The menopause and the female larynx, clinical aspects and therapeutic options: A literature review

Role of VPAC1 anD VPAC2 receptors in the etiology of pregnancy rhinitis: an experimental study in rats

Introduction

Pregnancy rhinitis is a common sex hormone-related otorhinolaryngological disorder. There are some epidemiological and physiological studies on pregnancy rhinitis, but histopathological and biomolecular changes have not been studied thoroughly.

Objectives

The receptors VPAC1 and VPAC2 are known for their roles in allergic rhinitis. On the other hand, activation of subclinical allergy has been suggested in the pathophysiology of pregnancy rhinitis. Therefore, we aimed to compare the physiological and gestational pattern of VPAC1 and VPAC2 expression in rat nasal mucosa.

Methods

Twenty adult Wister albino female rats were enrolled into the study. Two groups constituted as 10 control (group A) and 10 pregnant (group B) rats. They were fed ad libitum and sheltered at room temperature (22°±2 °C). The rats were sacrificed at the 20th day of gestation by intraperitoneal injection of 400 mg/kg Na-pentobarbitone. Then, 10 − 15 mL of blood was taken, and samples were reserved for the detection of serum estradiol and progesterone levels by ELISA test. The nasal septum was resected and divided in half for immunohistochemical analyses and real time polymerase chain reaction testing of VPAC1 and VPAC2.

Results

VPAC1 and VPAC2 were found to be in all layers of septal specimens, but the immunostaining of surface epithelium was more distinct in specimens of both groups. We demonstrated higher overall staining intensity in the pregnant group. PCR revealed significant increase in expression of VPAC1 (p = 0.023) and VPAC2 (p = 0.021) in pregnant group when compared with control group. In addition, we demonstrated upregulatory effect of estradiol and progesterone on the vasoactive intestinal peptide receptor expression.

Conclusions

Gestational up-regulation of nasal VPAC1 and VPAC2 was shown both by PCR and immunohistochemical analysis. These findings support the hypothesis that PR is caused by the activation of subclinical allergy that is present before pregnancy.

Respiratory Muscle Strength Training to Improve Vocal Function in Patients with Presbyphonia

BACKGROUND AND OBJECTIVE

The effects of presbyphonia are compounded by the decline in respiratory function that occurs with age. Commonly recommended exercises to optimize the use of respiratory muscles during speech, such as diaphragmatic breathing, are unlikely to be intensive enough to induce respiratory changes and impact vocal function. The objective of this study was to assess the effect of adding a targeted intervention, respiratory muscle strength training, to voice exercises in a sample of patients with presbyphonia.

METHODS/DESIGN

In this prospective, randomized-controlled trial, 12 participants received either (1) vocal function exercises (VFE), (2) VFE combined with inspiratory muscle strength training (IMST), or (3) VFE combined with expiratory muscle strength training (EMST). Data collected prior to and following 4 weekly intervention sessions included respiratory measures (pulmonary function and respiratory muscle strength) and voice measures (videostroboscopy, acoustic, auditory-perceptual, aerodynamic, and self-assessment measures).

RESULTS

Participants who received IMST improved their voice quality during connected speech (smoothed cepstral peak prominence and ratings of overall voice quality) and their scores on the three self-assessment questionnaires with large to very large within-group effect sizes (|d| = 0.82-1.61). In addition, participants in the IMST group reduced their subglottal pressure with a large effect size (d = -0.92). Participants who received EMST improved their maximum expiratory strength and smoothed cepstral peak prominence with large effect sizes (d = 0.80 and 0.99, respectively) but had limited improvements in other outcomes. Participants who received only VFE decreased their amount of vocal fold bowing, improved their voice quality on a sustained vowel (amplitude perturbation quotient), and improved their Glottal Function Index score with large effect sizes (|d| = 0.74-1.00).

CONCLUSION

Preliminary data indicate that adding IMST to voice exercises may lead to the greatest benefits in patients with presbyphonia by promoting improved subglottal pressure control as well as increasing air available for phonation, resulting in improved self-assessment outcomes.

The Impact of Respiratory Function on Voice in Patients with Presbyphonia

BACKGROUND AND OBJECTIVE

Presbyphonia is an age-related voice disorder characterized by vocal fold atrophy and incomplete glottal closure during phonation. The extent to which the effects of presbyphonia may be compounded by age-related declines in the respiratory system and further impact communication and quality of life remains unknown. Therefore, the objective of this study was to determine how variations in respiratory function impacts voice measures in a sample of participants with presbyphonia.

