Central Nervous System Control of Voice and Swallowing

The Functional Capacity of the Upper Airway in Older Adults with Chronic Stroke

(1) Background: Older adults with chronic stroke may experience compromised upper airway functions due to stroke-related changes and aging. This study aimed to evaluate the functional capacity of the upper airway in older adults with chronic stroke. (2) Methods: A total of 44 patients (22 in each group) were included in the study. The respiratory assessment involved measuring forced vital capacity, forced expiratory volume in one second, maximum voluntary ventilation, and peak cough flow. The voice assessment recorded intensity, frequency, shimmer, and the harmonics-to-noise ratio during a monologue task. Additionally, the maximum phonation time of /a/ and /s/ was recorded. The swallowing assessment included the Eating Assessment Tool-10 and the Swallowing Quality of Life questionnaire. (3) Results: Significant differences were found in the experimental group compared to the control group in maximum voluntary ventilation (44.59 ± 15.61 vs. 58.50 ± 28.08, p = 0.049) and peak cough flow (173.64 ± 101.09 vs. 291.59 ± 176.58, p = 0.009). Additionally, the experimental group showed poorer results than the control group in monologue intensity (66.60 ± 3.72 vs. 114.72 ± 63.09, p = 0.001), the harmonics-to-noise ratio (9.08 ± 2.06 vs. 10.26 ± 1.59, p = 0.042), and the maximum phonation time of /s/ (4.36 ± 1.67 vs. 8.09 ± 4.07, p < 0.001). Patients with stroke also had significantly lower values for swallowing efficiency and safety compared to the control group (7.05 ± 8.44 vs. 2.23 ± 4.14, p = 0.021) and reported poorer quality of life related to swallowing difficulties (185.50 ± 23.66 vs. 200.32 ± 19.60, p = 0.029). (4) Conclusions: Older adults with chronic stroke exhibited significantly reduced cough strength, voice intensity, maximum phonation time, and swallowing function compared to controls.

Baroreflex Sensitivity in Patients With Laryngopharyngeal Dysfunction-The Overwhelmed Vagus Hypothesis

Importance

The autonomic nervous system maintains internal stability by concurrently prioritizing and managing different functions. It is currently not known whether dysfunction at the aerodigestive junction could overwhelm autonomic control and impair other functions.

Objective

To compare baroreflex sensitivity, a prognostically significant index of the autonomic system's ability to stabilize blood pressure, between patients with predominantly esophagogastric (digestive) and patients with predominantly laryngopharyngeal (aerodigestive) symptoms.

Design, Setting, and Participants

A cross-sectional study, between 2018 and 2019, of adults undergoing esophagal manometry or transnasal panendoscopy was carried out in a specialist center. The analysis took place between 2023 and 2024.

Main Outcomes and Measures

Heart rate and blood pressure were recorded and baroreflex sensitivity and heart rate variability were derived. Esophageal physiology was assessed with high-resolution manometry.

Results

There were 30 and 23 patients in the digestive and aerodigestive groups, respectively. The mean (SD) age was 61 (15) years and there were 26 women and 27 men. Compared with patients in the digestive group, more patients in the aerodigestive group had voice or throat symptoms and fewer had classic reflux symptoms (odds ratio [OR], 5.65; 95% CI, 1.82-17.5; OR, 2.07; 95% CI, 1.28-3.33; and OR, 0.60; 95% CI, 0.38-0.95, respectively). Patients in the aerodigestive group had higher mean (SD) resting heart rate (93 [17] vs 75 [13] min-1; difference of means, -18 min-1; 95% CI, -26 to -10), lower resting mean (SD) arterial pressure (94 [16] vs 104 [23] mm Hg, OR, 10; 95% CI, -1 to 21), lower mean (SD) baroreflex sensitivity (3.77 [0.79] vs 9.76 [2.92] s-3mm Hg-1; OR, 6.0 s-3mmHg-1; 95% CI, 4.7-7.2), and lower mean (SD) parasympathetic-spectrum heart rate variability (0.68 [0.15] vs 1.30 [0.53]; OR, 0.62; 95% CI, 0.39-0.85). There was a correlation between reduced lower esophageal relaxation (integrated relaxation pressure) and reduced baroreflex sensitivity (r = -0.33; 95% CI, -0.58 to -0.03).

Conclusions

In this cross-sectional study of adults undergoing esophageal manometry or transnasal panendoscopy, patients with laryngopharyngeal symptoms had reduced baroreflex sensitivity, indicating diminished vagal control compared with patients with esophagogastric symptoms. The overwhelmed vagus hypothesis may explain these responses by considering autonomic functions as competing consumers of the finite regulatory resources of a common controller. The regulatory demands of maintaining a safe airway with concurrent laryngopharyngeal sensorimotor dysfunction, superadded to baseline demands for dual speech and aerodigestive control, could overwhelm and force the system to deprioritize less immediate functions like esophageal relaxation and the baroreflex. Measuring baroreflex sensitivity, now possible in routine clinical practice, could enable phenotyping and objective outcome assessment for laryngopharyngeal dysfunction. A neurophysiological model for considering laryngopharyngeal sensorimotor dysfunction could in turn move patient care toward a more holistic autonomic health footing.

Single-Session Cerebellar Transcranial Direct Current Stimulation Improves Postural Stability and Reduces Ataxia Symptoms in Spinocerebellar Ataxia

Spinocerebellar ataxia (SCA) results in balance and coordination impairment, and current treatments have limited efficacy. Recent evidence suggests that combining postural training with cerebellar transcranial direct current stimulation (ctDCS) can improve these symptoms. However, the combined effects of ctDCS and postural training on individuals with spinocerebellar ataxia remain underexplored. Ten volunteers with (SCA type 3) participated in a triple-blind, randomized, crossover study to receive a single session of ctDCS (2 mA for 20 min) and a sham ctDCS session separated by at least one week. The Biodex Balance System was used to assess balance at each session, measuring overall stability index, anteroposterior stability index, and medial-lateral stability index. As secondary outcomes, cerebellar ataxia symptoms were evaluated using the 8-item Scale for Assessment and Rating of Ataxia. The assessments were conducted before and after each session. The results indicated that ctDCS enhanced the overall stability index when compared to sham ctDCS (Z = -2.10, p = 0.03), although it did not significantly affect the anteroposterior or medial-lateral stability indices. Compared to the baseline, a single session of ctDCS reduced appendicular symptoms related to cerebellar ataxia, as evidenced by improvements in the nose-finger test (Z = -2.07, p = 0.04), fast alternating hand movements (Z = -2.15, p = 0.03), and heel-to-shin slide (Z = -1.91, p = 0.05). In conclusion, our study suggests that a single session of ctDCS, in combination with postural training, can enhance balance and alleviate ataxia symptoms in individuals with cerebellar ataxia. This study was approved by the local research ethics committee (No. 2.877.813) and registered on clinicaltrials.org (NCT04039048 - https://www.clinicaltrials.gov/study/NCT04039048 ) on 2019-07-28.

The effects of simulated gastroesophageal reflux on infant pig oropharyngeal feeding physiology

The neural connectivity among the oral cavity, pharynx, and esophagus is a critical component of infant feeding physiology. Central integration of oral and pharyngeal afferents alters motor outputs to structures that power swallowing, but the potential effects of esophageal afferents on preesophageal feeding physiology are unclear. These effects may explain the prevalence of oropharyngeal dysphagia in infants suffering from gastroesophageal reflux (GER), though the mechanism underlying this relationship remains unknown. Here we use the validated infant pig model to assess the impacts of simulated GER on preesophageal feeding parameters. We used high-speed videofluoroscopy and electromyography to record bottle-feeding before and following the infusion of a capsaicin-containing solution into the lower esophagus. Sucking parameters were minimally affected by capsaicin exposure, such that genioglossus activity was unchanged and tongue kinematics were largely unaffected. Aspects of the pharyngeal swallow were altered with simulated GER, including increased thyrohyoid muscle activity, increased excursions of the hyoid and thyroid per swallow, decreased swallow frequency, and increased bolus sizes. These results suggest that esophageal afferents can elicit changes in pharyngeal swallowing. In addition, decreased swallowing frequency may be the mechanism by which esophageal pathologies induce oropharyngeal dysphagia. Although recent work indicates that oral or pharyngeal capsaicin may improve dysphagia symptoms, the decreased performance following esophageal capsaicin exposure highlights the importance of designing sensory interventions based upon neurophysiology and the mechanisms underlying disordered feeding. This mechanistic approach requires comprehensive data collection across the entirety of the feeding process, which can be achieved using models such as the infant pig.NEW & NOTEWORTHY Simulated gastroesophageal reflux (GER) in an infant pig model resulted in significant changes in pharyngeal swallowing, which suggests that esophageal afferents are centrally integrated to alter motor outputs to the pharynx. In addition, decreased swallow frequency and increased bolus sizes may be underlying mechanisms by which esophageal pathologies induce oropharyngeal dysphagia. The infant pig model used here allows for a mechanistic approach, which can facilitate the design of intervention strategies based on neurophysiology.

