Congenital glottic stenosis as a clinical manifestation of FREM1-associated disorders in a neonate with respiratory distress and aphonia

A female infant born at 38 weeks and 2 days via induced vaginal delivery was admitted to the neonatal intensive care unit for respiratory distress soon after birth. Noted to have aphonia on examination, the patient underwent direct laryngoscopy and was diagnosed with an anterior glottic web and subglottic stenosis. The patient underwent a genetic workup including whole exome sequencing which resulted in a diagnosis of a FREM1-associated disorder. Congenital glottic webs and subglottic stenoses have not been previously described as clinical manifestations of FREM1-associated disorders.

Impact of syllable stress and phonetic context on the distribution of intermittent aphonia

The occurrence of intermittent aphonia, perceived as sudden interruptions of voicing in connected speech, often reflects high stiffness of the vocal fold mucosa as part of a voice disorder. This retrospective study aimed to investigate the overarching hypothesis that the aphonic instances in voices with intermittent aphonia are not totally randomly appearing, but related to syllable stress and phonetic context. Recordings of 31 dysphonic patients with intermittent aphonia reading a standard text were analyzed perceptually. All vowels of the text were labelled and categorized with regard to syllable stress and character of the phoneme preceding the vowel. The occurrence of aphonic instances within each syllable category was analyzed. Four different hypotheses were formulated and analyzed by the non-parametric Wilcoxon's signed-ranks test. The results showed a significantly higher occurrence of aphonic instances in unstressed syllables as opposed to stressed, in vowels following an unvoiced phoneme as opposed to a voiced, and in vowels following two or more unvoiced phonemes as opposed to one unvoiced phoneme. No significant difference was found between vowels following aspirated stops [p], [t], [k] as opposed to unaspirated stops [b], [d], [g]. The findings support the theory that both physiological and functional aspects may contribute to the phenomenon of intermittent aphonia.

Arytenoid adduction to treat impaired adduction of the vocal fold due to rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting the synovial membrane and causing joint damage and bone destruction. The symptoms of cricoarytenoid joint (CJ) arthritis often include hoarseness, and a sense of pharyngeal fullness in the throat. Sometimes, in cases with bilateral CJ involvement, an urgent tracheostomy might be required for acute airway obstruction. In this report, we describe a woman suffering from aphonia due to hampered adduction of the vocal fold which was caused by RA with unilateral CJ involvement. Arytenoid adduction surgery on the affected side was performed. She retrieved a normal voice immediately after the surgery.

[Diagnosis and treatment and prevention of iatrogenic functional aphonia]

OBJECTIVE

To discuss the diagnosis, treatment and prevention of iatrogenic functional aphonia.

METHODS

Twenty three patients who either lost their voice or only could whisper after surgery in other hospitals were included in this study as the first group, history was well collected and laryngostroboscopy performed. All cases were confirmed as iatrogenic functional aphonia patients and received phonation therapy. In another group of patients who received vocal cord surgery in our hospital from 2003 to 2005, speaking was restricted while not prohibited after surgery, voice quality was closely observed, and 1028 cases were included.

RESULTS

All 23 cases of functional aphonia were cured with phonation therapy. No iatrogenic functional aphonia occurred in the second group of patients.

CONCLUSIONS

The iatrogenic functional aphonia can be caused by post operative mistreatment and could be cured with phonation therapy, and it is preventable if speaking is not strictly prohibited after surgery.

[Management and therapy in functional aphonia: analysis of 500 cases]

INTRODUCTION

The article reviews current opinions on etiopathogenesis and management of functional total loss of the ability to produce loud voice. Psychogenic aphonia refers to involuntary whispering despite a basically normal larynx.

MATERIAL AND METHODS

[corrected] The longitudinal study was carried out on 500 patients treated for psychogenic aphonia during 32 years (1972-2004). Of the facilitating techniques, the following were useful for phoniatric therapy: relaxation and respiration, gargle, chewing, pushing, inhalation phonation, masking, phonetic exercises.

RESULTS

During the first day of vocal exercises the voice return to 410 patients (82%). The others required carrying on vocal therapy.

