Auditory Feedback Control Mechanisms Do Not Contribute to Cortical Hyperactivity Within the Voice Production Network in Adductor Spasmodic Dysphonia

How to cut the pie is no piece of cake: Toward a process-oriented approach to assessment and diagnosis of speech sound disorders

BACKGROUND

'Speech sound disorder' is an umbrella term that encompasses dysarthria, articulation disorders, childhood apraxia of speech and phonological disorders. However, differential diagnosis between these disorders is a persistent challenge in speech pathology, as many diagnostic procedures use symptom clusters instead of identifying an origin of breakdown in the speech and language system.

AIMS

This article reviews typical and disordered speech through the lens of two well-developed models of production-one focused on phonological encoding and one focused on speech motor planning. We illustrate potential breakdown locations within these models that may relate to childhood apraxia of speech and phonological disorders.

MAIN CONTRIBUTION

This paper presents an overview of an approach to conceptualisation of speech sound disorders that is grounded in current models of speech production and emphasises consideration of underlying processes. The paper also sketches a research agenda for the development of valid, reliable and clinically feasible assessment protocols for children with speech sound disorders.

CONCLUSION

The process-oriented approach outlined here is in the early stages of development but holds promise for developing a more detailed and comprehensive understanding of, and assessment protocols for speech sound disorders that go beyond broad diagnostic labels based on error analysis. Directions for future research are discussed.

WHAT THIS PAPER ADDS

What is already known on the subject Speech sound disorders (SSD) are heterogeneous, and there is agreement that some children have a phonological impairment (phonological disorders, PD) whereas others have an impairment of speech motor planning (childhood apraxia of speech, CAS). There is also recognition that speech production involves multiple processes, and several approaches to the assessment and diagnosis of SSD have been proposed. What this paper adds to existing knowledge This paper provides a more detailed conceptualisation of potential impairments in children with SSD that is grounded in current models of speech production and encourages greater consideration of underlying processes. The paper illustrates this approach and provides guidance for further development. One consequence of this perspective is the notion that broad diagnostic category labels (PD, CAS) may each comprise different subtypes or profiles depending on the processes that are affected. What are the potential or actual clinical implications of this work? Although the approach is in the early stages of development and no comprehensive validated set of tasks and measures is available to assess all processes, clinicians may find the conceptualisation of different underlying processes and the notion of potential subtypes within PD and CAS informative when evaluating SSD. In addition, this perspective discourages either/or thinking (PD or CAS) and instead encourages consideration of the possibility that children may have different combinations of impairments at different processing stages.

Sensory processing in the auditory and olfactory domains is normal in laryngeal dystonia

Abnormal sensory discriminatory processing has been implicated as an endophenotypic marker of isolated dystonia. However, the extent of alterations across the different sensory domains and their commonality in different forms of dystonia are unclear. Based on the previous findings of abnormal temporal but not spatial discrimination in patients with laryngeal dystonia, we investigated sensory processing in the auditory and olfactory domains as potentially additional contributors to the disorder pathophysiology. We tested auditory temporal discrimination and olfactory function, including odor identification, threshold, and discrimination, in 102 laryngeal dystonia patients and 44 healthy controls, using dichotically presented pure tones and the extended Sniffin' Sticks smell test protocol, respectively. Statistical significance was assessed using analysis of variance with non-parametric bootstrapping. Patients had a lower mean auditory temporal discrimination threshold, with abnormal values found in three patients. Hyposmia was found in 64 patients and anosmia in 2 patients. However, there were no statistically significant differences in either auditory temporal discrimination threshold or olfactory identification, threshold, and discrimination between the groups. A significant positive relationship was found between olfactory threshold and disorder severity based on the Burke-Fahn-Marsden dystonia rating scale. Our findings demonstrate that, contrary to altered visual temporal discrimination, auditory temporal discrimination and olfactory function are likely not candidate endophenotypic markers of laryngeal dystonia.

Temporal specificity of abnormal neural oscillations during phonatory events in laryngeal dystonia

Laryngeal dystonia is a debilitating disorder of voicing in which the laryngeal muscles are intermittently in spasm resulting in involuntary interruptions during speech. The central pathophysiology of laryngeal dystonia, underlying computational impairments in vocal motor control, remains poorly understood. Although prior imaging studies have found aberrant activity in the CNS during phonation in patients with laryngeal dystonia, it is not known at what timepoints during phonation these abnormalities emerge and what function may be impaired. To investigate this question, we recruited 22 adductor laryngeal dystonia patients (15 female, age range = 28.83-72.46 years) and 18 controls (eight female, age range = 27.40-71.34 years). We leveraged the fine temporal resolution of magnetoencephalography to monitor neural activity around glottal movement onset, subsequent voice onset and after the onset of pitch feedback perturbations. We examined event-related beta-band (12-30 Hz) and high-gamma-band (65-150 Hz) neural oscillations. Prior to glottal movement onset, we observed abnormal frontoparietal motor preparatory activity. After glottal movement onset, we observed abnormal activity in the somatosensory cortex persisting through voice onset. Prior to voice onset and continuing after, we also observed abnormal activity in the auditory cortex and the cerebellum. After pitch feedback perturbation onset, we observed no differences between controls and patients in their behavioural responses to the perturbation. But in patients, we did find abnormal activity in brain regions thought to be involved in the auditory feedback control of vocal pitch (premotor, motor, somatosensory and auditory cortices). Our study results confirm the abnormal processing of somatosensory feedback that has been seen in other studies. However, there were several remarkable findings in our study. First, patients have impaired vocal motor activity even before glottal movement onset, suggesting abnormal movement preparation. These results are significant because (i) they occur before movement onset, abnormalities in patients cannot be ascribed to deficits in vocal performance and (ii) they show that neural abnormalities in laryngeal dystonia are more than just abnormal responses to sensory feedback during phonation as has been hypothesized in some previous studies. Second, abnormal auditory cortical activity in patients begins even before voice onset, suggesting abnormalities in setting up auditory predictions before the arrival of auditory feedback at voice onset. Generally, activation abnormalities identified in key brain regions within the speech motor network around various phonation events not only provide temporal specificity to neuroimaging phenotypes in laryngeal dystonia but also may serve as potential therapeutic targets for neuromodulation.