The partial upward migration of the laryngeal motor cortex: A window to the human brain evolution

The pioneer cortical electrical stimulation studies of the last century did not explicitly mark the location of the human laryngeal motor cortex (LMC), but only the "vocalization area" in the lower half of the lateral motor cortex. In the final years of 2010́s, neuroimaging studies did demonstrate two human cortical laryngeal representations, located at the opposing ends of the orofacial motor zone, therefore termed dorsal (LMCd) and ventral laryngeal motor cortex (LMCv). Since then, there has been a continuing debate regarding the origin, function and evolutionary significance of these areas. The "local duplication model" posits that the LMCd evolved by a duplication of an adjacent region of the motor cortex. The "duplication and migration model" assumes that the dorsal LMCd arose by a duplication of motor regions related to vocalization, such as the ancestry LMC, followed by a migration into the orofacial region of the motor cortex. This paper reviews the basic arguments of these viewpoints and suggests a new explanation, declaring that the LMCd in man is rather induced through the division of the unitary LMC in nonhuman primates, upward shift and relocation of its motor part due to the disproportional growth of the head, face, mouth, lips, and tongue motor areas in the ventral part of the human motor homunculus. This explanation may be called "expansion-division and relocation model".

Neural Correlates of Healthy Sustained Vowel Phonation Tasks: A Systematic Review and Meta-Analysis of Neuroimaging Studies

OBJECTIVE

This review of the methodology and results of studies involving a sustained vowel phonation task during functional Magnetic Resonance Imaging (fMRI) aims to contribute to the identification of brain regions involved in phonation for healthy subjects.

DATA SOURCES

This review was performed using the PubMed electronic database.

REVIEW METHODS

A review was conducted, according to PRISMA guidelines, between September and November 2020, using the following search term pairs: "fMRI and Phonation" and "fMRI and Voice." Activation likelihood estimation analysis was performed. A qualitative analysis was also performed to specify the frequency of activation of each region, as well as the various activation clusters within a single region.

RESULTS

Seven studies were included and analyzed. Five of the seven studies were selected for the activation likelihood estimation meta-analysis which revealed significant convergent activation for only one cluster located in the left precentral gyrus (BA4). A qualitative review provides an overview of brain activation. Primary motor and premotor areas were the only activated areas in all studies included. Other regions previously considered to be implicated in phonation were often activated in sustained vowel phonation tasks. Additionally, areas generally associated with articulation or language also showed activation.

CONCLUSION

Methodological recommendations are suggested to isolate the phonatory component and reduce variability between future studies. Based on the qualitative analysis, this review does not support a distinction between regions more related to phonation and regions more related to articulation. Further research is required seeking to isolate the vocal component and to improve insight into human brain network involved in phonation.

Can Voice Parameters Provide Cutoff Values to Predict Dysphagia in Individuals with Multiple Sclerosis?

In dysphagia assessment, along with well-defined measurements and signs, voice parameters can potentially support clinical decision as a marker, but more evidence is needed. This study aims to determine the voice parameters that can predict the risk of dysphagia and to determine optimal cutoff values in individuals with multiple sclerosis (IwMS). Seventy-six adults participated in the study, including 39 IwMS and 37 healthy individuals (HI). The study used the Dysphagia in Multiple Sclerosis Questionnaire (DYMUS), Gugging Swallowing Screen (GUSS), and Voice Handicap Index (VHI-10) and recorded voice samples using Praat programme. Voice recordings were taken pre- and post-swallowing. The voice parameters analysed are fundamental frequency (F0), standard deviation F0 (SD F0), jitter (local), shimmer (local), and harmonic-to-noise ratio (HNR). Roc analysis was performed to examine the diagnostic accuracy performance of the risk for dysphagia/penetration. The parameters of IwMS pre-swallowing differed significantly from those of HI on the VHI-10, DYMUS, GUSS scores, and jitter (local), shimmer (local), and HNR. IwMS but not HI exhibited significant differences in shimmer (local) and HNR between the pre- and post-swallowing measurements. In IwMS, GUSS revealed significant differences in shimmer (local) pre- and post-swallowing between the groups with and without dysphagia/penetration. In the ROC analysis results, the area under the curve (AUC) for shimmer (local) pre-swallowing was 73.1% (cutoff = 1.69); post-swallowing, it was 78.6% (cutoff = 1.57). In conclusion, IwMS can be associated with differences in shimmer (local) and HNR parameters, low quality of life-related to voice, and dysphagia/penetration risk. The AUC values for shimmer (local) in IwMS pre- and post-swallowing may help to strengthen diagnostic decisions of dysphagia risk.

Self-perceived affective, behavioral, and cognitive reactions associated with voice use in people with Parkinson's disease: a pilot study

PURPOSE

This study aimed to compare the affective, behavioral, and cognitive reactions related to vocal function in people with Parkinson's disease (PWPD) and healthy controls using the Behavior Assessment Battery - Voice (BAB-Voice). The test's internal consistency was also described.

METHODS

31 PWPD and 19 healthy controls were recruited from September 2020 to March 2021. Participants completed four BAB-Voice subtests: Speech Situation Checklist - Emotional Reaction (SSC-ER), the Speech Situation Checklist - Speech Disruption (SSC-SD), Behavior Checklist (BCL), and Communication Attitude Test for Adults (BigCAT), describing the experienced negative emotional reaction, voice disruptions, coping behaviors, and negative attitude regarding communication respectively. Subtest scores were calculated and analyzed.

RESULTS

The scores of the PWPD were significantly different from those of the controls (Pillai's Trace = 0.344, F[4] = 5.508, p = .001, ηp2 = .344): PWPD showed more negative emotions and voice problems, more coping behaviors, and more negative speech-related attitude compared to healthy controls. All subtests showed excellent internal consistency.

CONCLUSIONS

The BAB-Voice proved a tool with a good internal consistency that measured different psychosocial reactions in PWPD versus controls. PWPD exhibited significantly more negative emotions and voice problems in specific speech situations, more coping behaviors, and a more negative speech-related attitude. The specificity of information obtained from the BAB-Voice may aid in improving the treatment planning of voice disorders in PWPD.

A scoping review of music-based interventions for swallowing difficulties: implications for treating older adults with presbyphagia

Objectives

Presbyphagia refers to age-related changes in the swallowing mechanism (e.g., reduced skeletal muscle strength that decreases bolus control). If left untreated, these changes can lead to dysphagia, which refers to impaired swallowing (e.g., coughing or choking when eating). Given that swallowing difficulties are common among older adults that they make up the fastest growing age group globally, the need for interventions to address presbyphagia is gaining urgency. To begin to address this need, we conducted a scoping review to analyze music therapy research aimed at enhancing swallowing function. The objective was to identify key intervention characteristics and propose clinical implications for treating presbyphagia using music therapy.

Methods

This review followed the methodological frameworks outlined by Arksey and O'Malley and Levac et al. and used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews for analysis and reporting. Four electronic databases (i.e., ProQuest, PubMed, RISS, Web of Science) were searched for quantitative and qualitative studies in English or Korean that used music-based interventions to address swallowing function in older adults. Content analysis was conducted to identify and compare the main features of music interventions for swallowing difficulties among older adults.