METHODS

In this pilot study, 21 participants with presbyphonia underwent respiratory assessments (spirometry and respiratory muscle strength testing) and voice assessments (videostroboscopy, acoustic analysis, auditory-perceptual ratings, aerodynamic assessment, and self-assessments). Factor and cluster analyses were conducted to extract voice and respiratory constructs and to identify groups of participants with similar profiles. Correlations and regression analyses were conducted to better describe the relationships between voice and respiratory function.

RESULTS

Respiratory function was found to impact voice via two main pathways: through its physiological effect on voice and through its impact on general health and impairment. A lower respiratory function was associated with a lower vocal fold pliability and regularity of vibration and with an elevated aerodynamic resistance accompanied by laryngeal hyperfunction. Standardized measures of respiratory function were associated with perceived voice-related handicap. Respiratory function did not associate with voice quality, which was mostly influenced by the severity of vocal fold atrophy.

CONCLUSION

Poor respiratory health exacerbates the burden of vocal fold atrophy and, therefore, implementation of respiratory screening prior to starting voice therapy may significantly affect the treatment plan and consequently the outcomes of voice therapy in this patient population.

Acoustic characteristics of healthy voices of adults: from young to middle age

PURPOSE

Characterize voices of adult individuals without vocal complaints and verify the effect of gender and age with the use of acoustic measures.

METHODS

One-hundred and seventy-six voice recordings belonging to adults between 19 and 59 years old, divided into four age groups, for decade, recorded in a database were analyzed. All voices analyzed were classified with no deviation in vocal quality. Acoustic analysis of the parameters was performed: Fundamental Frequency (sustained vowel and connected speech), Jitter, Shimmer and Noise-to-Harmonic Ratio through Multi Dimension Voice Program (KayPentax) software. The effect of gender, age and possible interactions were verified through the Factorial Anova test. When necessary, post hoc was performed with the Least Significant Difference test.

RESULTS

There were changes in the voice as a function of age, with a decrease in the Fundamental Frequency in the vowel and connected speech modalities in women and in the Fundamental Frequency of the speech in men. In men, an increase in shimmer measure was observed with the advancing age. Differences between genders were found in the measures of Fundamental Frequency, Jitter and Noise to Harmonic Ratio.

CONCLUSION

Vocal changes due to advancing age can be identified acoustically at the end of adulthood, and in women, these changes can be marked previously to the menopausal period.

Medications and Adverse Voice Effects

OBJECTIVES

To identify the medications used by patients with dysphonia, describe the voice symptoms reported on initial speech-language pathology (SLP) examination, evaluate the possible direct and indirect effects of medications on voice production, and determine the association between direct and indirect adverse voice effects and self-reported voice symptoms, hydration and smoking habits, comorbidities, vocal assessment, and type and degree of dysphonia.

STUDY DESIGN

This is a retrospective cross-sectional study.

METHODS

Fifty-five patients were evaluated and the vocal signs and symptoms indicated in the Dysphonia Risk Protocol were considered, as well as data on hydration, smoking and medication use. We analyzed the associations between type of side effect and self-reported vocal signs/symptoms, hydration, smoking, comorbidities, type of dysphonia, and auditory-perceptual and acoustic parameters.

RESULTS

Sixty percent were women, the mean age was 51.8 years, 29 symptoms were reported on the screening, and 73 active ingredients were identified with 8.2% directly and 91.8% indirectly affecting vocal function. There were associations between the use of drugs with direct adverse voice effects, self-reported symptoms, general degree of vocal deviation, and pitch deviation.

CONCLUSIONS

The symptoms of dry throat and shortness of breath were associated with the direct vocal side effect of the medicine, as well as the general degree of vocal deviation and the greater pitch deviation. Shortness of breath when speaking was also associated with the greatest degree of vocal deviation.

