transmission and recording in Zoom minimally altered time- and magnitude-based estimates of fo modulation with male and female simulations of EVT. Therefore, acoustical and perceptual assessments of EVT should be performed using audio recordings that are collected locally on the participant- or client-end, particularly when measuring modulation of intensity and CPP or estimating vocal tremor severity and voice quality. Development of procedures for collecting local audio recordings in remote settings may expand data collection for treatment research and enhance telepractice.
Collapse
Affiliation(s)
- Rosemary A Lester-Smith
- Department of Speech, Language, and Hearing Sciences, Moody College of Communication, The University of Texas at Austin, Austin, Texas.
| | - Charles G Jebaily
- Department of Speech, Language, and Hearing Sciences, Moody College of Communication, The University of Texas at Austin, Austin, Texas; Texas NeuroRehab Center, Austin, Texas
| | - Brad H Story
- Department of Speech, Language, and Hearing Sciences, The University of Arizona, Tucson, Arizona
| |
Collapse
|
4
|
Lester-Smith RA, Derrick E, Larson CR. Characterization of Source-Filter Interactions in Vocal Vibrato Using a Neck-Surface Vibration Sensor: A Pilot Study. J Voice 2024; 38:1-9. [PMID: 34649740 PMCID: PMC8995401 DOI: 10.1016/j.jvoice.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/18/2021] [Accepted: 08/23/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Vocal vibrato is a singing technique that involves periodic modulation of fundamental frequency (fo) and intensity. The physiological sources of modulation within the speech mechanism and the interactions between the laryngeal source and vocal tract filter in vibrato are not fully understood. Therefore, the purpose of this study was to determine if differences in the rate and extent of fo and intensity modulation could be captured using simultaneously recorded signals from a neck-surface vibration sensor and a microphone, which represent features of the source before and after supraglottal vocal tract filtering. METHOD Nine classically-trained singers produced sustained vowels with vibrato while simultaneous signals were recorded using a vibration sensor and a microphone. Acoustical analyses were performed to measure the rate and extent of fo and intensity modulation for each trial. Paired-samples sign tests were used to analyze differences between the rate and extent of fo and intensity modulation in the vibration sensor and microphone signals. RESULTS The rate and extent of fo modulation and the extent of intensity modulation were equivalent in the vibration sensor and microphone signals, but the rate of intensity modulation was significantly higher in the microphone signal than in the vibration sensor signal. Larger differences in the rate of intensity modulation were seen with vowels that typically have smaller differences between the first and second formant frequencies. CONCLUSIONS This study demonstrated that the rate of intensity modulation at the source prior to supraglottal vocal tract filtering, as measured in neck-surface vibration sensor signals, was lower than the rate of intensity modulation after supraglottal vocal tract filtering, as measured in microphone signals. The difference in rate varied based on the vowel. These findings provide further support of the resonance-harmonics interaction in vocal vibrato. Further investigation is warranted to determine if differences in the physiological source(s) of vibrato account for inconsistent relationships between the extent of intensity modulation in neck-surface vibration sensor and microphone signals.
Collapse
Affiliation(s)
- Rosemary A Lester-Smith
- Department of Physical Medicine & Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Elaina Derrick
- Department of Speech, Language and Hearing Sciences, Moody College of Communication, The University of Texas at Austin, Austin, Texas
| | - Charles R Larson
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois
| |
Collapse
|
5
|
Larner P, Jonas R, Gutierrez CN, McGarey P, Lott J, Moosa S, Elias WJ, Daniero J. Voice Improvement After Essential Tremor Treatment via Focused Ultrasound and Deep Brain Stimulation. Laryngoscope 2024; 134:367-373. [PMID: 37458326 DOI: 10.1002/lary.30884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 05/05/2023] [Accepted: 06/09/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVES The primary objective of this study was to determine whether two neurosurgical procedures, deep brain stimulation (DBS) and focused ultrasound (FUS), to treat essential tremor (ET) of the upper limb also reduce vocal tremor (VT) in patients with comorbid dysphonia. METHODS Twelve patients with ET and concomitant VT scheduled for neurosurgical intervention (FUS or DBS) or returning for follow-up after DBS implantation were assessed. FUS patients were assessed pre- and post-intervention and DBS patients were assessed with the electrodes turned on and off post-implantation. Three voice recordings of a sustained /a/ were obtained for each participant condition. Percent fundamental frequency variability (FFV) was calculated for each recorded sustained vowel. Additionally, blinded expert perceptual VT rating (VTR) was performed to assess subjective changes in tremors. RESULTS Of the 12 patients, seven underwent unilateral FUS, and five underwent bilateral DBS. Mean FFV without neurosurgical intervention was 18.3%, SD = 7.8 and with neurosurgical intervention was 6.3%, SD = 3.0 (t (70) =8.7, p < 0.001). Mean FFV decreased in the FUS cohort from 22.0%, SD = 7.1 pre-ablation to 6.7%, SD = 2.4 post-ablation (t (40) = 7.7, p < 0.001). Mean FFV also decreased in the DBS cohort from 15.7%, SD = 7.0 to 6.0%, SD = 3.3 when stimulation was turned on (t (28)=5.7 p < 0.001). In the FUS group, mean VTR decreased from 4.0 to 1.4 post-ablation (Z = 7.8, p < 0.001). In the DBS group, mean VTR decreased from 3.3 to 2.1 with stimulation (Z = 4.1, p < 0.001). CONCLUSION Neurosurgical interventions for ET (bilateral DBS and unilateral FUS) demonstrate acoustic and perceptual benefits for VT. LEVEL OF EVIDENCE 4 Laryngoscope, 134:367-373, 2024.
Collapse
Affiliation(s)
- Peter Larner
- School of Medicine, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Rachel Jonas
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Claudia N Gutierrez
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Patrick McGarey
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Joanna Lott
- Department of Therapy Services, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Shayan Moosa
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - W Jeffrey Elias
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - James Daniero
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| |
Collapse
|
6
|
Patel RR, Lulich SM, Francisco P. Laryngeal, Respiratory, and Acoustic Characteristics of Vocal Trillo With Simultaneous High-Speed Videoendoscopy, Inductive Plethysmography, and Acoustic Recordings. J Voice 2023:S0892-1997(23)00362-4. [PMID: 38008677 DOI: 10.1016/j.jvoice.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE This study aimeed to examine the characteristics of formed and unformed trillo, an essential ornament found in 17th-century Italian vocal music, using simultaneous multimodality voice measurements. PARTICIPANT AND METHODS A 28-year-old female with 12 years of classical voice training and 7 years of advanced training in historical performance produced formed trillo, unformed trillo, oscillating trill, vibrato, and straight tone on the vowel /i/. Simultaneous high-speed videoendoscopy, inductive plethysmography, and acoustic recordings were conducted to examine the laryngeal motion, respiratory kinematics, and output sound characteristics. RESULTS The study findings reveal that trillo in this single participant is not only produced by the periodic adduction/abduction of the vocal fold but also with underlying differences in oscillatory mechanisms and increased glottal flow (use of percent vital capacity) controlled by increased activation of abdominal muscles and/or decreased activation (inspiratory braking) of the diaphragm relative to tidal breathing when compared with straight tone, vibrato, and oscillating trill. The formed trillo differs from the unformed trillo in the oscillatory mechanisms and glottal airflow utilization. CONCLUSIONS The physiological mechanism responsible for trillo is more complex than simply adduction and abduction. Future studies with a greater number of participants are needed to evaluate the mechanisms responsible for the formation of and the auditory-perceptual differences between the formed versus unformed trillo.