Results

Ten articles were identified and analyzed. It was found that three core components-respiration, vocalization, and singing-were employed to enhance swallowing function in populations with neurological impairments, dementia, or head and neck cancer. Notably, actions closely linked to swallowing function, such as laryngeal elevation and oral movements, were utilized therapeutically to speak or sing. Based on these characteristics, clinical implications are proposed to address presbyphagia.

Conclusion

Singing entails a systematic and focused incorporation of stepwise activities that can be used to address swallowing disorders. In this context, critical clinical implications that music therapists should consider when treating individuals with presbyphagia include warmup breathing, vocalizing targeting laryngeal control, and singing targeting oral motor control. This review can contribute to the expansion of music therapy with older adults and the advancement of music therapy techniques.

Treatment of vocal tremor with bilateral magnetic resonance imaging-guided focused ultrasound of the ventral intermediate thalamic nucleus: illustrative case

BACKGROUND

Essential vocal tremor is a difficult disease entity to treat with a poor response to existing medical management and limited options for surgical management of the disease. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an emerging treatment modality with encouraging results for limb tremor in patients with essential tremor, but data are limited for the treatment of vocal tremor.

OBSERVATIONS

This is the case of a 69-year-old male with a history of essential vocal tremor severely limiting his ability to perform his occupation as an opera singer. He underwent staged bilateral ventral intermediate nucleus of the thalamus thalamotomy with MRgFUS for the treatment of his bilateral upper extremity tremor with near complete resolution of his vocal tremor after a second procedure.

LESSONS

Bilateral MRgFUS may be a safe and efficacious option for the treatment of essential vocal tremor. Further research into optimal patient selection, precise target location, and treatment parameters is needed.

The Relationship Between Vocal Fold Mobility Disorders and Ineffective Esophageal Motility

OBJECTIVE

Deglutition, speech production, and airway protection are extraordinarily complex, interrelated functions that are coordinated, in large part, by the motor and sensory innervation of CN X. Previous studies assessing the relationship between neurogenic voice disorders and dysphagia have focused on the risk of aspiration due to glottic insufficiency and the association of vocal fold hypomobility (VFH) with systemic neurologic disease. The purpose of this study was to investigate the relationship between VFH disorders and ineffective esophageal motility (IEM).

METHODS

Adult voice patients who underwent laryngeal electromyography (LEMG) and dual 24-hour pH impedance with high-resolution manometry (HRM) testing were included in the study. Subjects were assigned to one of two groups based on the presence or absence of moderate-to-severe RLN and/or SLN VFH (Mo-SLNH/RLNH) using results from six muscle LEMG tests. In subjects with Mo-SLNH/RLNH, there was 0-60% muscle recruitment on LEMG, whereas control subjects in the non-Mo-SLNH/RLNH group demonstrated 61-100% muscle recruitment. Analysis of mild-to-severe VFH (80% muscle recruitment or less) was also performed in a similar manner. The prevalence of IEM, defined using Chicago Classification Version 4.0 (CCv4.0), was compared between groups, as were HRM parameters.

RESULTS

One hundred sixty-two subjects were included (37.7% male/62.3% female, mean age of 43.88 ± 17.285). No differences in IEM prevalence were found when stratifying for cases of mild-to-severe VFH. However, there was significantly higher percentage of IEM in those with Mo-SLNH/RLNH. Mo-SLNH/RLNH subjects demonstrated higher rates of weak swallows and inefficient swallows, as well as lower IBP and UES residual pressures on HRM.

CONCLUSIONS

Patients with Mo-SLNH/RLNH demonstrated a significantly higher prevalence of IEM. Those with mild-to-severe VFH did not. Higher rates of ineffective and weak swallows, and lower IBP and UES residual pressures among Mo-SLNH/RLNH subjects suggest a possible connection between Mo-SLNH/RLNH and IEM disorders. These manometric differences were more prominent with sub-stratification of the Mo-SLNH/RLNH group by IEM. Additional research is advised.

Brain activity associated with taste stimulation: A mechanism for neuroplastic change?

PURPOSE

Neuroplasticity may be enhanced by increasing brain activation and bloodflow in neural regions relevant to the target behavior. We administered precisely formulated and dosed taste stimuli to determine whether the associated brain activity patterns included areas that underlie swallowing control.

METHODS

Five taste stimuli (unflavored, sour, sweet-sour, lemon, and orange suspensions) were administered in timing-regulated and temperature-controlled 3 mL doses via a customized pump/tubing system to 21 healthy adults during functional magnetic resonance imaging (fMRI). Whole-brain analyses of fMRI data assessed main effects of taste stimulation as well as differential effects of taste profile.

RESULTS

Differences in brain activity associated with taste stimulation overall as well as specific stimulus type were observed in key taste and swallowing regions including the orbitofrontal cortex, insula, cingulate, and pre- and postcentral gyri. Overall, taste stimulation elicited increased activation in swallowing-related brain regions compared to unflavored trials. Different patterns of blood oxygen level-dependent (BOLD) signal were noted by taste profile. For most areas, sweet-sour and sour trials elicited increases in BOLD compared to unflavored trials within that region, whereas lemon and orange trials yielded reductions in BOLD. This was despite identical concentrations of citric acid and sweetener in the lemon, orange, and sweet-sour solutions.

CONCLUSIONS

These results suggest that neural activity in swallowing-relevant regions can be amplified with taste stimuli and may be differentially affected by specific properties within very similar taste profiles. These findings provide critical foundational information for interpreting disparities in previous studies of taste effects on brain activity and swallowing function, defining optimal stimuli to increase brain activity in swallowing-relevant regions, and harnessing taste to enhance neuroplasticity and recovery for persons with swallowing disorders.

Effects of bilateral cerebellar repetitive transcranial magnetic stimulation in poststroke dysphagia: A randomized sham-controlled trial

BACKGROUND

Although increasing evidence indicates that cerebellar repetitive transcranial magnetic stimulation (rTMS) may be beneficial in the treatment of dysphagia, its clinical efficacy is still uncertain.

OBJECTIVE

To evaluate the effect of high-frequency cerebellar rTMS on poststroke dysphagia.

METHODS

This was a randomized, sham-controlled, double-blind trial. A total of eighty-four study participants were randomly assigned into the cerebellum and control groups. The cerebellum group received bilateral 10 Hz rTMS treatment of the pharyngeal motor area of the cerebellum. The control group was administered with sham rTMS of the pharyngeal motor area of the cerebellum. All patients underwent the same conventional swallowing rehabilitation training after the intervention 5 days a week for a total of 10 days. Assessment of swallowing function was done before treatment (baseline), after treatment (2 weeks), and during follow-up (2 weeks after treatment) using the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and the Penetration-Aspiration Scale (PAS).

RESULTS

The interaction between time and intervention had a significant effect on PAS (P < 0.001) and FEDSS (P < 0.001). Compared to the control group, the cerebellum group exhibited significantly improved clinical swallowing function scores (PAS: P = 0.007, FEDSS: P = 0.002).

CONCLUSION

Bilateral cerebellar rTMS is a potential new neurorehabilitation technique for post-stroke dysphagia. Studies should aim at investigating the therapeutic mechanism of cerebellar rTMS and improve this technique.

Cortical Activation of Swallowing Using fNIRS: A Proof of Concept Study with Healthy Adults

The purpose of this study was to determine whether functional near-infrared spectroscopy (fNIRS) could reliably identify cortical activation patterns as healthy adults engaged in single sip and continuous swallowing tasks. Thirty-three right-handed adults completed two functional swallowing tasks, one control jaw movement task, and one rest task while being imaged with fNIRS. Swallowing tasks included a single sip of 5 mL of water via syringe and continuous straw drinking. fNIRS patches for acquisition of neuroimaging data were placed parallel over left and right hemispheres. Stimuli presentation was controlled with set time intervals and audio instructions. Using a series of linear mixed effect models, results demonstrated clear cortical activation patterns during swallowing. The continuous swallowing task demonstrated significant differences in blood oxygenation and deoxygenation concentration values across nearly all regions examined, but most notably M1 in both hemispheres. Of note is that there were areas of greater activation, particularly on the right hemisphere, when comparing the single sip swallow to the jaw movement control and rest tasks. Results from the current study support the use of fNIRS during investigation of swallowing. The utilization of healthy adults as a method for acquiring normative data is vital for comparison purposes when investigating individuals with disorders, but also in the development of rehabilitation techniques. Identifying activation areas that pertain to swallowing will have important implications for individuals requiring dysphagia therapy.