CONCLUSIONS

The basic importance of phoniatric therapy is recovering the voice during the first day of vocal exercises. Sometimes the aphonic patient profits most from symptomatic voice therapy concurrent with psychotherapy.

Marked depression and anxiety in patients with functional dysphonia

The etiology of functional dysphonia is still unclear, but psychological factors are assumed to play an important role . The purpose of this report is to investigate the impact of depression and anxiety in functional dysphonia. Sixty-one patients with functional dysphonia were screened for additional psychiatric disorders (besides 300.11) by a clinical psychiatric interview. They were then compared with healthy controls, matched by age, sex and occupation, with respect to self-reported symptoms of depression, generalized anxiety, and specific anxiety concerning health. The patients had significantly higher scores than the controls in depressive symptoms, in the symptoms of nonspecific and general anxiety, and in the symptoms of specific anxiety concerning health. Fifty-seven percent of the patients also fulfilled DSM-IV criteria for a mood disorder, an anxiety disorder, or an adjustment disorder. Multivariate analysis of covariance, performed to correct for the influence of co-morbid psychiatric diagnoses on self-rated symptoms of depression and anxiety, confirmed significant differences between patients and controls in the symptoms of depression and specific anxiety concerning "somatic complaints." Both symptoms of depression and anxiety should be taken into consideration in the diagnostic as well as the therapeutic process of patients with functional dysphonia.

Expressive aprosody and amusia as a manifestation of right hemisphere seizures

PURPOSE

Aprosody and amusia are disorders commonly associated with right hemisphere abnormalities. They are regarded as negative phenomena and usually seen after strokes. We report a case of a patient who had both expressive aprosody and amusia as a clinical manifestation of right temporooccipital seizures.

METHODS

A 43-year-old woman had a 1-month history of monotonic speech and difficulty singing. Her examination revealed both expressive aprosody and amusia. Magnetic resonance imaging of the head was normal, but her EEG revealed several electrographic seizures of right temporooccipital origin.

RESULTS

Treatment with phenytoin (PHT) almost immediately caused her speech and singing to return to baseline. A repeated EEG was normal

CONCLUSIONS

Seizures of right temporooccipital origin can manifest with expressive aprosody and amusia.

Vocal cord paralysis secondary to impacted esophageal foreign bodies in young children

Impacted foreign bodies in the esophagus can result in respiratory symptoms including stridor and aphonia. Several mechanisms have been proposed to explain these symptoms, but the possibility of vocal cord paralysis and its cause has not been adequately emphasized. Two cases of young children with esophageal foreign body are described; both presented with respiratory symptoms, 1 with aphonia and the other with stridor. In both cases, the symptoms were secondary to vocal cord paralysis. A possible mechanism of recurrent nerve injury is proposed.

Hysterical aphonia--an analysis of 25 cases

Hysteria is a common neurotic disorder in psychiatric practice. Many of its conversion symptoms have not been studied in detail. In the present prospective study in a tertiary care teaching hospital, 25 cases of hysterical aphonia were analysed. There were 17 females and 8 males. Mean age of presentation was 18.4 years in females and 21.2 years in males. Majority of patients were literate upto primary class, belonging to joint family and had urban background. Duration of symptoms was within 2 weeks. Most common precipitating factor was stress of examination or failure followed by quarrels with peers or spouse. In 20% cases, cause was not known. Comorbid psychiatric disorders were found in 80% cases, the most common being mixed anxiety and depressive disorder (36%) followed by generalized anxiety disorder (20%).

Is an organic/functional distinction psychologically meaningful in patients with dysphonia?

Dysphonia (hoarseness) is a common clinical condition and, if persistent, patients are referred to otolaryngology clinics for clinical examination. During the examination, a clinical distinction is often made among three types of patients: (1) those with a clear organic basis for dysphonia (cancer, vocal cord palsy): (2) those with some degree of organic pathology; and (3) those with an apparently functional etiology. Functional patients are often characterized as having a psychogenic disorder. This study assessed the psychological validity of the functional category in 204 out-patients (aged 17 to 87 years) with persistent hoarseness of types (2) and (3). Following clinical examination, a consultant otolaryngologist categorized patients as having functional or organic etiology. Subjects were then compared on measures of personality and psychological distress. Dysphonic subjects showed marked psychological distress compared with norms, and reported significantly more previous psychosomatic symptoms than norms, but there were no differences in personality or psychological distress between organic and functional subgroups of dysphonics.