Collapse
Affiliation(s)
- Rita R Patel
- Department of Speech, Language and Hearing Sciences, Indiana University, Bloomington, Indiana.
| | - Steven M Lulich
- Department of Speech, Language and Hearing Sciences, Indiana University, Bloomington, Indiana
| | - Paulina Francisco
- Historical Performance Department, Jacobs School of Music, Indiana University, Bloomington, Indiana
| |
Collapse
|
7
|
O’Flynn LC, Frucht SJ, Simonyan K. Sodium Oxybate in Alcohol-Responsive Essential Tremor of Voice: An Open-Label Phase II Study. Mov Disord 2023; 38:1936-1944. [PMID: 37448353 PMCID: PMC10615702 DOI: 10.1002/mds.29529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/10/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Essential tremor of voice (ETv) is characterized by involuntary oscillations of laryngeal and upper airway muscles, causing rhythmic alterations in pitch and loudness during both passive breathing and active laryngeal tasks, such as speaking and singing. Treatment of ETv is challenging and typically less effective compared with treatment of ET affecting extremities. OBJECTIVE We conducted a proof-of-concept, open-label phase II study to examine the efficacy and central effects of sodium oxybate in patients with alcohol-responsive ETv. METHODS All subjects received 1.0 to 1.5 g of oral sodium oxybate and underwent brain functional magnetic resonance imaging. The primary endpoint was the number of patients (% from total) with reduced ETv symptoms by at least 10% at about 40 to 45 minutes after sodium oxybate intake based on the combined visual analog scale score of ETv symptom severity. The secondary endpoint included changes in brain activity after sodium oxybate intake compared to baseline. RESULTS Sodium oxybate reduced ETv symptoms on average by 40.8% in 92.9% of patients. Drug effects were observed about 40 to 45 minutes after intake, lasting about 3.5 hours, and gradually wearing off by the end of the fifth hour. The central effects of sodium oxybate were associated with normalized activity in the cerebellum, inferior/superior parietal lobules, inferior frontal gyrus, and insula and re-established functional relationships between these regions. CONCLUSIONS Sodium oxybate showed high efficacy in ETv patients, with a likely central action on disorder pathophysiology. Sodium oxybate may be an effective novel oral drug for treatment of alcohol-responsive ETv patients. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Lena C. O’Flynn
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
- Program in Speech Hearing Bioscience and Technology, Harvard University, 260 Longwood Avenue, Boston, MA 02115, USA
| | - Steven J. Frucht
- Department of Neurology, NYU Langone Health, New York, NY 10017, USA
| | - Kristina Simonyan
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
- Program in Speech Hearing Bioscience and Technology, Harvard University, 260 Longwood Avenue, Boston, MA 02115, USA
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| |
Collapse
|
8
|
Lester-Smith RA, Miller CH, Cherney LR. Behavioral Therapy for Tremor or Dystonia Affecting Voice in Speakers with Hyperkinetic Dysarthria: A Systematic Review. J Voice 2023; 37:561-573. [PMID: 34112549 DOI: 10.1016/j.jvoice.2021.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Hyperkinetic dysarthria is characterized by atypical involuntary movements within the speech mechanism that may affect the respiratory, laryngeal, pharyngeal-oral, or velopharyngeal-nasal subsystems and may alter speech production. Although articulatory impairments are commonly considered in hyperkinetic dysarthria, speakers with hyperkinetic dysarthria may also present with changes in voice quality, pitch, and loudness. In approximately 70% of speakers with hyperkinetic dysarthria, these voice alterations are associated with tremor or dystonia. The purpose of this systematic review was to investigate the association between behavioral therapy for tremor or dystonia affecting voice in speakers with hyperkinetic dysarthria and improvement in the functional, perceptual, acoustical, aerodynamic, or endoscopic characteristics of voice. METHOD MEDLINE (PubMed), Embase, PsycINFO, and ClinicalTrials.gov online databases were searched in August 2017, December 2018, and April 2020 for relevant studies. The searches provided 4,921 unique records, and six additional unique records were added from other sources. Twelve studies met the criteria for inclusion in the systematic review. Participants who received concurrent medical treatment were included in this review to ensure that the search was inclusive of all relevant studies and informative for typical clinical scenarios. RESULTS The most commonly administered treatment ingredient was relaxation training, which was investigated in three of the four studies on tremor and three of the eight studies on dystonia. Of these six studies, only one used an experimental design and administered relaxation training as the only behavioral approach. This single-case experiment reported a significant reduction in participant ratings of tremor severity and interference with activities of daily living, although the speaking subscale reportedly did not improve and oral medications were administered concurrently. In two group studies that tested potential behavioral therapy targets, production of a low pitch improved acoustical measures for participants with essential tremor and improved auditory-perceptual judgments for participants with laryngeal dystonia. Behavioral therapy improved functional, acoustical, and aerodynamic outcomes in participants with laryngeal dystonia who were also receiving botulinum toxin injections in a randomized cross-over study and a non-randomized controlled study. Because one study employed easy onset and breathing exercises, while the other employed loud voice exercises, the mechanism of action for improvement in voice associated with behavioral therapy requires further investigation. CONCLUSION This systematic review describes the current evidence for treatment of tremor and dystonia affecting voice in speakers with hyperkinetic dysarthria and highlights the need for future research on behavioral therapy for these disorders.
Collapse
Affiliation(s)
- Rosemary A Lester-Smith
- Department of Physical Medicine & Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Think + Speak Lab, Shirley Ryan AbilityLab, Chicago, Illinois.
| | - Corinne H Miller
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Leora R Cherney
- Department of Physical Medicine & Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Think + Speak Lab, Shirley Ryan AbilityLab, Chicago, Illinois
| |
Collapse
|
9
|
Silek H, Dogan M. Voice Analysis in Patients with Essential Tremor. J Voice 2023:S0892-1997(23)00144-3. [PMID: 37336699 DOI: 10.1016/j.jvoice.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE The objective of this study was to reveal the phonetic characteristics of patients with or without voice tremor in patients with essential tremor (ET), determine whether these phonetic features are ET specific, and test the influence of ET on vocal tremor. METHODS The study included a total of 30 patients with ET and 29 healthy volunteers. The severity of ET was evaluated using the Washington Heights Inwood Genetic Study of Essential Tremor (WHIGET) tremor rating scale. Patients with major tremor complaints for at least 3years, WHIGET scoring scores below 15, and patients newly diagnosed in our clinic and for whom drug therapy has not yet been started were selected. RESULTS A total of 59 participants (n = 34 with ET and n = 25 as control) were included in the study. The ages of the participants ranged from 20 to 82years, with a mean age of 54.50 ± 15.04years. The gender distribution was 57.6% male and 42.4% female, and there was no statistically significant difference between the two groups in terms of age and gender. The study found that individuals with ET had significantly higher jitter, shimmer, S/Z, Pataka, frequency tremor intensity index, amplitude tremor intensity index, and frequency tremor power index values than the control group. However, there was no statistically significant difference between the two groups in terms of MPT, frequency tremor cyclicality, amplitude tremor cyclicality, frequency tremor frequency, and amplitude tremor frequency values. CONCLUSION Our study shows that, even in the absence of essential voice tremor, there is an effect of ET on voice quality. These findings contribute to the understanding of the nonmotor symptoms of ET and may aid in the diagnosis and management of this condition. Further research is needed to explore the potential use of acoustic analysis parameters in the diagnosis and monitoring of ET.