Mimicking partial to total placental insufficiency in a rabbit model of cerebral palsy

All placental abruptions begin as partial abruptions, which sometimes manifest as fetal bradycardia. The progression from partial to total abruption was mimicked by a new rabbit model of placental insufficiency, and we compared it, with sufficient statistical power, with the previous model mimicking total placental abruption. The previous model uses total uterine ischemia at E22 or E25 (70% or 79% term, respectively), in pregnant New Zealand white rabbits for 40 min (Full H-I). The new model, Partial+Full H-I, added a 30-min partial ischemia before the 40-min total ischemia. Fetuses were delivered either at E31.5 (full term) vaginally for neurobehavior testing, or by C-section at E25 for ex vivo brain cell viability evaluation. The onset of fetal bradycardia was within the first 2 min of either H-I protocol. There was no difference between Full H-I (n = 442 for E22, 312 for E25) and Partial+Full H-I (n = 154 and 80) groups in death or severely affected kits at E22 (76% vs. 79%) or at E25 (66% vs. 64%), or normal kits at E22 or E25, or any of the individual newborn neurobehavioral tests at any age. No sex differences were found. Partial+Full H-I (n = 6) showed less cell viability than Full H-I (n = 8) at 72-hr ex vivo in the brain regions studied. Partial+Full H-I insult produced similar cerebral palsy phenotype as our previous Full H-I model in a sufficiently powered study and may be more suitable for testing of potential neuroprotectants.

Voice Tremor and Botulinum Neurotoxin Therapy: A Contemporary Review

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.

When laughter arrests speech: fMRI-based evidence

Who has not experienced that sensation of losing the power of speech owing to an involuntary bout of laughter? An investigation of this phenomenon affords an insight into the neuronal processes that underlie laughter. In our functional magnetic resonance imaging study, participants were made to laugh by tickling in a first condition; in a second one they were requested to produce vocal utterances under the provocation of laughter by tickling. This investigation reveals increased neuronal activity in the sensorimotor cortex, the anterior cingulate gyrus, the insula, the nucleus accumbens, the hypothalamus and the periaqueductal grey for both conditions, thereby replicating the results of previous studies on ticklish laughter. However, further analysis indicates the activity in the emotion-associated regions to be lower when tickling is accompanied by voluntary vocalization. Here, a typical pattern of activation is identified, including the primary sensory cortex, a ventral area of the anterior insula and the ventral tegmental field, to which belongs to the nucleus ambiguus, namely, the common effector organ for voluntary and involuntary vocalizations. During the conflictual voluntary-vocalization versus laughter experience, the laughter-triggering network appears to rely heavily on a sensory and a deep interoceptive analysis, as well as on motor effectors in the brainstem. This article is part of the theme issue 'Cracking the laugh code: laughter through the lens of biology, psychology and neuroscience'.

Can Swallowing Cerebral Neurophysiology Be Evaluated during Ecological Food Intake Conditions? A Systematic Literature Review

Swallowing is a complex function that relies on both brainstem and cerebral control. Cerebral neurofunctional evaluations are mostly based on functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), performed with the individual laying down; which is a non-ecological/non-natural position for swallowing. According to the PRISMA guidelines, a review of the non-invasive non-radiating neurofunctional tools, other than fMRI and PET, was conducted to explore the cerebral activity in swallowing during natural food intake, in accordance with the PRISMA guidelines. Using Embase and PubMed, we included human studies focusing on neurofunctional imaging during an ecologic swallowing task. From 5948 unique records, we retained 43 original articles, reporting on three different techniques: electroencephalography (EEG), magnetoencephalography (MEG) and functional near infra-red spectroscopy (fNIRS). During swallowing, all three techniques showed activity of the pericentral cortex. Variations were associated with the modality of the swallowing process (volitional or non-volitional) and the substance used (mostly water and saliva). All techniques have been used in both healthy and pathological conditions to explore the precise time course, localization or network structure of the swallowing cerebral activity, sometimes even more precisely than fMRI. EEG and MEG are the most advanced and mastered techniques but fNIRS is the most ready-to-use and the most therapeutically promising. Ongoing development of these techniques will support and improve our future understanding of the cerebral control of swallowing.

The effect of pyridostigmine on post-stroke dysphagia: A randomized clinical trial

Background: Swallowing is one of the most complex functions of the central nervous system (CNS), which is controlled by different parts of the brain. Oropharyngeal dysphagia (OD) is one of the most common complications after stroke. Despite a variety of behavioral, compensatory, and rehabilitative methods, many stroke patients still suffer from swallowing disorders that adversely affect their quality of life (QOL). The aim of this study was to evaluate the effect of pyridostigmine on patients with post-stroke dysphagia. Methods: A randomized, double-blind, placebo-controlled clinical trial was carried out on 40 patients suffering from post-stroke dysphagia. Patients were assigned randomly into two groups: intervention and control groups (20 in each group). The intervention group was treated with pyridostigmine (60 mg, three times a day, 30 minutes before each meal for three weeks), and the control group received placebo treatment in the same way. All patients (intervention and control) were evaluated according to National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and Functional Communication Measures (FCM)/American Speech-Language-Hearing Association (ASHA) criteria at baseline and after three weeks of intervention. Values of P < 0.05 were considered statistically significant. Results: In the intervention group, the mean values of NIHSS, mRS, and ASHA/FCM were significantly reduced following three weeks of treatment with pyridostigmine (P = 0.002, P = 0.003, and P < 0.001, respectively), but no significant differences were found in the mean NIHSS, mRS, and ASHA/FCM in the placebo group. Conclusion: Although pyridogestamine is somewhat effective in post-stroke dysphagia, it has not been shown to be more important in preventing aspiration pneumonia and length of hospital stay.

Systemic Administration of Tempol, a Superoxide Dismutase Mimetic, Augments Upper Airway Muscle Activity in Obese Zucker Rats

Obstructive sleep apnea (OSA) is characterized by repetitive partial/complete collapse of the pharynx during sleep, which results in apnea/hypopnea leading to arterial oxygen desaturations and arousals. Repetitive apnea/hypopnea-arousal episodes cause hypoxia/reoxygenation cycles, which increase free radical generation and oxidative stress that cause motor/sensory nerve impairments and muscle damage. We hypothesize that antioxidants may protect and/or reverse from oxidative stress-induced damage in OSA patients. To understand the acute protective effects of antioxidants on respiratory muscles, we studied the systemic effects of a membrane permeable superoxide dismutase mimetic, Tempol, on genioglossus (EMG_GG) and diaphragmatic (EMG_DIA) electro-myographic activities, hypoglossal motoneuron (HMN) nerve activity and cardiorespiratory parameters (mean arterial blood pressure, heart rate) in adult isoflurane-anesthetized obese Zucker rats (OZR) and age-matched lean Zucker rats (LZR). Tempol dose-dependently (1-100 mg/kg) increased EMG_GG without changing EMG_DIA in OZR and LZR. Tempol increased respiratory rate and tidal volume in OZR and LZR. Tempol (1-25 mg/kg) dose-dependently increased HMN nerve activity in healthy Sprague Dawley rats. Tempol (100 mg/kg) increased EMG_GG output by 189% in OZR and 163% in LZR. With respect to mechanisms of effect, Tempol (100 mg/kg) did not augment EMG_GG after bilateral HMN transection in Sprague Dawley rats. Although future studies are warranted, available data suggest that in addition to its antioxidant and antihypertensive properties, Tempol can selectively augment EMG_GG through modulating HMN and this effect may prevent collapsibility and/or improve stability of the upper airway pharyngeal dilator muscles during episodes of partial and/or complete collapse of the upper airway in OSA human subjects.