Menstrual Cycle Phase Modulates Auditory-Motor Integration for Vocal Pitch Regulation

In adult females, previous work has demonstrated that changes in auditory function and vocal motor behaviors may accompany changes in gonadal steroids. Less is known, however, about the influence of gonadal steroids on auditory-motor integration for voice control in humans. The present event-related potential (ERP) study sought to examine the interaction between gonadal steroids and auditory feedback-based vocal pitch regulation across the menstrual cycle. Participants produced sustained vowels while hearing their voice unexpectedly pitch-shifted during the menstrual, follicular, and luteal phases of the menstrual cycle. Measurement of vocal and cortical responses to pitch feedback perturbations and assessment of estradiol and progesterone levels were performed in all three phases. The behavioral results showed that the menstrual phase (when estradiol levels are low) as associated with larger magnitudes of vocal responses than the follicular and luteal phases (when estradiol levels are high). Furthermore, there was a significant negative correlation between the magnitudes of vocal responses and estradiol levels. At the cortical level, ERP P2 responses were smaller during the luteal phase (when progesterone levels were high) than the menstrual and follicular phases (when progesterone levels were low). These findings show neurobehavioral evidence for the modulation of auditory-motor integration for vocal pitch regulation across the menstrual cycle, and provide important insights into the neural mechanisms and functional outcomes of gonadal steroids' influence on speech motor control in adult women.

Emirati Teachers' Perceptions of Voice Handicap

OBJECTIVES

The purpose of the study was to explore Emirati teachers' perceptions of voice handicap and to analyze their acoustic characteristics to determine whether acoustic measures of teachers' voice would verify their perceptions of voice handicap.

METHODS

Sixty-six Emirati school teachers (33 men and 33 women), with different years of teaching experience and age, and 100 control participants (50 men and 50 women) underwent vocal assessment that included the Voice Handicap Index (VHI-Arab) and acoustic measures (F0, jitter%, shimmer%, signal to noise ratio [SNR]).

RESULTS

Significant differences between the teachers' group scores and the control group scores on the following subscales of VHI-Arab: physical (P = 0.006), emotional (P = 0.004), and total score of the test (P = 0.002). No significant differences were found among teachers in the three VHI subscales, and the total score regarding gender (functional P = 0.307; physical P = 0.341; emotional P = 0.126; and total P = 0.184), age (functional P = 0.972; physical P = 0.525; emotional P = 0.772; and total P = 0.848), and years of teaching experience (functional P = 0.319; physical P = 0.619; emotional P = 0.926; and total P = 0.638). The significant differences between the teacher's group and the control group in three acoustic measures: F0 (P = 0.000), shimmer% (P = 0.000), and SNR (P = 0.000) were further investigated. Significant differences were found among female and male teachers in F0 (P = 0.00) and SNR (P = 0.007). As for teachers' age, significant differences were found in SNR (P = 0.028). Teachers' years of experience did not show significant differences in any of the acoustic measures.

CONCLUSIONS

Teachers have a higher perception of voice handicap. However, they were able to produce better voice quality than control participants were, as expressed in better SNRs. This might have been caused either by manipulation of vocal properties or abusive overloading the vocal system to produce a procedurally acceptable voice quality.

Is the speaking fundamental frequency in females related to body height?

The aim of the study was to determine the impact of body height on speaking fundamental frequency (SF0) while controlling for as many as possible influencing factors such as habits, biophysical conditions, medication, diseases, and others. Fifty-eight females were analyzed during spontaneous speech (i.e. explaining driving directions or a cooking recipe) of at least 60 seconds at comfortable pitch and loudness. The subjects showed a moderate negative and significant correlation between body height and SF0 (r = -0.40, P = 0.002). With r(2) = 0.16, however, a reasonable portion (16%) of the variance in SF0 is explained by the variance in body height. In comparison with other factors for which a correlation with SF0 was mentioned in literature (hypothyrodism, hemodialysis, auditory-maleness after female-to-male transsexualism, body weight, body mass index, and body fat), body height accounted for most of the proportion of SF0 in females. It is therefore possible to validate body height as a factor to account for in clinical F0 measurement.

The effects of hormonal status on upper airway patency in normal female subjects during propofol anesthesia

STUDY OBJECTIVE

To determine the mechanical upper airway properties and compensatory neuromuscular responses to obstruction during propofol anesthesia in the follicular and luteal phases of the menstrual cycle.

DESIGN

Prospective, randomized study.

SETTING

University-affiliated hospital.

SUBJECTS

12 premenopausal female volunteers for studies of upper airway collapse throughout their menstrual cycle during the follicular phase (6 -10 days) and mid-late luteal phase (20 - 24 days).

MEASUREMENTS

The level of propofol anesthesia (1.5 - 2.0 μg/mL) required to suppress arousal responses was determined by Observer's Assessment of Alertness/Sedation scoring (level 2) and confirmed by bispectral index monitoring. Pressure-flow relationships were constructed to evaluate collapsibility (P(CRIT)) and up-stream resistance (R(US)) during acute [Passive; hypotonic electromyography (EMG)] and sustained (Active; elevated EMG) changes in nasal mask pressure. The difference between passive P(CRIT) and active P(CRIT) (ΔP(CRIT A-P)) represented the magnitude of the compensatory response to obstruction.