Collapse
Affiliation(s)
- Hakan Silek
- Department of Neurology, Faculty of Medicine, Yeditepe University, Istanbul, Turkey.
| | - Muzeyyen Dogan
- Department of Otolaryngology and Head & Neck Surgery, Faculty of Medicine, Yeditepe University, Istanbul, Turkey
| |
Collapse
|
10
|
Lester-Smith RA, Kim JH, Hilger A, Chan CL, Larson CR. Auditory-Motor Control of Fundamental Frequency in Vocal Vibrato. J Voice 2023; 37:296.e9-296.e19. [PMID: 33461882 PMCID: PMC8282806 DOI: 10.1016/j.jvoice.2020.12.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of this study was to investigate how classically trained singers use their auditory feedback to control fundamental frequency (fo) during production of vocal vibrato. Two main questions were addressed: (1) Do singers produce reflexive foresponses to sudden perturbation of the fo of their auditory feedback during production of vibrato indicative of feedback control? (2) Do singers produce adaptive foresponses to repeated perturbation of the fo of their auditory feedback during production of vibrato indicative of feedback and feedforward control? In addition, one methodological question was addressed to determine if adaptive fo responses were more precisely assessed with or without an auditory cue for fo during the repeated fo perturbation paradigm. METHOD Ten classically trained singers produced sustained vowels with vibrato while the fo and harmonics of their auditory feedback were suddenly perturbed by 100 cents to assess reflexive control or repeatedly perturbed by 100 cents to assess adaptive control. Half of the participants completed the repeated perturbation experiment with an auditory cue for fo, and the other half completed the experiment without an auditory cue for fo. Acoustical analyses measured changes in mean fo in response to the auditory feedback perturbations. RESULTS On average, participants produced compensatory responses to both sudden and repeated perturbation of the fo of their auditory feedback. The magnitude of the responses to repeated perturbations was larger than the responses to sudden perturbations. Responses were also larger in the cued, repeated fo perturbation experiment than in the uncued, repeated fo perturbation experiment. CONCLUSIONS These findings indicate that classically-trained singers use both feedforward and feedback mechanisms to control their average fo during production of vibrato. When compared to prior studies of singers producing a steady voice, the reflexive fo responses were larger in the current study, which may indicate that the feedback control system is engaged more during production of vibrato.
Collapse
Affiliation(s)
- Rosemary A Lester-Smith
- Department of Physical Medicine & Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Jason H Kim
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois
| | - Allison Hilger
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois
| | - Chun-Liang Chan
- Department of Linguistics, Northwestern University, Evanston, Illinois
| | - Charles R Larson
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois
| |
Collapse
|
11
|
Ruckart KW, Wilson C, Moya-Mendez ME, Madden LL, Laxton A, Siddiqui MS. Effect of Ventral Intermediate Nucleus Deep Brain Stimulation on Vocal Tremor in Essential Tremor. Tremor Other Hyperkinet Mov (N Y) 2023; 13:13. [PMID: 37152623 PMCID: PMC10162197 DOI: 10.5334/tohm.757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/18/2023] [Indexed: 05/09/2023] Open
Abstract
Background There is a paucity of literature examining the effect of Ventral Intermediate Nucleus (VIM) deep brain stimulation (DBS) on voice in patients with vocal tremor (VT). Objective Investigate the effect of unilateral and bilateral VIM DBS on voice in patients with Essential Tremor (ET) and VT. Methods All patients receiving VIM DBS surgery underwent voice evaluation pre- and six-months post-operatively. We collected patient-reported quality-of-life outcome measures and acoustic voice measures of sustained phonation and connected speech. Acoustic measures specific to VT included amplitude tremor intensity index (ATRI), frequency tremor intensity index (FTRI), rate and extent of F0 modulation, and rate and extent of intensity modulation. Results Five patients, age 72.8 ± 2.6 years, 4 female, 1 male with mean disease duration of 29 ± 26.2 years met the inclusion criteria and were included. Two subjects had bilateral procedure and three had unilateral. We observed significant improvements in measures of vocal tremor including ATRI, FTRI, rate of F0 modulation, rate of intensity modulation, and extent of intensity modulation, as well as patient reported voice-related quality of life measured by VHI-10. Bilateral VIM DBS cases showed greater improvement in VT than unilateral cases. Conclusion Both unilateral and bilateral VIM DBS resulted in significant improvement of VT, with more improvement demonstrated in patients having bilateral as compared to unilateral VIM DBS. In addition, patients also reported significant improvements in voice-related quality of life. If larger studies confirm our results, VIM DBS has the potential to become a treatment specifically for disabling VT.
Collapse
Affiliation(s)
- Kathryn W. Ruckart
- Department of Otolaryngology-Head and Neck Surgery, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| | - Caroline Wilson
- Department of Radiology, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| | | | - Lyndsay L. Madden
- Department of Otolaryngology-Head and Neck Surgery, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| | - Adrian Laxton
- Department of Neurology, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| | - Mustafa S. Siddiqui
- Department of Neurology, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| |
Collapse
|
12
|
Voice Tremor and Botulinum Neurotoxin Therapy: A Contemporary Review. Toxins (Basel) 2022; 14:toxins14110773. [PMID: 36356023 PMCID: PMC9698548 DOI: 10.3390/toxins14110773] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Voice tremor is a common, yet debilitating symptom for patients suffering from a number of tremor-associated disorders. The key to targeting effective treatments for voice tremor requires a fundamental understanding of the pathophysiology that underpins the tremor mechanism and accurate identification of the disease in affected patients. An updated review of the literature detailing the current understanding of voice tremor (with or without essential tremor), its accurate diagnosis and targeted treatment options was conducted, with a specific focus on the role of botulinum neurotoxin. Judicious patient selection, following detailed characterisation of voice tremor qualities, is essential to optimising treatment outcomes for botulinum neurotoxin therapy, as well as other targeted therapies. Further focused investigation is required to characterise the response to targeted treatment in voice tremor patients and to guide the development of innovative treatment options.