Effect of Electro-Acupuncture on Lateralization of the Human Swallowing Motor Cortex Excitability by Navigation-Transcranial Magnetic Stimulation-Electromyography

Background

The use of transcranial magnetic stimulation combined with electromyography for the functional evaluation of the cerebral cortex in both clinical and non-clinical populations is becoming increasingly common. Numerous studies have shown that electro-acupuncture (EA) can regulate cerebral cortical excitability. However, the effect of EA on the lateralization of the human swallowing motor cortex excitability is not yet fully understood.

Objective

The aim of this study was to assess whether lateralization is present in the swallowing motor cortex of healthy subjects, and to investigate the impact of EA at Lianquan (CV23) and Fengfu (GV16) on lateralization.

Methods

Forty subjects were randomized 1:1 into the EA group and the sham-EA group. The bilateral swallowing motor cortices was located by a neuroimaging navigation system. Then, the resting motor threshold (RMT) and motor evoked potential (MEP) of the mylohyoid of healthy subjects were recorded while applying combined transcranial magnetic stimulation and electromyography before and after EA or sham-EA.

Results

First, the RMT and MEP latency of the contralateral mylohyoid innervated by the right swallowing cortex (71.50 ± 1.67%, 8.30 ± 0.06 ms) were lower than those innervated by the left (79.38 ± 1.27%, 8.40 ± 0.06 ms). Second, EA at CV23 and GV16 reduced the bilateral RMT and enhanced the bilateral MEP latency and amplitude (P = 0.005, P < 0.001; P = 0.002, P = 0.001; P = 0.002, P = 0.009), while sham-EA did not (P > 0.05). Third, EA had an effect on the RMT and MEP latency in terms of lateralization changes, but this was not significant (P = 0.067, P = 0.156).

Conclusion

The right swallowing motor cortex of healthy subjects is more excitable than that of the left at resting state. Thus, we found that lateralization is present in the swallowing motor cortex of healthy people, which might indicate a hemispheric dominance of swallowing predominates in the right swallowing motor cortex. In addition, EA at CV23 and GV16 can instantly promote the excitability of the bilateral swallowing motor cortices. But there was no significant difference in EA stimulation in terms of lateralization.

Quantification of brainstem norepinephrine relative to vocal impairment and anxiety in the Pink1-/- rat model of Parkinson disease

Vocal communication impairment and anxiety are co-occurring and interacting signs of Parkinson Disease (PD) that are common, poorly understood, and under-treated. Both vocal communication and anxiety are influenced by the noradrenergic system. In light of this shared neural substrate and considering that noradrenergic dysfunction is a defining characteristic of PD, tandem investigation of vocal impairment and anxiety in PD relative to noradrenergic mechanisms is likely to yield insights into the underlying disease-specific causes of these impairments. In order to address this gap in knowledge, we assessed vocal impairment and anxiety behavior relative to brainstem noradrenergic markers in a genetic rat model of early-onset PD (Pink1-/-) and wild type controls (WT). We hypothesized that 1) brainstem noradrenergic markers would be disrupted in Pink1-/-, and 2) brainstem noradrenergic markers would be associated with vocal acoustic changes and anxiety level. Rats underwent testing of ultrasonic vocalization and anxiety (elevated plus maze) at 4, 8, and 12 months of age. At 12 months, brainstem norepinephrine markers were quantified with immunohistochemistry. Results demonstrated that vocal impairment and anxiety were increased in Pink1-/- rats, and increased anxiety was associated with greater vocal deficit in this model of PD. Further, brainstem noradrenergic markers including TH and α1 adrenoreceptor immunoreactivity in the locus coeruleus, and β1 adrenoreceptor immunoreactivity in vagal nuclei differed by genotype, and were associated with vocalization and anxiety behavior. These findings demonstrate statistically significant relationships among vocal impairment, anxiety, and brainstem norepinephrine in the Pink1-/- rat model of PD.

Overt speech feasibility using continuous functional magnetic resonance imaging: Isolation of areas involved in phonology and prosody

To avoid motion artifacts, almost all speech-related functional magnetic resonance imagings (fMRIs) are performed covertly to detect language activations. This method may be difficult to execute, especially by patients with brain tumors, and does not allow the identification of phonological areas. Here, we aimed to evaluate overt task feasibility. Thirty-three volunteers participated in this study. They performed two functional sessions of covert and overt generation of a short sentence semantically linked with a word. Three main contrasts were performed: Covert and Overt for the isolation of language-activated areas, and Overt > Covert for the isolation of the motor cortical activation of speech. fMRI data preprocessing was performed with and without unwarping, and with and without regression of movement parameters as confounding variables. All types of results were compared to each other. For the Overt contrast, Dice coefficients showed strong overlap between each pair of types of results: 0.98 for the pair with and without unwarping, and 0.9 for the pair with and without movement parameter regression. The Overt > Covert contrast allowed isolation of motor laryngeal activations with high statistical reliability and revealed the right-lateralized temporal activity related to acoustic feedback. Overt speaking during magnetic resonance imaging induced few artifacts and did not significantly affect the results, allowing the identification of areas involved in primary motor control and prosodic regulation of speech. Unwarping and motion artifact regression in the postprocessing step, seem to not be necessary. Changes in lateralization of cortical activity by overt speech shall be explored before using these tasks for presurgical mapping.

The Prevalence of Esophageal Disorders Among Voice Patients With Laryngopharyngeal Reflux-A Retrospective Study

OBJECTIVE

The goal of this study was to determine the prevalence of esophageal disorders among voice patients with intractable laryngopharyngeal reflux (LPR) who have undergone 24 pH impedance and esophageal manometry.

METHODS

A retrospective chart review was performed of patients with LPR-associated dysphonia in the absence of subjective dysphagia who presented between January 1, 2007 and June 30, 2019 and underwent 24 pH impedance and esophageal manometry studies after inadequate response to lifestyle modifications, high dose of Proton Pump Inhibitor (PPIs), H2 blockers, alkaline water, and Gaviscon (GlaxoSmithKline, Warren, NJ, USA). The comorbidities, medications, Strobovideolaryngoscopy findings, 24 pH impedance, and esophageal manometry results were analyzed.

RESULTS

The study included 109 patients ages 19 to 80 years old, with a mean age of 51.5 (SD 16.8). About 24.8% of the 109 subjects were found to have peristaltic wave abnormalities indicating esophageal dysmotility (11% with esophageal stasis). Lower esophageal sphincter pressures were normotensive in 56.9% of patients, hypertensive in 24.8%, and hypotensive in 18.4% of patients. In addition, the upper esophageal sphincter pressures were normotensive in 57.8% of patients, hypertensive in 36.7%, and hypotensive in 2.8% of patients. About 12.6% had both lower esophageal sphincter and upper esophageal sphincter dysfunction (hypertensive or hypotensive). The average total reflux events in patients exhibiting dysmotility on manometry 101.81, which was significantly higher compared with the mean total of 61.28 in the group of patients without dysmotility (P= 0.0396). In addition, there was a significantly higher prevalence of total events that were weakly acidic in the group with dysmotility compared with the group without (all patients performed the study on reflux medications, mean of total weakly acidic events 70.2 in dysmotility group vs 44.2 in normal motility group, P= 0.0427).Finally, the average number of total supine reflux events and the total acidic supine events were both significantly higher in the dysmotility group compared with the group without motility problems (P = 0.0199 and P = 0.0213, respectively).

CONCLUSION

Esophageal dysmotility may be a significant cofactor in voice patients with refractory LPR on appropriate reflux medications and lifestyle modifications. Further research is advised.

Impact of Perioperative Brain Injury and Development on Feeding Modality in Infants With Single Ventricle Heart Disease

Background

Tube‐assisted feeding in infancy is common in patients with single‐ventricle physiology (SVP). Postnatal brain development is delayed, and injury is common, in patients with SVP. The role of brain findings in feeding outcomes remains unclear. We sought to determine the association between neonatal perioperative brain injury and postnatal brain maturation with feeding‐tube dependency in patients with SVP at neonatal discharge and just before the stage‐2 palliation.