MAIN RESULTS

Passive P(CRIT) was significantly higher in the mid-late luteal phase (-4.7 cm H(2)O) than in the follicular phase (-6.2 cmH(2)O; P < 0.05). Active P(CRIT) significantly decreased compared with passive P(CRIT) in the follicular phase (-10.1 cm H(2)O) and in the mid-late luteal phase (-7.7 cm H(2)O) and (P < 0.05). No significant difference was noted in ΔP(CRIT) between the follicular (3.9 ± 2.9 cm H(2)O) and mid-late luteal phases (3.0 ± 2.6 cm H(2)O). No differences were seen in R(US) between the menstrual phases for either the passive (P = 0.8) or active (P = 0.75) states.

CONCLUSIONS

Menstrual phase has an effect on anatomical alterations (mechanical properties) in the hypotonic upper airway during propofol anesthesia.

[Medical treatment of singers' voices]

ENT/phoniatrics specialists are frequently the primary reference persons for patients who have problems with the professional use of their voice. Singers show the highest risk factors for voice disorders among all professional voice users. The treatment and care of singers requires specific knowledge and competence of the physician, as well as a treatment setting adapted to the needs of this special group of patients, whose existence depends on the use of their voice. To some extent, evidence based concepts can be taken into account when treating professional singers. In cases for which no concepts have yet been developed and evaluated, recourse to clinical experience is necessary. In the present paper, current concepts for the treatment of singers are discussed on the basis of scientific publications and on long-standing experience of consultations in musician's medicine and ENT, under the aspects of diagnosis, therapy as well as prevention, taking into account the most frequent voice problems in professional singers.

The impact of menopause and hormone therapy on nasal resonance

The purpose of this study was to investigate the impact of menopause and hormone therapy on nasal resonance by comparing premenopausal women and postmenopausal women with and without hormone therapy. A total of 147 middle-aged Flemish (Dutch)-speaking women participated in the study and were divided into three groups: premenopausal women (n =42), and postmenopausal women with (n =63) and without (n =42) hormone therapy. Nasal resonance scores of isolated sounds and connected speech were measured using the Nasometer. For the isolated sounds as well as for the reading texts, no differences were found in nasal resonance scores between the three groups (ANCOVA). The results of this study indicate that menopause and hormone therapy do not have an impact on the nasal resonance in middle-aged women.

Nasal resonance in middle-aged women: a multiparameter approach

OBJECTIVES

Aging influences several speech characteristics in middle-aged women. However, the effect of aging on nasal resonance has not been widely investigated, and findings are contradictory. The purpose of this study was to investigate the effect of aging on nasal resonance by comparing young women (between 20 and 28 years of age) with middle-aged women (between 45 and 55 years of age).

METHODS

Thirty-one middle-aged women with a mean age of 48 years participated in the subject group. The control group consisted of 22 young women with a mean age of 23 years. To investigate nasal resonance, we used a multiparameter approach by means of the Nasal Severity Index (NSI). Objective acoustic (nasal resonance scores of sounds and connected speech measured with the Nasometer) and aerodynamic measurements (maximum duration time of /s/, vital capacity, and mirror fogging test), as well as perceptual evaluations (Gutzmann /a/-i/test), were performed.

RESULTS

The results of this study showed no differences in aerodynamic measurements and nasal resonance scores of connected speech and the sounds /i/, /u/, and /m/. Only the mean nasal resonance score of /a/ and the Gutzmann /a/ test were significantly different between the young and middle-aged women. The mean (+/- SD) NSI scores of the young women (12.93 +/- 17.9) and the middle-aged women (-1.49 +/- 14.4) both corresponded to normal nasal resonance.

CONCLUSIONS

The results of this study indicate that both young and middle-aged women show a normal nasal resonance. Differences in objective and subjective measurements of nasal resonance were only found in isolated vowels, and not in connected speech.

The relation between body mass index and speaking fundamental frequency in premenopausal and postmenopausal women

OBJECTIVE

The purpose of this study was to investigate the association between body mass index (BMI) and speaking fundamental frequency (SFF) in premenopausal and postmenopausal women with and without hormone therapy (HT).