Collapse
|
13
|
Patel RR, Zauber SE, Yadav AP, Witt TC, Halum S, Gupta K. Globus Pallidus Interna and Ventral Intermediate Nucleus of the Thalamus Deep Brain Stimulation for Adductor Laryngeal Dystonia: a Case Report of Blinded Analyses of Objective Voice Outcomes in 2 Patients. Neurosurgery 2022; 90:457-463. [PMID: 35138294 DOI: 10.1227/neu.0000000000001851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adductor laryngeal dystonia (ADLD) is a substantially debilitating focal progressive neurological voice disorder. Current standard of care is symptomatic treatment with repeated injections of botulinum toxin into specific intrinsic laryngeal muscles with extremely variable and temporary benefits. We report the use of bilateral deep brain stimulation (DBS) of globus pallidus (GPi) for long-term improvement of ADLD voice symptoms. OBJECTIVE To investigate the effects of bilateral DBS of the GPi and ventral intermediate nucleus (VIM) of the thalamus on vocal function in 2 patients with ADLD associated with voice and hand tremor. METHODS Blinded objective and quantitative analyses of voice were conducted before and after treatment in 2 female patients (70 and 69 years). Paired t-tests were conducted to compare voice measurements pre-GPi and post-GPi and VIM-DBS. A 2-way analysis of variance was conducted to determine the interaction between target (GPi/VIM) and time (pre/post) for each voice measure. RESULTS Although the follow-up period differed between patients, the GPi-DBS implanted patient had notable improvement in vowel voicing (%), extent of tremor intensity (%), and overall speech intelligibility (%), compared with preoperative status. GPi-DBS also resulted in significant improvement in cepstral peak prominence (dB). VIM-DBS resulted in a significantly greater change in the tremor rate (Hz). CONCLUSION Changes in phonatory function provide preliminary support for the use of bilateral GPi-DBS for treatment of ADLD and bilateral VIM-DBS for vocal tremor predominant ADLD. Future studies with larger sample sizes and standardized follow-up periods are needed to better assess the role of DBS for ADLD.
Collapse
Affiliation(s)
- Rita R Patel
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine/Indiana University Bloomington, Indianapolis, Indiana, USA
| | - S Elizabeth Zauber
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amol P Yadav
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thomas C Witt
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stacey Halum
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine/Indiana University Bloomington, Indianapolis, Indiana, USA
| | - Kunal Gupta
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
14
|
Akkunje PS, Yamini BK, Yadav R, Shivashankar N, Malo PK, Thennarasu K, Hegde S, Pal PK. Phonatory Characteristics of Male Patients with Classic Essential Tremor. J Mov Disord 2021; 14:226-230. [PMID: 34399566 PMCID: PMC10657739 DOI: 10.14802/jmd.21010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/22/2021] [Accepted: 06/08/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Voice tremor (VT) is one of the characteristics of essential tremor (ET). This study was designed to describe the group and phonatory characteristics of classic ET patients with VT. METHODS This retrospective case-control study compared classic ET patients with age and sex-matched controls. The ET population was subgrouped based on auditory perceptual voice analysis. Electroglottography and acoustic voice samples obtained from both groups were analyzed for contact quotient (CQ) and multidimensional voice program parameters, i.e., fundamental frequency (F0), perturbation, noise, and tremor parameters. RESULTS The CQ, F0, perturbation, noise, and tremor characteristics significantly increased from the moderate VT group to the severe VT group. CONCLUSION The CQ, F0, and noise characteristics reflected the vocal folds' functionality. The perturbation and tremor parameters variation were reasoned considering the tremor-related changes occurring in the laryngeal, vocal tract, and expiratory muscles in patients with ET. Thus, phonatory analysis may help in monitoring the progression of ET.
Collapse
Affiliation(s)
- Preetie Shetty Akkunje
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Belur Keshavaprasad Yamini
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Ravi Yadav
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Nagarajarao Shivashankar
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Palash Kumar Malo
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Kandavel Thennarasu
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Shantala Hegde
- Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| |
Collapse
|
15
|
Rao Mv A, Yamini BK, Ketan J, Preetie Shetty A, Pal PK, Shivashankar N, Ghosh PK. Automatic Classification of Healthy Subjects and Patients With Essential Vocal Tremor Using Probabilistic Source-Filter Model Based Noise Robust Pitch Estimation. J Voice 2021; 37:314-321. [PMID: 33579623 DOI: 10.1016/j.jvoice.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/08/2021] [Accepted: 01/13/2021] [Indexed: 11/18/2022]
Abstract
Essential voice tremor (EVT) is a voice disorder resulting from dyscoordination within the laryngeal musculature. A low-frequency fluctuations of fundamental voice frequency or the strength of excitation amplitude is the main consequence of the disorder. The automatic classification of healthy control and EVT is useful tool for the clinicians. A typical automatic EVT classification involves three steps. The first step is to compute the pitch contour from the speech. The second step is to compute the features from the pitch contour, and the final step is to use a classifier to classify the features into healthy or EVT. It is shown that a high-resolution pitch contour estimated from the glottal closure instants (GCIs) is useful for EVT classification. The HPRC estimation can be very poor in the presence of noise. Hence, a probabilistic source filter model based noise robust GCI detection is used for HPRC estimation. The Empirical mode decomposition based feature extraction is used followed by a support vector machine classifier. The EVT classification performance is evaluated using recordings from 45 subjects. The proposed method is found to perform better than the baseline techniques in eight different additive noise conditions with six SNR levels.
Collapse
Affiliation(s)
- Achuth Rao Mv
- Electrical Engineering, Indian Institute of science (IISc), Bangalore, 560012, India.
| | - B K Yamini
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 560029, India
| | - J Ketan
- Department of Neurology, University of South Florida, Tampa, 33620, USA
| | - A Preetie Shetty
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 560029, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 560029, India
| | - N Shivashankar
- Speech Pathology and Audiology, Apollo Hospital, Jayanagar, Bangalore, 560029, India
| | - Prasanta Kumar Ghosh
- Speech Pathology and Audiology, Apollo Hospital, Jayanagar, Bangalore, 560029, India
| |
Collapse
|
16
|
Erickson-DiRenzo E, Kuijper FM, Barbosa DAN, Lim EA, Lin PT, Lising MA, Huang Y, Sung CK, Halpern CH. Multiparametric laryngeal assessment of the effect of thalamic deep brain stimulation on essential vocal tremor. Parkinsonism Relat Disord 2020; 81:106-112. [PMID: 33120071 DOI: 10.1016/j.parkreldis.2020.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE EVT is a refractory voice disorder that significantly affects quality of life. This work aims to conduct a multiparametric assessment of the effect of deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (VIM) on essential vocal tremor (EVT) and investigate the relation between DBS lead location and EVT outcomes. METHODS Nine participants underwent DBS for essential tremor and were diagnosed with co-occurring EVT in this prospective cohort study. Objective measurements including acoustic evaluation of vocal fundamental frequency (F0) and intensity modulation and subjective measurements including physiologic evaluation of the oscillatory movement of the laryngeal muscles and vocal tract and perceptual ratings of tremor severity were collected PRE and POST DBS. Finally, we investigated the relation between DBS lead location and EVT outcomes. RESULTS Acoustic modulations of F0 and intensity were significantly improved POST DBS. Physiologic assessment showed a POST DBS reduction of oscillatory movement in the laryngeal muscles and vocal tract, but not significantly. Listener and participant perception, of EVT severity was also significantly reduced. Finally, our results indicate better EVT control with increased distance to midline of left VIM thalamic stimulation. CONCLUSIONS By employing a battery of objective and subjective measures, our study supports the benefit of DBS for the treatment of EVT and specifies the acoustic and physiologic mechanisms that mediate its positive effect. We further provide preliminary results on the relation between lead location and EVT outcomes, laying the foundation for future studies to clarify the optimal DBS target for the treatment of EVT.