Methods and Results

We evaluated a cohort of 48 term neonates with SVP who underwent pre‐ and postoperative brain magnetic resonance imaging. Perioperative brain injury and microstructural brain development were measured with diffusion tensor imaging including fractional anisotropy in white matter and apparent diffusion coefficient in gray matter. The primary outcome was defined as being 100% orally fed (binary). Of the patients 79% (38/48) were tube fed at hospital discharge, and 27% (12/45) were tube fed before stage‐2 palliation. Perioperative brain injury did not differ by group. Orally fed patients had a faster rate of decrease in apparent diffusion coefficient (3%, 95% CI 1.7% to 4.6%, P<0.001) at discharge and a faster rate of increase in fractional anisotropy (1.4%, 95% CI 0.6% to 2.2%, P=0.001) at the time of stage‐2 palliation compared with tube‐fed patients, denoting more robust brain development.

Conclusions

Slower rate of postnatal brain maturation but not perioperative brain injury is associated with feeding modality in infancy. These results support the importance of brain health in optimizing feeding outcomes in patients with SVP.

Neuronal intranuclear inclusion disease presenting with dysphagia: a report of three cases

Neuronal intranuclear inclusion disease (NIID) is a rare neurodegenerative disease that is pathologically characterized by the presence of eosinophilic hyaline intranuclear inclusions in neurons, astrocytes, and specific somatic cells. Previously reported cases of NIID displayed various neurological symptoms, including dementia, muscle weakness, ataxia, etc. However, dysphagia associated with NIID have rarely been reported. Here, we report on three cases of NIID with dysphagia. Bolus mastication and transport were impaired in all three cases. Delay of the initiation of pharyngeal swallowing and silent aspiration was observed in two cases. Combined with the brain magnetic resonance imaging (MRI) findings, oropharyngeal dysphagia associated with NIID was suggested to be attributed to diffuse subcortical lesions.

Brain Cortex Activity in Children With Anterior Open Bite: A Pilot Study

Anterior open bite (AOB) is related to functional alterations of the stomatognathic system. There are no studies concerning brain activation of the cortex comparing children with and without AOB during rest and activities such as deglutition and phonation. The aim of this study was to determine the activity of the brain cortex of children with AOB at rest and during phonation and deglutition and to evaluate the association of intelligence quotient (IQ), attention (Test of Variables of Attention, known as TOVA), beats per minute (BPM), and oxygen saturation measurement (SpO₂) with brain activity in subjects with AOB. Fourteen children (seven with AOB and seven without AOB) with mixed dentition, aged 10–13 years, underwent an IQ test, TOVA, SpO₂, and quantitative electroencephalography (QEEG). Electrodes were set in the scalp, according to the 10–20 protocol. Data were analyzed using statistical tests to assess comparisons between children with and without AOB. The results showed that IQ, TOVA, SpO₂, or BPM did not show any statistically significant differences between the groups, except for the response time (contained in TOVA) (p = 0.03). Significant differences were found for the brain activity during rest (Condition 1) of the tongue, between children with and without AOB (p < 0.05 for alpha/theta and alpha peaks), whereas there were no differences during function (Condition 2). The findings of this investigation provide insights about the cortex activity of the brain while the tongue is in the resting position in children with AOB. This may imply an altered activity of the brain cortex, which should be considered when diagnosing and treating AOB. Other diagnostic techniques derived from investigations based on neuroscience could develop new diagnostic and therapeutic techniques to give better solutions to children with malocclusions. Treatments should be focused not only on the teeth but also on the brain cortex.

The Effect of Cranial Nerve Stimulation on Swallowing: A Systematic Review

This systematic review summarizes published studies on the effect of cranial nerve stimulation (CNS) on swallowing and determines the level of evidence of the included studies to guide the development of future research on new treatment strategies for oropharyngeal dysphagia (OD) using CNS. Studies published between January 1990 and October 2019 were found via a systematic comprehensive electronic database search using PubMed, Embase, and the Cochrane Library. Two independent reviewers screened all articles based on the title and abstract using strict inclusion criteria. They independently screened the full text of this initial set of articles. The level of evidence of the included studies was assessed independently by the two reviewers using the A-B-C rating scale. In total, 3267 articles were found in the databases. In the majority of these studies, CNS was used for treatment-resistant depression or intractable epilepsy. Finally, twenty-eight studies were included; seven studies on treatment of depression, thirteen on epilepsy, and eight on heterogeneous indications. Of these, eight studies reported the effects of CNS on swallowing and in 20 studies the swallowing outcome was described as an adverse reaction. A meta-analysis could not be carried out due to the poor methodological quality and heterogeneity of study designs of the included studies. These preliminary data suggest that specific well-indicated CNS might be effective in reducing OD symptoms in selective patient groups. But it is much too early for conclusive statements on this topic. In conclusion, the results of these studies are encouraging for future research on CNS for OD. However, randomized, double-blind, sham-controlled clinical trials with sufficiently large sample sizes are necessary.

Right fronto-parietal white matter disruption contributes to speech impairments in amyotrophic lateral sclerosis

INTRODUCTION

Non-linguistic properties of speech are widely heterogeneous and require complex neurological integration. The association between white matter integrity and the severity of dysarthria was investigated in a group of patients diagnosed with amyotrophic lateral sclerosis (ALS).

METHODS

Thirty-six patients diagnosed with amyotrophic lateral sclerosis completed a magnetic resonance imaging protocol inclusive of diffusion-weighted images. A clinical assessment of pneumo-phono-articulatory abilities was conducted for each patient, and a composite score of residual speech capacity was calculated. Tract-Based Spatial Statistics was carried out to model the potential association between residual speech capacity and microstructural properties of white matter (fractional anisotropy, mean and radial diffusivity).

RESULTS

A significant negative association was found between residual speech capacity and mean diffusivity in a large white matter cluster located in frontal, parietal and right temporal regions. These subcortical areas were characterised by pathological microstructural disruption, as revealed by post hoc analyses.

CONCLUSIONS

Non-linguistic aspects of speech are associated with microstructural integrity of frontal, parietal and right temporal white matter in amyotrophic lateral sclerosis. Such mapping is consistent with the centres responsible of volitional control of speech and sensory feedback during non-linguistic speech production.

Isolated Voice Tremor: A Clinical Variant of Essential Tremor or a Distinct Clinical Phenotype?

Background

The consensus statement by the Task Force on Tremor of the International Parkinson and Movement Disorder Society excludes individuals with "isolated voice tremor" as a clinical variant of essential tremor (ET). This clinical viewpoint presents a rationale for reconsideration of "isolated voice tremor" as a clinical variant of ET.

Methods

Evidence from the literature was extracted to characterize the clinical phenotype of "isolated voice tremor," or essential vocal tremor (EVT). Clinical features were extracted from relevant literature available at pubmed.gov using the terms "EVT," "essential voice tremor," "primary voice tremor," and "organic voice tremor."

Results

The average age of onset in those with EVT was older than 60 years (range 19-84 years), with 75-93% being female. The typical duration of vocal tremor ranged from 1 to 13 years (average 6 years). The distribution of structures exhibiting tremor included the larynx, soft palate, pharynx, and base of tongue in the majority of patients, with some exhibiting tremor of the head and respiratory musculature. The condition of tremor occurred during speech and quiet respiration in 74% of individuals. Rate of tremor ranged from 4 to 10 Hz. Nearly 70% reported onset of vocal tremor prior to upper limb involvement. Family history of tremor was reported in 38-42% of individuals.

Discussion

Those previously classified with EVT demonstrate a similar familial history, rate, tremor classification, and body distribution of ET. EVT is proposed as a clinical variant of ET in the pattern of onset and progression of body distribution from the midline cranial to spinal neural pathways.