METHODS

A total of 105 middle-aged women participated and were divided into three groups: premenopausal women (n = 41), postmenopausal women without HT (n = 26), and postmenopausal women with HT (n = 38). The mean SFF (in hertz) of connected speech was measured using the Real-Time Pitch program from Computerized Speech Lab (Kay). Correlation coefficients were calculated using partial correlation between BMI and SFF, controlling for age.

RESULTS

A positive correlation was apparent between BMI and SFF in the group of postmenopausal women without HT (P = 0.021). In the group of premenopausal women and the group of postmenopausal women with HT, no correlation was found between BMI and SFF.

CONCLUSIONS

In postmenopausal women without HT, increasing BMI is associated with increasing SFF. This correlation is possibly related to the higher amount of estrogen production in adipose tissue in women with a higher BMI.

Effects of ovariectomy and estrogen replacement therapy on laryngeal tissue: a histopathological experimental animal study

OBJECTIVE

To determine the histopathological effect of estrogen deficiency and hormone replacement treatment on laryngeal tissue in ovariectomized rats.

STUDY DESIGN

Animal study.

SETTING

The study was conducted at the animal experiment laboratory of Marmara University School of Medicine, Istanbul, Turkey.

SUBJECTS AND METHODS

Six-month-old female Wistar albino rats were divided into the following 3 groups (n = 8 per group): sham-operated control, ovariectomized, and ovariectomized with estrogen replacement. Rats in the ovariectomized with estrogen replacement group received 17 β-estradiol valerate (200 µg/kg, subcutaneously) once a week. Animals were killed after 8 weeks of intervention.

RESULTS

Significant changes were observed in the ovariectomized group when edema in lamina propria, inflammation in squamous, respiratory epithelia and lamina propria, pseudostratification, and cilia loss were assessed. Except cilia loss, there were no significant differences in the assessments between the sham-operated control and ovariectomized with estrogen replacement groups.

CONCLUSIONS

On the basis of histopathological evaluations, it was shown that estrogen replacement helped to improve laryngeal changes due to experimentally induced menopause.

Gender differences affecting vocal health of women in vocally demanding careers

Studies suggest that occupational voice users have a greater incidence of vocal issues than the general population. Women have been found to experience vocal health problems more frequently than men, regardless of their occupation. Traditionally, it has been assumed that differences in the laryngeal system are the cause of this disproportion. Nevertheless, it is valuable to identify other potential gender distinctions which may make women more vulnerable to voice disorders. A search of the literature was conducted for gender-specific characteristics which might impact the vocal health of women. This search can be used by health care practitioners to help female patients avoid serious vocal health injuries, as well as to treat better those women who already suffer from such vocal health issues.

Pathophysiology and treatment of muscle tension dysphonia: a review of the current knowledge

OBJECTIVE

Muscle tension dysphonia (MTD) is a clinical and diagnostic term describing a spectrum of disturbed vocal fold behavior caused by increased tension of the (para)laryngeal musculature. Recent knowledge introduced MTD as a bridge between functional and organic disorders. This review addresses the causal and contributing factors of MTD and evaluates the different treatment options.

METHODS

We searched MEDLINE (Pubmed, 1950-2009) and CENTRAL (The Cochrane Library, Issue 2, 2009). Studies were included if they reviewed the classification of functional dysphonia or the pathophysiology of MTD. Etiology and pathophysiology of MTD and circumlaryngeal manual therapy (CMT) were obligatory based on reviews and prospective cohort studies because randomized controlled trials (RCTs) are nonexisting. Concerning the treatment options of voice therapy and vocal hygiene, selection was based on RCTs and systematic reviews.

RESULTS

Etiological factors can be categorized into three new subgroups: (1) psychological and/or personality factors, (2) vocal misuse and abuse, and (3) compensation for underlying disease. The effective treatment options for MTD are (1) indirect therapy: vocal hygiene and patient education; (2) direct therapy: voice therapy and CMT; (3) medical treatment; and (4) surgery for secondary organic lesions.

CONCLUSIONS

MTD is the pathological condition in which an excessive tension of the (para)laryngeal musculature, caused by a diverse number of etiological factors, leads to a disturbed voice. Etiological factors range from psychological/personality disorders and vocal misuse/abuse to compensatory vocal habits in case of laryngopharyngeal reflux, upper airway infections, and organic lesions. MTD needs to be approached in a multidisciplinary setting where close cooperation between a laryngologist and a speech language pathologist is possible.