Collapse
Affiliation(s)
- Elizabeth Erickson-DiRenzo
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Fiene Marie Kuijper
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Erika A Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter T Lin
- Valley Parkinson Clinic, 800 Pollard Road, Suite C-30, Los Gatos, CA, USA
| | - Melanie A Lising
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - C Kwang Sung
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
| |
Collapse
|
17
|
Erickson-DiRenzo E, Sung CK, Ho AL, Halpern CH. Intraoperative Evaluation of Essential Vocal Tremor in Deep Brain Stimulation Surgery. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:851-863. [PMID: 32073285 DOI: 10.1044/2019_ajslp-19-00079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose Essential vocal tremor (EVT) is a prevalent and difficult-to-manage voice disorder. There is evidence that deep brain stimulation (DBS) of the ventral intermediate nucleus (Vim) of the thalamus may be beneficial for treating EVT. The objective of this preliminary investigation was to conduct intraoperative voice assessments during Vim-DBS implantation in order to evaluate immediate voice outcomes in medication-refractory essential tremor patients with co-occurring EVT. Method Seven adult subjects diagnosed with EVT undergoing Vim-DBS surgery participated in this investigation. Voice samples of sustained vowels were collected by a speech-language pathologist preoperatively and intraoperatively, immediately following Vim-DBS electrode placement. Voice evaluation included objective acoustic assessment of the rate and extent of EVT fundamental frequency and intensity modulation and subjective perceptual ratings of EVT severity. Results The rate of intensity modulation, extent of fundamental frequency modulation, and perceptual rating of EVT severity were significantly reduced intraoperatively as compared to preoperatively. Moderate, positive correlations were appreciated between a subset of acoustic measures and perceptual severity ratings. Conclusions The results of this study demonstrate a speech-language pathologist can conduct intra-operative evaluation of EVT during DBS surgery. Using a noninvasive, simple acoustic recording method, we were able to supplement perceptual subjective observation with objective assessment and demonstrate immediate, intraoperative improvements in EVT. The findings of this analysis inform the added value of intraoperative voice evaluation in Vim-DBS patients and contribute to the growing body of literature seeking to evaluate the efficacy of DBS as a treatment for EVT.
Collapse
Affiliation(s)
| | - C Kwang Sung
- Department of Otolaryngology-Head & Neck Surgery, School of Medicine, Stanford University, CA
| | - Allen L Ho
- Department of Neurosurgery, School of Medicine, Stanford University, CA
| | - Casey H Halpern
- Department of Neurosurgery, School of Medicine, Stanford University, CA
| |
Collapse
|
18
|
Van Doren M, Faudoa E, Carroll TL. Treatment of Patients with Vocal Fold Atrophy and Comorbid Essential Voice Tremor: Long-Term Injection Augmentation Outcomes After Successful Diagnostic Vocal Fold Injection Augmentation. J Voice 2020; 34:471-476. [DOI: 10.1016/j.jvoice.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/12/2018] [Accepted: 11/05/2018] [Indexed: 11/29/2022]
|
19
|
Maryn Y, Leblans M, Zarowski A, Barkmeier-Kraemer J. Objective Acoustic Quantification of Perceived Voice Tremor Severity. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2019; 62:3689-3705. [PMID: 31619112 DOI: 10.1044/2019_jslhr-s-19-0024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose This study compared auditory-perceptual measures of presence/absence and severity of vocal tremor to acoustic markers of vocal tremor. The validity (both concurrent and diagnostic) of various acoustic markers of vocal tremor was also assessed. Method Fifty-six midvowel sustained [a:] recordings were selected to yield a representative convenience sample of vocal tremor. After training with 10 synthesized samples, 4 female audiologists rated these samples on "voice tremor severity" on a continuous 10-cm scale. Afterward, 15 randomly selected recordings were presented a 2nd time for intrarater reliability assessment. Customized audio signal processing in Praat yielded 12 acoustic measures of rate, extent and perturbation of fundamental frequency (f 0), and intensity level (IL) modulation. Enter-type multiple linear regression analysis was applied to weight and combine these acoustic variables into an acoustic model of vocal tremor severity. Results After removing the vocal tremor severity ratings of 1 of the audiologists because of insufficient intra- and interrater reliability, mean single-measures consistency-type intraclass correlation coefficients equaled .83 within raters and .72 between raters. Correlation between mean ratings and the 12 acoustic markers ranged from .76 for median extent of f 0 modulation to .11 for rate of IL modulation. Correlation between mean ratings and the acoustic model was .89. Analysis of this model's receiver operating characteristics yielded an area under receiver operating characteristic curve of .93, denoting sensitivity of .87 and specificity of .91. Conclusions This study demonstrated that auditory-perceptual ratings of vocal tremor severity are guided primarily by f 0 and IL modulation extent, less by modulation perturbation, and least by modulation rate. The acoustic model covering all these modulation properties yielded acceptable results in terms of both concurrent and diagnostic validity. However, external cross-validation of this model is warranted before applying it in clinical voice/speech assessment.