Laryngeal vibration as a non-invasive neuromodulation therapy for spasmodic dysphonia

Spasmodic dysphonia (SD) is an incurable focal dystonia of the larynx that impairs speech and communication. Vibro-tactile stimulation (VTS) alters afferent proprioceptive input to sensorimotor cortex that controls speech. This proof-of-concept study examined the effect of laryngeal VTS on speech quality and cortical activity in 13 SD participants who vocalized the vowel /a/ while receiving VTS for 29 minutes. In response to VTS, 9 participants (69%) exhibited a reduction of voice breaks and/or a meaningful increase in smoothed cepstral peak prominence, an acoustic measure of voice/speech quality. Symptom improvements persisted for 20 minutes past VTS. Application of VTS induced a significant suppression of theta band power over the left somatosensory-motor cortex and a significant rise of gamma rhythm over right somatosensory-motor cortex. Such suppression of theta oscillations is observed in patients with cervical dystonia who apply effective sensory tricks, suggesting that VTS in SD may activate a similar neurophysiological mechanism. Results of this feasibility study indicate that laryngeal VTS modulates neuronal synchronization over sensorimotor cortex, which can induce short-term improvements in voice quality. The effects of long-term VTS and its optimal dosage for treating voice symptoms in SD are still unknown and require further systematic study.

The Initiation of Swallowing Can Indicate the Prognosis of Disorders of Consciousness: A Self-Controlled Study

Objective: To detect the initiation of swallowing in patients with disorders of consciousness (DOC) as well as the relationship between the initiation of swallowing and the prognosis of DOC patients. Methods: Nineteen DOC patients were included in this study, and a self-controlled trial compared five different stimuli. The five different stimuli were as follows: (1) one command, as recommended by the Coma Recovery Scale-Revised (CRS-R), which was "open your mouth"; (2) placing a spoon in front of the patient's mouth without a command; (3) placing a spoon filled with water in front of the patient's mouth without a command; (4) one command-"there is a spoon; open your mouth"-with a spoon in front of the patient's mouth; (5) one command, "there is a spoon with water; open your mouth," with a spoon filled with water in front of the patient's mouth. All 19 patients were given these five stimuli randomly, and any one of the commands was presented four times to a patient, one at a time, at 15-s intervals. The sensitivity and specificity of the initiation of swallowing in detecting conscious awareness were determined. Results: None of the patients responded to the first four stimuli. However, six patients showed initiated swallowing toward the fifth stimulus. Among those six, five patients showed improvement in their consciousness state 6 months later. The sensitivity and specificity of the initiation of swallowing for DOC patients was 83.33% [95% CIs (36%, 100%)] and 92.31% [95% CIs (64%, 100%)], respectively. Conclusions: The initiation of swallowing can be an early indication of conscious behavior and can likely provide evidence of conscious awareness. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03508336; Date of registration: 2018/4/16.

Cerebellar repetitive transcranial magnetic stimulation restores pharyngeal brain activity and swallowing behaviour after disruption by a cortical virtual lesion

Key points

Despite evidence that the human cerebellum has an important role in swallowing neurophysiology, the effects of cerebellar stimulation on swallowing in the disrupted brain have not been explored.

In this study, for the first time, the application of cerebellar neurostimulation is characterized in a human model of disrupted swallowing (using a cortical virtual lesion).

It is demonstrated that cerebellar stimulation can reverse the suppressed activity in the cortical swallowing system and restore swallowing function in a challenging behavioural task, suggesting the findings may have important therapeutic implications.

Abstract

Repetitive transcranial magnetic stimulation (rTMS) can alter neuronal activity within the brain with therapeutic potential. Low frequency stimulation to the ‘dominant’ cortical swallowing projection induces a ‘virtual‐lesion’ transiently suppressing cortical excitability and disrupting swallowing behaviour. Here, we compared the ability of ipsi‐lesional, contra‐lesional and sham cerebellar rTMS to reverse the effects of a ‘virtual‐lesion’ in health. Two groups of healthy participants (n = 15/group) were intubated with pharyngeal catheters. Baseline pharyngeal motor evoked potentials (PMEPs) and swallowing performance (reaction task) were measured. Participants received 10 min of 1 Hz rTMS to the pharyngeal motor cortex which elicited the largest PMEPs to suppress cortical activity and disrupt swallowing behaviour. Over six visits, participants were randomized to receive 250 pulses of 10 Hz cerebellar rTMS to the ipsi‐lesional side, contra‐lesional side or sham while assessing PMEP amplitude or swallowing performance for an hour afterwards. Compared to sham, active cerebellar rTMS, whether administered ipsi‐lesionally (P = 0.011) or contra‐lesionally (P = 0.005), reversed the inhibitory effects of the cortical ‘virtual‐lesion’ on PMEPs and swallowing accuracy (ipsi‐lesional, P < 0.001, contra‐lesional, P < 0.001). Cerebellar rTMS was able to reverse the disruptive effects of a ‘virtual lesion’. These findings provide evidence for developing cerebellar rTMS into a treatment for post‐stroke dysphagia.

Despite evidence that the human cerebellum has an important role in swallowing neurophysiology, the effects of cerebellar stimulation on swallowing in the disrupted brain have not been explored.

In this study, for the first time, the application of cerebellar neurostimulation is characterized in a human model of disrupted swallowing (using a cortical virtual lesion).

It is demonstrated that cerebellar stimulation can reverse the suppressed activity in the cortical swallowing system and restore swallowing function in a challenging behavioural task, suggesting the findings may have important therapeutic implications.

Activation of TRPV1 and TRPM8 Channels in the Larynx and Associated Laryngopharyngeal Regions Facilitates the Swallowing Reflex

The larynx and associated laryngopharyngeal regions are innervated by the superior laryngeal nerve (SLN) and are highly reflexogenic. Transient receptor potential (TRP) channels have recently been detected in SLN innervated regions; however, their involvement in the swallowing reflex has not been fully elucidated. Here, we explore the contribution of two TRP channels, TRPV1 and TRPM8, located in SLN-innervated regions to the swallowing reflex. Immunohistochemistry identified TRPV1 and TRPM8 on cell bodies of SLN afferents located in the nodose-petrosal-jugular ganglionic complex. The majority of TRPV1 and TRPM8 immunoreactivity was located on unmyelinated neurons. Topical application of different concentrations of TRPV1 and TRPM8 agonists modulated SLN activity. Application of the agonists evoked a significantly greater number of swallowing reflexes compared with the number evoked by distilled water. The interval between the reflexes evoked by the agonists was shorter than that produced by distilled water. Prior topical application of respective TRPV1 or TRPM8 antagonists significantly reduced the number of agonist-evoked reflexes. The findings suggest that the activation of TRPV1 and TRPM8 channels present in the swallowing-related regions can facilitate the evoking of swallowing reflex. Targeting the TRP channels could be a potential therapeutic strategy for the management of dysphagia.

Functional connectivity of PAG with core limbic system and laryngeal cortico-motor structures during human phonation

Previous studies in animals and humans suggest the periaqueductal grey region (PAG) is a final integration station between the brain and laryngeal musculature during phonation. To date, a limited number of functional magnetic neuroimaging (fMRI) studies have examined the functional connectivity of the PAG during volitional human phonation. An event-related, stimulus-induced, volitional movement paradigm was used to examine neural activity during sustained vocalization in neurologically healthy adults and was compared to controlled exhalation through the nose. The contrast of vocalization greater than controlled expiration revealed activation of bilateral auditory cortex, dorsal and ventral laryngeal motor areas (dLMA and vLMA) (p < 0.05, corrected), and suggested activation of the cerbellum, insula, dorsomedial prefrontal cortex (dmPFC), amygdala, and PAG. The functionally defined PAG cluster was used as a seed region for psychophysiological interaction analysis (PPI) to identify regions with greater functional connectivity with PAG during volitional vocalization, while the above functionally defined amygdala cluster was used in an ROI PPI analysis. Whole-brain results revealed increased functional connectivity of the PAG with left vLMA during voicing, relative to controlled expiration, while trend-level evidence was observed for increased PAG/amygdala coupling during voicing (p = 0.07, uncorrected). Diffusion tensor imaging (DTI) analysis confirmed structural connectivity between PAG and vLMA. The present study sheds further light on neural mechanisms of volitional vocalization that include multiple inputs from both limbic and motor structures to PAG. Future studies should include investigation of how these neural mechanisms are affected in individuals with voice disorders during volitional vocalization.

