Endonasal approach of salpingopharyngeus muscle for the treatment of ear click related to palatal tremor

The Effects of Remote Signal Transmission and Recording on Acoustical Measures of Simulated Essential Vocal Tremor: Considerations for Remote Treatment Research and Telepractice

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.

Behavioral Therapy for Tremor or Dystonia Affecting Voice in Speakers with Hyperkinetic Dysarthria: A Systematic Review

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.

A Cadaveric and Magnetic Resonance Imaging Investigation of the Salpingopharyngeus

Purpose The aim of the study was to update our information regarding the salpingopharyngeus (SP) muscle using cadaveric and in vivo magnetic resonance imaging (MRI) data. Primary objectives were to (a) observe the presence/absence of the muscle and (b) quantify and describe its dimensions and course. Method SP specimens from 19 cadavers (10 women, nine men) were analyzed. Following head bisection, measurements of SP, including width of the cartilaginous attachment (CW) and width of the superior muscle base (SMW), were taken before and after removal of the overlying mucosa. In addition, SP was analyzed in 15 healthy subjects (eight men, seven women) using high-resolution three-dimensional MRI data. CW and SMW measures were replicated in the paraxial MRI view. Results The presence of the salpingopharyngeal fold and muscle was confirmed bilaterally in all cadaveric and living subjects. Following mucosa removal, mean cadaveric CW and SMW measurements were 5.6 and 3.8 mm, respectively. Mean in vivo CW and SMW were 6.1 and 3.7 mm, respectively. Results from the hierarchical regression analyses revealed that, in both cadaveric and living groups, SMW is dependent on the relationship between age and body weight, after controlling for sex. Conclusions The salpingopharyngeal fold and SP muscle are always present bilaterally and can be quantified at the superior origin using both cadaveric and in vivo three-dimensional MRI data. Though both the superior origin and inferior course of SP are highly variable, the size of the SP muscle is dependent on characteristics known to affect muscle fibers, such as the relationship between age and body weight. Given the consistent and quantifiable presence of the SP muscle, its potential role in velopharyngeal function for speech and swallowing is reconsidered. Supplemental Material https://doi.org/10.23641/asha.14347859.

Isolated Ear Clicks with Partial Voluntary Control

Background: Ear click is a rare type of objective tinnitus, classically described with associated palatal tremor/myoclonus (PT). Case report: A 15-year-old boy reported a constant bilateral ear clicking for 4 years, that could be stopped at will for a few seconds. Clinically, the ear clicks were audible without visible eardrum or palatal movement, and could be entrained by the examiner. Brain MRI was normal. Discussion: We propose to classify this as isolated ear clicks with partial voluntary control, putting it into context with other subcategories of “essential” or “isolated” PT.

Botulinum Toxin Treatment of Objective Tinnitus Because of Essential Palatal Tremor: A Systematic Review

INTRODUCTION

In contrast to subjective tinnitus, objective tinnitus can be heard by the examiner as well as by the patient. It can be triggered by, among many other etiologies, idiopathic muscular tremor in the soft palate, the essential palatal tremor (EPT). Many treatment modalities have been investigated, of which only Botulinum toxin (BT) injections have shown promising results.

GOAL

The aim of this study was to evaluate the effect of BT treatment on objective tinnitus due to EPT by a systematic review of the literature.

METHODS

In accordance with PRISMA guideline a systematic literature search in three databases was performed.

RESULTS

Twenty-two studies fulfilled the inclusion criteria, mainly case reports and case series. A total of 51 BT treated patients diagnosed with EPT were identified in the literature. The studies were evaluated with focus on diagnostics, injection technique and BT dose, follow-up, effect on objective tinnitus, complications, and adverse effects.

CONCLUSIONS

The included studies suffer from an extremely low evidence level with several sources of bias. When optimally injected, BT seems to be an effective treatment of objective tinnitus due to EPT, with few adverse effects and complications. We suggest BT injections as first choice in case of EPT and present a guideline regarding diagnostics, treatment, and follow-up.

Discriminating simulated vocal tremor source using amplitude modulation spectra

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.