Collapse
Affiliation(s)
- Youri Maryn
- Department of Otorhinolaryngology and Head & Neck Surgery, European Institute for ORL-HNS, GZA Sint-Augustinus, Wilrijk, Belgium
- Department of Speech, Language and Hearing Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Belgium
- Faculty of Education, Health & Social Work, University College Ghent, Belgium
- Faculty of Psychology and Educational Sciences, School of Logopedics, Louvain-La-Neuve, Belgium
- Phonanium, Lokeren, Belgium
| | - Marc Leblans
- Department of Otorhinolaryngology and Head & Neck Surgery, European Institute for ORL-HNS, GZA Sint-Augustinus, Wilrijk, Belgium
| | - Andrzej Zarowski
- Department of Otorhinolaryngology and Head & Neck Surgery, European Institute for ORL-HNS, GZA Sint-Augustinus, Wilrijk, Belgium
| | | |
Collapse
|
20
|
Iwarsson J, Hollen Nielsen R, Næs J. Mean fundamental frequency in connected speech and sustained vowel with and without a sentence-frame. LOGOP PHONIATR VOCO 2019; 45:91-96. [DOI: 10.1080/14015439.2019.1637455] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jenny Iwarsson
- Department of Audiologopedics, Institution for Scandinavian studies and Linguistics, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Hollen Nielsen
- Department of Audiologopedics, Institution for Scandinavian studies and Linguistics, University of Copenhagen, Copenhagen, Denmark
| | - Josefine Næs
- Department of Audiologopedics, Institution for Scandinavian studies and Linguistics, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
21
|
Vahabzadeh-Hagh AM, Pillutla P, Zhang Z, Chhetri DK. Dynamics of Intrinsic Laryngeal Muscle Contraction. Laryngoscope 2019; 129:E21-E25. [PMID: 30325497 PMCID: PMC6320299 DOI: 10.1002/lary.27353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/04/2018] [Accepted: 05/21/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Laryngeal function requires neuromuscular activation of the intrinsic laryngeal muscles (ILMs). Rapid activation of the ILMs occurs in cough, laughter, and voice-unvoiced-voiced segments in speech and singing. Abnormal activation is observed in hyperfunctional disorders such as vocal tremor and dystonia. In this study, we evaluate the dynamics of ILM contraction. STUDY/DESIGN Basic science study in an in vivo canine model. METHODS The following ILMs were stimulated: thyroarytenoid (TA), lateral cricoarytenoid/interarytenoid (LCA/IA), cricothyroid (CT), all laryngeal adductors (LCA/IA/TA), and the posterior cricoarytenoid (PCA). Neuromuscular stimulation was performed via the respective nerves at current levels needed to achieve maximum vocal fold posture change. Muscle contraction and posture changes were recorded with high speed video (HSV). HSV frames were then analyzed to measure response times required from the onset of muscle contraction to the time the vocal folds achieved maximum posture change. RESULTS In all muscles, the onset of posture change occurred within 10 to 12 milliseconds after neuromuscular stimulation. The average times ( ± standard deviation) to achieve final posture were as follows: TA 34.5 ± 6 ms (N = 15), LCA/IA 55 ± 12 ms (N = 14), recurrent laryngeal nerve 43 ± 8 ms (N = 18), CT 100.8 ± 17 ms (N = 26), and PCA 91.2 ± 8 ms (N = 3). Data distribution appeared normal. CONCLUSION Results showed a difference in muscle activation time between different ILMs consistent with reported differences in muscle fiber composition. These data also provide an estimate of the limits of laryngeal contraction frequency in physiologic and pathologic laryngeal states. LEVEL OF EVIDENCE NA Laryngoscope, 129:E21-E25, 2019.
Collapse
Affiliation(s)
- Andrew M Vahabzadeh-Hagh
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Pranati Pillutla
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, U.S.A
| | - Zhaoyan Zhang
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Dinesh K Chhetri
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| |
Collapse
|
22
|
Gillivan-Murphy P, Carding P, Miller N. Vocal tract characteristics in Parkinson's disease. Curr Opin Otolaryngol Head Neck Surg 2018; 24:175-82. [PMID: 26900819 DOI: 10.1097/moo.0000000000000252] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Voice tremor is strongly linked to the Parkinson's disease speech-voice symptom complex. Little is known about the underlying anatomic source(s) of voice tremor when it occurs. We review recent literature addressing this issue. Additionally we report findings from a study we conducted employing rating of vocal tract structures viewed using nasolaryngoscopy during vocal and nonspeech tasks. RECENT FINDINGS In Parkinson's disease, using laryngeal electromyography, tremor has not been identified in muscles in the vocal folds even when perceived auditorily. Preliminary findings using nasolaryngoscopy suggest that Parkinson's disease voice tremor is not associated with the vocal folds and may involve the palate, the global larynx, and the arytenoids. Tremor in the vertical larynx on /a/, and tremor in the arytenoid cartilages on /s/ differentiated patients with Parkinson's disease from neurologically healthy controls. Visual reliable detection of tremor when it is absent or borderline present, is challenging. SUMMARY Parkinson's disease voice tremor is likely to be related to oscillatory movement in structures across the vocal tract rather than just the vocal folds. To progress clinical practice, more refined tools for the visual rating of tremor would be beneficial. How far voice tremor represents a functionally significant factor for speakers would also add to the literature.
Collapse
Affiliation(s)
- Patricia Gillivan-Murphy
- aSpeech & Language Therapy Department, Mater Misericordiae University Hospital, Dublin, Ireland bFaculty of Health Sciences, Australian National Catholic University (Brisbane, Sydney, Melbourne), Australia cNewcastle University Institute for Ageing, Speech and Language Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | | | | |
Collapse
|
23
|
|
24
|
Reliability of High-speed Videoendoscopic Ratings of Essential Voice Tremor and Adductor Spasmodic Dysphonia. J Voice 2017; 33:16-26. [PMID: 29246397 DOI: 10.1016/j.jvoice.2017.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/06/2017] [Accepted: 10/11/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The main objectives of this study were to (1) examine intrarater and inter-rater reliabilities in perceptual ratings of vocal fold vibratory patterns and supraglottic characteristics for essential vocal tremor and adductor spasmodic dysphonia (AdSD) using high-speed videoendoscopy (HSV), and (2) to investigate the specificity of the parameters in differentiating these two voice disorders. METHODS HSV recordings of 34 cases diagnosed with essential vocal tremor, AdSD, or AdSD with vocal tremor were evaluated blindly by two voice speech pathologists. The two raters examined all HSV video segments twice across nine supraglottic and vocal fold vibratory characteristics for inter-rater and intrarater reliabilities. A separate consensus rating was then developed, with the results analyzed to explore differentiation. RESULTS Raters demonstrated moderate intrarater reliability with mean Spearman's rho correlation coefficients of 0.68 (rater 1) and 0.73 (rater 2). Moderate inter-rater reliability for the two raters was seen across all parameters with a mean Cohen's kappa coefficient of 0.51. Raters showed higher intrarater and inter-rater reliabilities for supraglottic parameters. Only the presence of tremor differentiated between the two voice disorders in cases with a consistent diagnosis. CONCLUSIONS The high level of concomitance between vocal tremor and AdSD may affect subjective perceptual analysis of supraglottic and vocal fold vibratory patterns. Results indicate similar global involvement of supraglottic laryngeal structures for both vocal tremor and AdSD.