The Consequences of Preterm Birth and Chorioamnionitis on Brainstem Respiratory Centers: Implications for Neurochemical Development and Altered Functions by Inflammation and Prostaglandins

Preterm birth is a major cause for neonatal morbidity and mortality, and is frequently associated with adverse neurological outcomes. The transition from intrauterine to extrauterine life at birth is particularly challenging for preterm infants. The main physiological driver for extrauterine transition is the establishment of spontaneous breathing. However, preterm infants have difficulty clearing lung liquid, have insufficient surfactant levels, and underdeveloped lungs. Further, preterm infants have an underdeveloped brainstem, resulting in reduced respiratory drive. These factors facilitate the increased requirement for respiratory support. A principal cause of preterm birth is intrauterine infection/inflammation (chorioamnionitis), and infants with chorioamnionitis have an increased risk and severity of neurological damage, but also demonstrate impaired autoresuscitation capacity and prevalent apnoeic episodes. The brainstem contains vital respiratory centers which provide the neural drive for breathing, but the impact of preterm birth and/or chorioamnionitis on this brain region is not well understood. The aim of this review is to provide an overview of the role and function of the brainstem respiratory centers, and to highlight the proposed mechanisms of how preterm birth and chorioamnionitis may affect central respiratory functions.

Brain activity during phonation in healthy female singers with supraglottic compression: an fMRI pilot study

This pilot study evaluated the usability of functional magnetic resonance imaging (fMRI) to detect brain activation during phonation in healthy female singers with supraglottic compression. Four healthy female classical singers (mean age: 26 years) participated in the study. All subjects had normal vocal folds and vocal characteristics and showed supraglottic compression. The fMRI experiment was carried out using a block design paradigm. Brain activation during phonation and exhalation was analyzed using Brain Voyager software (Brain Innovation B.V., Maastricht, The Netherlands). An fMRI data analysis showed a significant effect of phonation control in the bilateral pre/postcentral gyrus, and in the frontal, cingulate, superior and middle temporal gyrus, as well as in the parietal lobe, insula, lingual gyrus, cerebellum, thalamus and brainstem. These activation areas are consistent with previous reports using other fMRI protocols. In addition, a significant effect of phonation compared to exhalation control was found in the bilateral superior temporal gyrus, and the pre/postcentral gyrus. This fMRI pilot study allowed to detect a normal pattern of brain activity during phonation in healthy female singers with supraglottic compression using the proposed protocol. However, the pilot study detected problems with the experimental material/procedures that would necessitate refining the fMRI protocol. The phonation tasks were not capable to show brain activation difference between high-pitched and comfortable phonation. Further fMRI studies manipulating vocal parameters during phonation of the vowels /a/ and /i/ may elicit more distinctive hemodynamic response (HDR) activity patterns relative to voice modulation.

Central voice production and pathophysiology of spasmodic dysphonia

OBJECTIVE

Our ability to speak is complex, and the role of the central nervous system in controlling speech production is often overlooked in the field of otolaryngology. In this brief review, we present an integrated overview of speech production with a focus on the role of central nervous system. The role of central control of voice production is then further discussed in relation to the potential pathophysiology of spasmodic dysphonia (SD).

DATA SOURCES

Peer-review articles on central laryngeal control and SD were identified from PUBMED search. Selected articles were augmented with designated relevant publications.

REVIEW METHODS

Publications that discussed central and peripheral nervous system control of voice production and the central pathophysiology of laryngeal dystonia were chosen.

RESULTS

Our ability to speak is regulated by specialized complex mechanisms coordinated by high-level cortical signaling, brainstem reflexes, peripheral nerves, muscles, and mucosal actions. Recent studies suggest that SD results from a primary central disturbance associated with dysfunction at our highest levels of central voice control. The efficacy of botulinum toxin in treating SD may not be limited solely to its local effect on laryngeal muscles and also may modulate the disorder at the level of the central nervous system.

CONCLUSION

Future therapeutic options that target the central nervous system may help modulate the underlying disorder in SD and allow clinicians to better understand the principal pathophysiology.

LEVEL OF EVIDENCE

NA.Laryngoscope, 128:177-183, 2018.

A Diagnostic Marker to Discriminate Childhood Apraxia of Speech From Speech Delay: IV. The Pause Marker Index

Purpose

Three previous articles provided rationale, methods, and several forms of validity support for a diagnostic marker of childhood apraxia of speech (CAS), termed the pause marker (PM). Goals of the present article were to assess the validity and stability of the PM Index (PMI) to scale CAS severity.

Method

PM scores and speech, prosody, and voice precision-stability data were obtained for participants with CAS in idiopathic, neurogenetic, and complex neurodevelopmental disorders; adult-onset apraxia of speech consequent to stroke and primary progressive apraxia; and idiopathic speech delay. Three studies were completed including criterion and concurrent validity studies of the PMI and a temporal stability study of the PMI using retrospective case studies.

Results

PM scores were significantly correlated with other signs of CAS precision and stability. The best fit of the distribution of PM scores to index CAS severity was obtained by dividing scores into 4 ordinal severity classifications: mild, mild-moderate, moderate-severe, and severe. Severity findings for the 4 classifications and retrospective longitudinal findings from 8 participants with CAS supported the validity and stability of the PMI.

Conclusion

Findings support research and clinical use of the PMI to scale the severity of CAS.

Evaluation of the Cortical Silent Period of the Laryngeal Motor Cortex in Healthy Individuals

Objective: This work aimed to evaluate the cortical silent period (cSP) of the laryngeal motor cortex (LMC) using the bilateral thyroarytenoid (TA) muscles with transcranial magnetic stimulation (TMS).

Methods: In 11 healthy participants, fine-wire electromyography (EMG) was used to record bilateral TA muscle responses to single pulse TMS delivered to the LMC in both hemispheres. Peripheral responses to stimulation over the mastoid, where the vagus nerve exits the skull, were collected to verify the central origin of the cortical stimulation responses by comparing the latencies.

Results: The cSP duration ranged from 41.7 to 66.4 ms. The peripherally evoked motor-evoked potential (MEP) peak occurred 5–9 ms earlier than the cortical responses (for both sides of TAs: p < 0.0001) with no silent period. The right TA MEP latencies were earlier than the left TA responses for both peripheral and cortical measures (p ≤ 0.0001).

Conclusion: These findings demonstrate the feasibility of measuring cSP of LMC based on intrinsic laryngeal muscles responses during vocalization in healthy volunteers.

Significance: The technique could be used to study the pathophysiology of neurological disorders that affect TA muscles, such as spasmodic dysphonia. Further, the methodology has application to other muscles of the head and neck not accessible using surface electrodes.

Intraoperative Neurophysiological Monitoring of the Laryngeal Nerves During Anterior Neck Surgery: A Review

Contributions to the literature on intraoperative neuro monitoring (IONM) during endocrine and head and neck surgery have increased over recent years. Organizational support for neural monitoring during surgery is becoming evident and is increasingly recognized as an adjunct to visual nerve identification. A comprehensive understanding of the role of IONM for prevention of nerve injuries is critical to maximize safety during surgery of the anterior compartment of the neck. This review will explore the potential advantages of IONM to improve the outcomes among patients undergoing anterior neck surgery.

Voice Modulation: A Window into the Origins of Human Vocal Control?

An unresolved issue in comparative approaches to speech evolution is the apparent absence of an intermediate vocal communication system between human speech and the less flexible vocal repertoires of other primates. We argue that humans' ability to modulate nonverbal vocal features evolutionarily linked to expression of body size and sex (fundamental and formant frequencies) provides a largely overlooked window into the nature of this intermediate system. Recent behavioral and neural evidence indicates that humans' vocal control abilities, commonly assumed to subserve speech, extend to these nonverbal dimensions. This capacity appears in continuity with context-dependent frequency modulations recently identified in other mammals, including primates, and may represent a living relic of early vocal control abilities that led to articulated human speech.