[Atypical acute dystonia]

Acute dystonia is a common adverse effect following anti-psychotic medication, which mainly appears shortly after beginning treatment or increasing the dosage. Laryngeal dysfunction may carely occur as part of the picture of acute dystonia and, if so, usually with dyspnoea. We describe a case of acute dystonia with atypical onset without relation to changes in dosage and with laryngeal involvement with aphonia, but without dyspnoea.

[Voice pathology in patients with allergic rhinitis]

The aim of work was evaluation of voice pathology in patients with allergic rhinitis. Larynx organic pathology were found in 75% patients with coexisting allergic rhinitis in the form of Reinke's oedema, chronic hypertrophic laryngitis, larynx polyp and vocal nodules. It caused serious voice pathology (dysphonia) which was confirmed by an objective spectrographic method. Larynx organic pathology was not in 15% patients. In these cases rhinophonia was found in consequence of resonance nasal defect.

Ictal speech arrest and parasagittal lesions

Lesions in the parasagittal region may cause seizures with speech arrest. To correlate lesion localization within the parasagittal region with ictal speech function we studied 11 patients with parasagittal lesions. The exact lesion localization was assessed with magnetic resonance imaging. In all patients with speech arrest the lesion involved the left superior frontal gyrus (n = 6), in 3 patients the lesion was confined to this gyrus. Speech arrest did not occur in patients with right-sided lesions (n = 4) or left-sided lesions outside the superior frontal gyrus (n = 1). Our data suggest that a small lesion confined to the left superior frontal gyrus (the supplementary motor area) is sufficient to cause speech arrest.

Acute palsy of the recurrent laryngeal nerve complicating Epstein-Barr virus infection

We report an 11-year-old boy with active Epstein-Barr virus (EBV) infection who developed acute aphonia and had signs and symptoms of recurrent laryngeal nerve palsy. The association of isolated recurrent laryngeal nerve palsy and EBV infection has not previously been reported. This case report expands the spectrum of neurologic complications of EBV infection, and suggests that infectious mononucleosis should be considered in the differential diagnosis of acute aphonia in children.

A comparative study of psychological aspects of recurring and non-recurring functional aphonias

The present study is based on the hypothesis that patients with recurrent attacks of aphonia differ from those with non-recurring attacks of aphonia in their anxiety levels, social assertiveness and stress-coping strategies. A comparison was made between 21 women with recurring aphonia and 19 women with non-recurring aphonia with respect to these three factors. Seventeen healthy women served as volunteers. Compared to patients with non-recurring aphonias, patients with recurring aphonias exhibited a significantly higher level of anxiety and significantly more respect for social norms and codes of propriety. Their coping was also characterized by a higher escape tendency. Patients with recurring aphonias also reported a significantly higher number of problems in their private lives within the preceding 5-year period. In therapy patients should be encouraged to reflect upon a possible rigidity toward social norms and better understand fears regarding conflicts in personal relationships.

[Apraxia of the larynx]

Disturbances of vocal function in patients with apraxia of speech are well known in the literature and have often been described. Although apraxia of phonation is presumed, only 1 case is mentioned in the literature. We present a 51-year-old man (with missing signs of dysarthria and aphasia after spontaneous right temproparietal hemorrhagia) who had aphonia and missing respiration during speaking, whereas articulation was nearly undisturbed. After differential diagnostic exclusion of other central disorders of phonation we classify this patient as having apraxia of phonation or laryngeal apraxia.

Semi-automated voice evaluation

This report describes a voice evaluation procedure that in some way parallels the audiologic tests used for hearing and has multiple uses both clinically and in research. It uses a simultaneous eight-channel input, is not difficult to use, requiring between 12 and 25 minutes to administer, and provides the physician with a printout in standardized form before the patient leaves the room. This three-page report includes 15 abstracted or calculated values, normal ranges by sex for each value, notes that draw attention to deviations from the normal, a summary profile, a graphic representation of the evaluation, and raw data waveforms.