Collapse
|
25
|
|
26
|
Barkmeier-Kraemer JM, Clark HM. Speech-Language Pathology Evaluation and Management of Hyperkinetic Disorders Affecting Speech and Swallowing Function. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 7:489. [PMID: 28983422 PMCID: PMC5628324 DOI: 10.7916/d8z32b30] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 08/30/2017] [Indexed: 12/13/2022]
Abstract
Background Hyperkinetic dysarthria is characterized by abnormal involuntary movements affecting respiratory, phonatory, and articulatory structures impacting speech and deglutition. Speech–language pathologists (SLPs) play an important role in the evaluation and management of dysarthria and dysphagia. This review describes the standard clinical evaluation and treatment approaches by SLPs for addressing impaired speech and deglutition in specific hyperkinetic dysarthria populations. Methods A literature review was conducted using the data sources of PubMed, Cochrane Library, and Google Scholar. Search terms included 1) hyperkinetic dysarthria, essential voice tremor, voice tremor, vocal tremor, spasmodic dysphonia, spastic dysphonia, oromandibular dystonia, Meige syndrome, orofacial, cervical dystonia, dystonia, dyskinesia, chorea, Huntington’s Disease, myoclonus; and evaluation/treatment terms: 2) Speech–Language Pathology, Speech Pathology, Evaluation, Assessment, Dysphagia, Swallowing, Treatment, Management, and diagnosis. Results The standard SLP clinical speech and swallowing evaluation of chorea/Huntington’s disease, myoclonus, focal and segmental dystonia, and essential vocal tremor typically includes 1) case history; 2) examination of the tone, symmetry, and sensorimotor function of the speech structures during non-speech, speech and swallowing relevant activities (i.e., cranial nerve assessment); 3) evaluation of speech characteristics; and 4) patient self-report of the impact of their disorder on activities of daily living. SLP management of individuals with hyperkinetic dysarthria includes behavioral and compensatory strategies for addressing compromised speech and intelligibility. Swallowing disorders are managed based on individual symptoms and the underlying pathophysiology determined during evaluation. Discussion SLPs play an important role in contributing to the differential diagnosis and management of impaired speech and deglutition associated with hyperkinetic disorders.
Collapse
|
27
|
Hemmerich AL, Finnegan EM, Hoffman HT. The Distribution and Severity of Tremor in Speech Structures of Persons with Vocal Tremor. J Voice 2017; 31:366-377. [DOI: 10.1016/j.jvoice.2016.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 11/29/2022]
|
28
|
Haubenberger D, Abbruzzese G, Bain PG, Bajaj N, Benito-León J, Bhatia KP, Deuschl G, Forjaz MJ, Hallett M, Louis ED, Lyons KE, Mestre TA, Raethjen J, Stamelou M, Tan EK, Testa CM, Elble RJ. Transducer-based evaluation of tremor. Mov Disord 2016; 31:1327-36. [PMID: 27273470 DOI: 10.1002/mds.26671] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 04/04/2016] [Accepted: 04/07/2016] [Indexed: 11/11/2022] Open
Abstract
The International Parkinson and Movement Disorder Society established a task force on tremor that reviewed the use of transducer-based measures in the quantification and characterization of tremor. Studies of accelerometry, electromyography, activity monitoring, gyroscopy, digitizing tablet-based measures, vocal acoustic analysis, and several other transducer-based methods were identified by searching PubMed.gov. The availability, use, acceptability, reliability, validity, and responsiveness were reviewed for each measure using the following criteria: (1) used in the assessment of tremor; (2) used in published studies by people other than the developers; and (3) adequate clinimetric testing. Accelerometry, gyroscopy, electromyography, and digitizing tablet-based measures fulfilled all three criteria. Compared to rating scales, transducers are far more sensitive to changes in tremor amplitude and frequency, but they do not appear to be more capable of detecting a change that exceeds random variability in tremor amplitude (minimum detectable change). The use of transducer-based measures requires careful attention to their limitations and validity in a particular clinical or research setting. © 2016 International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Dietrich Haubenberger
- Clinical Trials Unit, Office of the Clinical Director, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.
| | | | - Peter G Bain
- Department of Neurology, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Nin Bajaj
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.,Department of Medicine, Complutense University, Madrid, Spain
| | - Kailash P Bhatia
- Sobell Department for Movement Neuroscience, UCL, Institute of Neurology, Queen Square, London, United Kingdom
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Maria João Forjaz
- National School of Public Health and Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Carlos III Institute of Health, Madrid, Spain
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Elan D Louis
- Departments of Neurology and Chronic Disease Epidemiology, Yale School of Medicine and Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Kelly E Lyons
- University of Kansas Medical Center, Kansas City, Kansas
| | - Tiago A Mestre
- Parkinson's disease and Movement Disorders Center, Division of Neurology, Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa Brain and Mind Research Institute, Ottawa, Ontario, Canada
| | - Jan Raethjen
- Department of Neurology, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Maria Stamelou
- Neurology Department, University of Athens, Greece and Neurology Department, Philipps University, Marburg, Germany
| | - Eng-King Tan
- Department of Neurology, National Neuroscience Institute (SGH campus), Duke NUS Medical School, Singapore General Hospital, Singapore
| | - Claudia M Testa
- Department of Neurology and Parkinson's and Movement Disorders Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Rodger J Elble
- Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| |
Collapse
|
29
|
Voice Tremor in Patients With Essential Tremor: Effects of Deep Brain Stimulation of Caudal Zona Incerta. J Voice 2016; 30:228-33. [DOI: 10.1016/j.jvoice.2015.04.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/02/2015] [Indexed: 11/23/2022]
|
30
|
Fluctuating flow. Vibrato, tremolo, or upper airway oscillation. Ann Am Thorac Soc 2016; 12:613-5. [PMID: 25897745 DOI: 10.1513/annalsats.201409-437cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
31
|
Maryn Y, Zarowski A. Calibration of Clinical Audio Recording and Analysis Systems for Sound Intensity Measurement. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2015; 24:608-618. [PMID: 26161588 DOI: 10.1044/2015_ajslp-14-0082] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 05/28/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE Sound intensity is an important acoustic feature of voice/speech signals. Yet recordings are performed with different microphone, amplifier, and computer configurations, and it is therefore crucial to calibrate sound intensity measures of clinical audio recording and analysis systems on the basis of output of a sound-level meter. This study was designed to evaluate feasibility, validity, and accuracy of calibration methods, including audiometric speech noise signals and human voice signals under typical speech conditions. METHOD Calibration consisted of 3 comparisons between data from 29 measurement microphone-and-computer systems and data from the sound-level meter: signal-specific comparison with audiometric speech noise at 5 levels, signal-specific comparison with natural voice at 3 levels, and cross-signal comparison with natural voice at 3 levels. Intensity measures from recording systems were then linearly converted into calibrated data on the basis of these comparisons, and validity and accuracy of calibrated sound intensity were investigated. RESULTS Very strong correlations and quasisimilarity were found between calibrated data and sound-level meter data across calibration methods and recording systems. CONCLUSIONS Calibration of clinical sound intensity measures according to this method is feasible, valid, accurate, and representative for a heterogeneous set of microphones and data acquisition systems in real-life circumstances with distinct noise contexts.
