Botulinum toxin injection for abductor spasmodic dysphonia under cervical ultrasonography guidance

Ultrasound (US) imaging effectively provides real-time anatomical information for clinical examinations. In otolaryngology, US imaging can visualize laryngeal muscles as well as cervical muscles. Here we present the case where US imaging was used while injecting botulinum toxin (BT) for the treatment of abductor spasmodic dysphonia, which provided definite results. We could visualize not only the injection pathway but also the infiltration of the BT solution into the posterior cricoarytenoid muscles. Therefore, our laryngeal US imaging is useful for both improving the success rate and avoiding injection complications of BT.

Extrinsic Laryngeal Muscle Tension in Primary Muscle Tension Dysphonia with Shear Wave Elastography

OBJECTIVES

It has been assumed that patients with primary muscle tension dysphonia (pMTD) have more extrinsic laryngeal muscle (ELM) tension, but tools to study this phenomenon lack. Shear wave elastography (SWE) is a potential method to address these shortcomings. The objectives of this study were to apply SWE to the ELMs, compare SWE measures to standard clinical metrics, and determine group differences in pMTD and typical voice users before and after vocal load.

METHODS

SWE measurements of the ELMs from ultrasound examinations of the anterior neck, supraglottic compression severities from laryngoscopic images, cepstral peak prominences (CPP) from voice recordings, and self-perceptual ratings of vocal effort and discomfort were obtained in voice users with (N = 30) and without (N = 35) pMTD, before and after a vocal load challenge.

RESULTS

ELM tension significantly increased from rest-to-voiced conditions in both groups. However, the groups were similar in their ELM stiffness levels at SWE at baseline, during vocalization, and post-vocal load. Levels of vocal effort and discomfort and supraglottic compression were significantly higher and CPP was significantly lower in the pMTD group. Vocal load had a significant effect on vocal effort and discomfort but not on laryngeal or acoustic patterns.

CONCLUSION

SWE can be used to quantify ELM tension with voicing. Although the pMTD group reported significantly higher levels of vocal effort and vocal tract discomfort and, on average, exhibited significantly more severe supraglottic compression and lower CPP values, there were no group differences in levels of ELM tension using SWE.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:3482-3491, 2023.

Transcranial magnetic stimulation and functional magnet resonance imaging evaluation of adductor spasmodic dysphonia during phonation

BACKGROUND

Reduced intracortical inhibition is a neurophysiologic finding in focal dystonia that suggests a broader problem of impaired cortical excitability within the brain. A robust understanding of the neurophysiology in dystonia is essential to elucidate the pathophysiology of the disorder and develop new treatments. The cortical silent period (cSP) is a reliable, non-invasive method to measure intracortical inhibition in the primary motor cortex associated with a muscle of interest. In adductor spasmodic dysphonia (AdSD), cSP of the laryngeal motor cortex (LMC) which directly corresponds to the affected musculature, the thyroarytenoid (TA), has not been examined.

OBJECTIVE

This work evaluated the cSP of the LMC and the relationship between cSP and functional magnetic resonance imaging (fMRI) blood-oxygen-level dependent (BOLD) activation in people with AdSD (n = 12) compared to healthy controls (CTL, n = 14).

RESULTS

Shortened LMC cSP were observed bilaterally in people with AdSD vs CTL (F(1, 99) = 19.5226, p < 0.0001), with a large effect size (η2 = 0.1834). Between-group fMRI analysis revealed greater activation in bilateral LMC in the AdSD > CTL contrast as compared to CTL > AdSD contrast. Correlation analysis showed that people with AdSD have positive correlation of left LMC BOLD activation and the cSP. Further, the right LMC cSP lacks either positive or negative associations with BOLD activation. CTL individuals displayed both positive and negative correlations between cSP and BOLD activation in the left LMC. In CTL, the LMC cSP and BOLD activation showed exclusively negative correlations in both hemispheres.

CONCLUSION

In AdSD, the cortical activation during phonation may not be efficiently or effectively associated with inhibitory processes, leading to muscular dysfunction. These findings may give insight into the maladaptive cortical control during phonation in people with AdSD.