Middle ear myoclonus: two informative cases and a systematic discussion of myogenic tinnitus

Background

The term middle ear myoclonus (MEM) has been invoked to explain symptoms of tinnitus presumably caused by the dysfunctional movement of either of the two muscles that insert in the middle ear: tensor tympani and stapedius. MEM has been characterized through heterogeneous case reports in the otolaryngology literature, where clinical presentation is variable, phenomenology is scarcely described, the pathogenic muscle is usually not specified, natural history is unknown, and the presumptive definitive treatment, tensor tympani or stapedius tendon lysis, is inconsistently effective. It is not surprising that no unique acoustogenic mechanism or pathophysiologic process has been identified to explain MEM, one of several descriptive diagnoses associated with the complicated disorders of myogenic tinnitus.

Methods

Here, we explore MEM from the neurologist’s perspective. Following the detailed descriptions of two informative cases from our clinic, we systematically evaluate the different mechanisms and movement disorder phenomena that could lead to a diagnosis of MEM.

Results

From a functional neuroanatomic perspective, we explain how tensor tympani MEM is best explained as a form of peritubal myogenic tinnitus, similar to the related disorder of essential palatal tremor. From a pathogenic perspective, we discuss how MEM symptomatology may reflect different mechanical and neurologic processes. We emphasize the diagnostic imperative to recognize when myogenic tinnitus is consistent with a psychogenic origin.

Discussion

Both individual patient care and further elucidation of MEM will rely on more detailed clinical characterization as well as multidisciplinary input from neurology, otolaryngology, and dentistry.

Updates on Vocal Tremor and its Management

Vocal tremor is a neurogenic voice disorder characterized by a nearly periodic modulation in pitch and loudness during sustained phonation. This voicing pattern is the result of tremor affecting structures within the speech mechanism, resulting in modulation of lung pressure, phonation, articulation, and resonance during speaking. Speaking patterns in these individuals may be perceived as similar to spasmodic dysphonia or muscle tension dysphonia. The key to determining the presence of vocal tremor and distinguishing it from other voice disorders requires familiarity with the perceptual, acoustic, and physiologic patterns associated with vocal tremor during different voicing and speech contexts. Management of those with vocal tremor can be challenging because of its co-occurrence with other neurological disorders. The two most common methods for managing vocal tremor include pharmaceutical treatment, most commonly applied via injections of Botulinum Toxin Type A (Botox®), and behavioral modification of speaking patterns. The latter approach is in early clinical phases of research and has not yet been subjected to clinical trials. In this paper, I will summarize the clinical characteristics of vocal tremor in comparison to what is known about tremor in general and describe Botox® and behavioral approaches for managing individuals with this voice disorder.

Objective tinnitus from palatal myoclonus. Use of botulinum toxin: a case report

Objective tinnitus can have many different etiologies, palatal myoclonus being one of the less frequent. This type of tinnitus is generated by involuntary rhythmic contraction of the soft palate, which generates an audible click for the patient and for the explorer. Botulinum toxin achieves temporary muscle paralysis through presynaptic inhibition of the acetylcholine level at the neuromuscular union. We present a patient with long-term objective tinnitus, along with this patient's response to botulinum toxin injection.

Difference in outcome of botulinum toxin treatment of essential palatal tremor in children and adults

PURPOSE

The objective of this clinical study was to investigate the history and clinical findings in 10 patients having an essential palatal tremor. Furthermore, a botulinum toxin A (BTA) therapy in 5 cases was carried out, and the outcome was analyzed.

MATERIALS AND METHODS

Seven adult and 3 pediatric patients with essential palatal tremor were examined at presentation, before and after start of treatment, and every 3 months or when symptoms recurred. Findings were documented by endoscopic video recordings, electromyography, tympanometry, and ear canal microphone recording. The BTA injections were performed in local or general anesthesia, under elecromyographic guidance.

RESULTS

The BTA therapy in all 5 patients was successful. Surprisingly, 2 of these patients, aged 10 and 6 years, remained in remission for several years after a single successful injection.

CONCLUSION

Botulinum toxin therapy is a safe and effective treatment of essential palatal tremor and seems to be especially useful in pediatric patients. The long lasting effect in children hints toward a pathophysiologic difference between pediatric and adult essential palatal tremor.