Collapse
|
32
|
Lester RA, Story BH. The effects of physiological adjustments on the perceptual and acoustical characteristics of simulated laryngeal vocal tremor. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2015; 138:953-63. [PMID: 26328711 PMCID: PMC4545074 DOI: 10.1121/1.4927561] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The purpose of this study was to determine if adjustments to the voice source [i.e., fundamental frequency (F0), degree of vocal fold adduction] or vocal tract filter (i.e., vocal tract shape for vowels) reduce the perception of simulated laryngeal vocal tremor and to determine if listener perception could be explained by characteristics of the acoustical modulations. This research was carried out using a computational model of speech production that allowed for precise control and manipulation of the glottal and vocal tract configurations. Forty-two healthy adults participated in a perceptual study involving pair-comparisons of the magnitude of "shakiness" with simulated samples of laryngeal vocal tremor. Results revealed that listeners perceived a higher magnitude of voice modulation when simulated samples had a higher mean F0, greater degree of vocal fold adduction, and vocal tract shape for /i/ vs /ɑ/. However, the effect of F0 was significant only when glottal noise was not present in the acoustic signal. Acoustical analyses were performed with the simulated samples to determine the features that affected listeners' judgments. Based on regression analyses, listeners' judgments were predicted to some extent by modulation information present in both low and high frequency bands.
Collapse
Affiliation(s)
- Rosemary A Lester
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, Arizona 85721, USA
| | - Brad H Story
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, Arizona 85721, USA
| |
Collapse
|
33
|
Ho AL, Choudhri O, Sung CK, DiRenzo EE, Halpern CH. Deep Brain Stimulation for Essential Vocal Tremor: A Technical Report. Cureus 2015; 7:e256. [PMID: 26180680 PMCID: PMC4494540 DOI: 10.7759/cureus.256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 11/11/2022] Open
Abstract
Essential vocal tremor (EVT) is the presence of a tremulous voice that is commonly associated with essential tremor. Patients with EVT often report a necessary increase in vocal effort that significantly worsens with stress and anxiety and can significantly impact quality of life despite optimal medical and behavioral treatment options. Deep brain stimulation (DBS) has been proposed as an effective therapy for vocal tremor, but very few studies exist in the literature that comprehensively evaluate the efficacy of DBS for specifically addressing EVT. We present a technical report on our multidisciplinary, comprehensive operative methodology for treatment of EVT with frameless, awake deep brain stimulation (DBS).
Collapse
Affiliation(s)
- Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine
| | | | - C Kwang Sung
- Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center
| | - Elizabeth E DiRenzo
- Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University Medical Center
| |
Collapse
|
34
|
Ho AL, Erickson-Direnzo E, Pendharkar AV, Sung CK, Halpern CH. Deep brain stimulation for vocal tremor: a comprehensive, multidisciplinary methodology. Neurosurg Focus 2015; 38:E6. [DOI: 10.3171/2015.3.focus1537] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Tremulous voice is a characteristic feature of a multitude of movement disorders, but when it occurs in individuals diagnosed with essential tremor, it is referred to as essential vocal tremor (EVT). For individuals with EVT, their tremulous voice is associated with significant social embarrassment and in severe cases may result in the discontinuation of employment and hobbies. Management of EVT is extremely difficult, and current behavioral and medical interventions for vocal tremor result in suboptimal outcomes. Deep brain stimulation (DBS) has been proposed as a potential therapeutic avenue for EVT, but few studies can be identified that have systematically examined improvements in EVT following DBS. The authors describe a case of awake bilateral DBS targeting the ventral intermediate nucleus for a patient suffering from severe voice and arm tremor. They also present their comprehensive, multidisciplinary methodology for definitive treatment of EVT via DBS. To the authors’ knowledge, this is the first time comprehensive intraoperative voice evaluation has been used to guide microelectrode/stimulator placement, as well as the first time that standard pre- and post-DBS assessments have been conducted, demonstrating the efficacy of this tailored DBS approach.
Collapse
Affiliation(s)
| | | | | | - Chih-Kwang Sung
- 2Otolaryngology (Head and Neck Surgery), Stanford University School of Medicine, Stanford, California
| | | |
Collapse
|
35
|
Carbonell KM, Lester RA, Story BH, Lotto AJ. Discriminating simulated vocal tremor source using amplitude modulation spectra. J Voice 2014; 29:140-7. [PMID: 25532813 DOI: 10.1016/j.jvoice.2014.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 07/31/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES/HYPOTHESIS Sources of vocal tremor are difficult to categorize perceptually and acoustically. This article describes a preliminary attempt to discriminate vocal tremor sources through the use of spectral measures of the amplitude envelope. The hypothesis is that different vocal tremor sources are associated with distinct patterns of acoustic amplitude modulations. STUDY DESIGN Statistical categorization methods (discriminant function analysis) were used to discriminate signals from simulated vocal tremor with different sources using only acoustic measures derived from the amplitude envelopes. METHODS Simulations of vocal tremor were created by modulating parameters of a vocal fold model corresponding to oscillations of respiratory driving pressure (respiratory tremor), degree of vocal fold adduction (adductory tremor), and fundamental frequency of vocal fold vibration (F0 tremor). The acoustic measures were based on spectral analyses of the amplitude envelope computed across the entire signal and within select frequency bands. RESULTS The signals could be categorized (with accuracy well above chance) in terms of the simulated tremor source using only measures of the amplitude envelope spectrum even when multiple sources of tremor were included. CONCLUSIONS These results supply initial support for an amplitude-envelope-based approach to identify the source of vocal tremor and provide further evidence for the rich information about talker characteristics present in the temporal structure of the amplitude envelope.
Collapse
Affiliation(s)
- Kathy M Carbonell
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, Arizona.
| | - Rosemary A Lester
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, Arizona
| | - Brad H Story
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, Arizona
| | - Andrew J Lotto
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, Arizona
| |
Collapse
|
36
|
Isetti D, Xuereb L, Eadie TL. Inferring speaker attributes in adductor spasmodic dysphonia: ratings from unfamiliar listeners. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2014; 23:134-45. [PMID: 24686338 DOI: 10.1044/2013_ajslp-13-0010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
PURPOSE To determine whether unfamiliar listeners' perceptions of speakers with adductor spasmodic dysphonia (ADSD) differ from control speakers on the parameters of relative age, confidence, tearfulness, and vocal effort and are related to speaker-rated vocal effort or voice-specific quality of life. METHOD Twenty speakers with ADSD (including 6 speakers with ADSD plus tremor) and 20 age- and sex-matched controls provided speech recordings, completed a voice-specific quality-of-life instrument (Voice Handicap Index; Jacobson et al., 1997), and rated their own vocal effort. Twenty listeners evaluated speech samples for relative age, confidence, tearfulness, and vocal effort using rating scales. RESULTS Listeners judged speakers with ADSD as sounding significantly older, less confident, more tearful, and more effortful than control speakers (p < .01). Increased vocal effort was strongly associated with decreased speaker confidence (rs = .88-.89) and sounding more tearful (rs = .83-.85). Self-rated speaker effort was moderately related (rs = .45-.52) to listener impressions. Listeners' perceptions of confidence and tearfulness were also moderately associated with higher Voice Handicap Index scores (rs = .65-.70). CONCLUSION Unfamiliar listeners judge speakers with ADSD more negatively than control speakers, with judgments extending beyond typical clinical measures. The results have implications for counseling and understanding the psychosocial effects of ADSD.
Collapse
|