A Computational Model for Estimating the Speech Motor System's Sensitivity to Auditory Prediction Errors

Purpose The speech motor system uses feedforward and feedback control mechanisms that are both reliant on prediction errors. Here, we developed a state-space model to estimate the error sensitivity of the control systems. We examined (a) whether the model accounts for the error sensitivity of the control systems and (b) whether the two systems have similar error sensitivity. Method Participants (N = 50) completed an adaptation paradigm, in which their first and second formants were perturbed such that a participant's /ε/ would sound like her /ӕ/. We measured adaptive responses to the perturbations at early (0-80 ms) and late (220-300 ms) time points relative to the onset of the perturbations. As data-driven correlates of the error sensitivity of the feedforward and feedback systems, we used the average early responses and difference responses (i.e., late minus early responses), respectively. We fitted the state-space model to participants' adaptive responses and used the model's parameters as model-based estimates of error sensitivity. Results We found that the late responses were larger than the early responses. Additionally, the model-based estimates of error sensitivity strongly correlated with the data-driven estimates. However, the data-driven and model-based estimates of error sensitivity of the feedforward system did not correlate with those of the feedback system. Conclusions Overall, our results suggested that the dynamics of adaptive responses as well as error sensitivity of the control systems can be accurately predicted by the model. Furthermore, our results suggested that the feedforward and feedback control systems function independently. Supplemental Material https://doi.org/10.23641/asha.14669808.

Auditory Feedback Control of Vocal Pitch in Spasmodic Dysphonia

OBJECTIVES/HYPOTHESIS

Hearing plays an important role in the maintenance of vocal control in normal individuals. In patients with spasmodic dysphonia (SD), however, the ability to maintain sustained control of phonation is impaired. The origins of SD are unknown, and it is unclear whether auditory feedback-dependent vocal control is compromised in these patients.

STUDY DESIGN

Prospective case-control study.

METHODS

We tested 15 SD patients and 11 age-matched controls. Voice recordings were performed while subjects repeated the vowel /e/ and auditory feedback of their vocal sounds was altered in real-time to introduce a pitch-shift (±2 semitones), presented back to subjects using headphones. Recordings were analyzed to determine voice changes following the pitch-shifted feedback. Results were further compared with patient demographics and subjective measures of dysphonia, including the Voice Handicap Index (VHI).

RESULTS

Despite considerable pitch variability and vocal breaks, SD patients exhibited significantly higher average vocal pitch compensation than control subjects. SD patients also exhibited greater variability than controls. However, there were no significant correlations between vocal compensation and patient demographics, although there was a significant inverse correlation with VHI.

CONCLUSIONS

In this pilot study, patients with SD exhibited increased sensitivity to altered auditory feedback during sustained phonation. These results are consistent with recent theories of SD as a disorder of sensory-motor feedback processing, and suggest possible avenues for future investigation.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:2070-2075, 2021.

Compensatory Responses to Formant Perturbations Proportionally Decrease as Perturbations Increase

Purpose We continuously monitor our speech output to detect potential errors in our productions. When we encounter errors, we rapidly change our speech output to compensate for the errors. However, it remains unclear whether we adjust the magnitude of our compensatory responses based on the characteristics of errors. Method Participants (N = 30 adults) produced monosyllabic words containing /ɛ/ (/hɛp/, /hɛd/, /hɛk/) while receiving perturbed or unperturbed auditory feedback. In the perturbed trials, we applied two different types of formant perturbations: (a) the F1 shift, in which the first formant of /ɛ/ was increased, and (b) the F1-F2 shift, in which the first formant was increased and the second formant was decreased to make a participant's /ɛ/ sound like his or her /æ/. In each perturbation condition, we applied three participant-specific perturbation magnitudes (0.5, 1.0, and 1.5 ɛ-æ distance). Results Compensatory responses to perturbations with the magnitude of 1.5 ɛ-æ were proportionally smaller than responses to perturbation magnitudes of 0.5 ɛ-æ. Responses to the F1-F2 shift were larger than responses to the F1 shift regardless of the perturbation magnitude. Additionally, compensatory responses for /hɛd/ were smaller than responses for /hɛp/ and /hɛk/. Conclusions Overall, these results suggest that the brain uses its error evaluation to determine the extent of compensatory responses. The brain may also consider categorical errors and phonemic environments (e.g., articulatory configurations of the following phoneme) to determine the magnitude of its compensatory responses to auditory errors.