[A case of the abdominal form of Wilson's disease with atypical clinical symptoms in a 19-year-old man]

A case of the abdominal form of Wilson's disease is described in a male patient aged 19 years. The case progressed rapidly and presented rarely observed signs of central nervous system damage. Morphological examination of the brain demonstrated well developed picture of tissue damage characteristic of this disease entity.

The long-term period measurement, an instrumental method in phoniatry

With the help of an Analog to Digital Converter we are able to perform serial and statistical analysis in the time domain. The difficulty in those long-term period measurements consists in the correct extraction of the periodicity in human voice. A simple method is the electroglottography, which, however, is not applicable in all cases. The analysis of the acoustic wave (translated via microphone) demands a lot of electronics if to be precise. Our investigation consists of a compromise between precision and amount of instrumentation, and we only took one parameter as a criterion. The possible error is negligible. We present the results of this measurement type using the patterns of one normal voice and eight different kinds of voice disorders.

Clinical aspects of spasmodic dysphonia

The clinical features of 12 patients with spasmodic dysphonia are described. In 11 patients, the voice was strained, harsh, tight, and tremulous, and was low in volume and pitch. Speech, which was sometimes barely intelligible, was interrupted by irregular stoppages and catches of the voice; it required considerable effort, and was accompanied by facial grimacing. The dysphonia was part of a more widespread neurological disorder (idiopathic torsion dystonia) in one case, while it coexisted with blepharospasm in another, and with postural tremor in two. There was a buccolingual hyskinesia in another of these 11 patients, but this may have been related to her previous drug regime. In the twelfth patient, who had a familial tremor, the voice was characterised by marked breathiness, with intermittent aphonia. The disorder is probably due to a focal dystonia of the laryngeal musculature, and this would be consistent with the type of neurological disorders that were associated with it in our cases. Symptomatic benefit follows the therapeutic division of one of the recurrent laryngeal nerves, in selected cases.

[The lombard reflex as a test of vocal function (author's transl)]

Any impairment of audio-phonatory control by background noise is followed by an increase in both the intensity and pitch of the speaking voice (Lombard reflex, 1911), thus increasing vocal strain. As a consequence, it might be anticipated that persons reacting to noise with marked changes in voice might be more liable to develop dysphonia. 22 singers, 34 normal controls, and 22 patients with hyperfunctional dysphonia where studied. In all patients, both ears were gradually masked with white noise. The change of the mean intensity level and of the mean pitch level of the speaking voice were then measured objectively with a special fundamental frequency analyzer (Fedders and Schultz-Coulon, 1975). Results show that the increase of intensity is comparable in all subjects, whereas the elevation of the mean pitch level differs significantly: trained voices (singers) react with the least pitch increment whereas dysphonic patients react with the most. The following conclusions were made from the present investigation: 1. Extreme increments in pitch level can be considered to be a more significant etiological factor of dysphonia than intensity increments; 2. Vocal therapy and voice training may have a favorable effect on the Lombard reflex (probably by improvement of the kinesthetic control mechanism) so that the speaking voice in a noisy environment is raised less with less vocal strain. The study also indicates that measurement of pitch changes during binaural masking can provide important information for the diagnosis, therapy and prophylaxis of dysphonia.

Spastic dysphonia

130 cases of spastic dysphonia are reviewed with special emphasis on the etiology of the disorder. An analysis of the circumstances surrounding the onset of the disease points strongly to a psychogenic origin of the disease in, at least, the vast majority of the cases.

The validity and significance of the clinical diagnosis of hysteria (Briquet's syndrome)

The author states that a valid diagnostic classification based on the medical model is a sine qua non for progress in psychiatric research and treatment and that such classification requires follow-up and family studies. To illustrate this point he reports on studies showing that hysteria, or Briquet's syndrome, is a valid clinical entity that follows a predictable course and clusters in certain families. He also reports that an association between hysteria and sociopathy has been demonstrated, suggesting that the two conditions may arise from sililar etiologic and pathogenetic factors.