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Patel R, Burroughs L, Higgins A, Zauber SE, Isbaine F, Schneider D, Hohman R, Gupta K. Bilateral Deep Brain Stimulation of the Ventral Intermediate Nucleus of the Thalamus Improves Objective Acoustic Measures of Essential Vocal Tremor. Neurosurgery 2024; 95:915-923. [PMID: 38787392 DOI: 10.1227/neu.0000000000002955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/28/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Deep brain stimulation of the ventral intermediate nucleus of the thalamus (VIM-DBS) is an established treatment for medically refractory essential tremor. However, the effect of VIM-DBS on vocal tremor remains poorly understood, with results varying by method of vocal tremor assessment and stimulation laterality. This single-center study measures the effect of bilateral VIM-DBS on essential vocal tremor using blinded objective acoustic voice analysis. METHODS Ten patients with consecutive essential tremor with comorbid vocal tremor receiving bilateral VIM-DBS underwent voice testing before and after implantation of DBS in this prospective cohort study. Objective acoustic measures were extracted from the middle one second of steady-state phonation including cepstral peak prominence, signal-to-noise ratio, percentage voicing, tremor rate, extent of fundamental frequency modulation, and extent of intensity modulation. DBS surgery was performed awake with microelectrode recording and intraoperative testing. Postoperative voice testing was performed after stable programming. RESULTS Patients included 6 female and 4 male, with a mean age of 67 ± 6.7 years. The VIM was targeted with the following coordinates relative to the mid-anterior commissure:posterior commissure point: 13.2 ± 0.6 mm lateral, 6.2 ± 0.7 mm posterior, and 0.0 mm below. Mean programming parameters were amplitude 1.72.0 ± 0.6 mA, pulse width 63.0 ± 12.7 µs, and rate 130.6 ± 0.0 Hz. VIM-DBS significantly improved tremor rate from 4.43 ± 0.8 Hz to 3.2 ± 0.8 Hz ( P = .001) CI (0.546, 1.895), jitter from 1 ± 0.94 to 0.53 ± 0.219 ( P = .02) CI (-0.124, 1.038), cepstral peak prominence from 13.6 ± 3.9 to 18.8 ± 2.9 ( P = .016) CI (-4.100, -0.235), signal-to-noise ratio from 15.7 ± 3.9 to 18.5 ± 3.7 ( P = .02) CI (-5.598, -0.037), and articulation rate from 0.77 ± 0.2 to 0.82 ± .14 ( P = .04) CI (-0.097, 0.008). There were no major complications in this series. CONCLUSION Objective acoustic voice analyses suggest that bilateral VIM-DBS effectively reduces vocal tremor rate and improves voicing. Further studies using objective acoustic analyses and laryngeal imaging may help refine surgical and stimulation techniques and evaluate the effect of laterality on vocal tremor.
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Affiliation(s)
- Rita Patel
- Department of Otolaryngology Head & Neck Surgery, Indiana University School of Medicine, Indianapolis/Indiana University Bloomington, Bloomington , Indiana , USA
| | - Leah Burroughs
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Alexis Higgins
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - S Elizabeth Zauber
- Department of Neurology, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Faical Isbaine
- Department of Neurosurgery, Emory University, Atlanta , Georgia , USA
| | - Dylan Schneider
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Ryane Hohman
- Department of Speech, Language and Hearing Sciences, Indiana University Bloomington, Bloomington , Indiana , USA
| | - Kunal Gupta
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee , Wisconsin , USA
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Simonyan K, Barkmeier-Kraemer J, Blitzer A, Hallett M, Houde JF, Jacobson Kimberley T, Ozelius LJ, Pitman MJ, Richardson RM, Sharma N, Tanner K. Laryngeal Dystonia: Multidisciplinary Update on Terminology, Pathophysiology, and Research Priorities. Neurology 2021; 96:989-1001. [PMID: 33858994 DOI: 10.1212/wnl.0000000000011922] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To delineate research priorities for improving clinical management of laryngeal dystonia, the NIH convened a multidisciplinary panel of experts for a 1-day workshop to examine the current progress in understanding its etiopathophysiology and clinical care. METHODS The participants reviewed the current terminology of disorder and discussed advances in understanding its pathophysiology since a similar workshop was held in 2005. Clinical and research gaps were identified, and recommendations for future directions were delineated. RESULTS The panel unanimously agreed to adopt the term "laryngeal dystonia" instead of "spasmodic dysphonia" to reflect the current progress in characterizations of this disorder. Laryngeal dystonia was recognized as a multifactorial, phenotypically heterogeneous form of isolated dystonia. Its etiology remains unknown, whereas the pathophysiology likely involves large-scale functional and structural brain network disorganization. Current challenges include the lack of clinically validated diagnostic markers and outcome measures and the paucity of therapies that address the disorder pathophysiology. CONCLUSION Research priorities should be guided by challenges in clinical management of laryngeal dystonia. Identification of disorder-specific biomarkers would allow the development of novel diagnostic tools and unified measures of treatment outcome. Elucidation of the critical nodes within neural networks that cause or modulate symptoms would allow the development of targeted therapies that address the underlying pathophysiology. Given the rarity of laryngeal dystonia, future rapid research progress may be facilitated by multicenter, national and international collaborations.
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Affiliation(s)
- Kristina Simonyan
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT.
| | - Julie Barkmeier-Kraemer
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Andrew Blitzer
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Mark Hallett
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - John F Houde
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Teresa Jacobson Kimberley
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Laurie J Ozelius
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Michael J Pitman
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Robert Mark Richardson
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Nutan Sharma
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Kristine Tanner
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
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