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

Purpose Adductor spasmodic dysphonia (ADSD), the most common form of spasmodic dysphonia, is a debilitating voice disorder characterized by hyperactivity and muscle spasms in the vocal folds during speech. Prior neuroimaging studies have noted excessive brain activity during speech in participants with ADSD compared to controls. Speech involves an auditory feedback control mechanism that generates motor commands aimed at eliminating disparities between desired and actual auditory signals. Thus, excessive neural activity in ADSD during speech may reflect, at least in part, increased engagement of the auditory feedback control mechanism as it attempts to correct vocal production errors detected through audition. Method To test this possibility, functional magnetic resonance imaging was used to identify differences between participants with ADSD (n = 12) and age-matched controls (n = 12) in (a) brain activity when producing speech under different auditory feedback conditions and (b) resting-state functional connectivity within the cortical network responsible for vocalization. Results As seen in prior studies, the ADSD group had significantly higher activity than the control group during speech with normal auditory feedback (compared to a silent baseline task) in three left-hemisphere cortical regions: ventral Rolandic (sensorimotor) cortex, anterior planum temporale, and posterior superior temporal gyrus/planum temporale. Importantly, this same pattern of hyperactivity was also found when auditory feedback control of speech was eliminated through masking noise. Furthermore, the ADSD group had significantly higher resting-state functional connectivity between sensorimotor and auditory cortical regions within the left hemisphere as well as between the left and right hemispheres. Conclusions Together, our results indicate that hyperactivation in the cortical speech network of individuals with ADSD does not result from hyperactive auditory feedback control mechanisms and rather is likely related to impairments in somatosensory feedback control and/or feedforward control mechanisms.

Clinical Application of Two-Dimensional Scanning Digital Kymography in Discrimination of Diplophonia

Purpose The purpose of this study was to investigate the characteristics of diplophonia using an auditory perception and multimodal simultaneous examination, which included sound waveform analysis, electroglottography (EGG), digital kymography (DKG), and 2-dimensional scanning digital kymography (2D DKG). Additionally, we compared the diagnostic accuracy of each method using a binary classifier in confusion matrix and convenience of discrimination, based on the time required for interpretation. Method One normophonic male, 12 patients with diplophonia, and 12 dysphonia patients without diplophonia were enrolled. A multimodal simultaneous evaluation was used to analyze the vibration pattern of diplophonia. Sensitivity, specificity, accuracy, area under the curve, and interpretation time were used to compare the various diagnostic methods. Discrimination was determined by 3 raters. Results There are 3 types of asymmetric vibratory patterns in diplophonia. The types are based on the oscillators vibrating at different frequencies: asymmetry of the left and right cords (6 subjects with unilateral palsy and 1 subject with vocal polyps), asymmetry of anterior and posterior cords (2 subjects with vocal polyps), and asymmetry of true and false cords (3 subjects with muscle tension dysphonia). All evaluation methods were useful as diagnostic tools, with all areas under the curve > .70. The diagnostic accuracy was highest with DKG (95.83%), followed by 2D DKG (83.33%), EGG (81.94%), auditory-perceptual evaluation (80.56%), and sound waveform (77.78%). The interpretation time was the shortest for auditory-perceptual evaluation (6.07 ± 1.34 s), followed by 2D DKG (10.04 ± 3.00 s), EGG (12.49 ± 2.76 s), and DKG (13.53 ± 2.60 s). Conclusions Auditory-perceptual judgment was the easiest and fastest method for experienced raters, but its diagnostic accuracy was lower than that of DKG or 2D DKG. The diagnostic accuracy of DKG was the highest, but 2D DKG allowed rapid interpretation and showed relatively high diagnostic accuracy, except in cases with space-occupying lesions. Supplemental Material https://doi.org/10.23641/asha.9911786.

Polygenic Risk of Spasmodic Dysphonia is Associated With Vulnerable Sensorimotor Connectivity

Spasmodic dysphonia (SD), or laryngeal dystonia, is an isolated task-specific dystonia of unknown causes and pathophysiology that selectively affects speech production. Using next-generation whole-exome sequencing in SD patients, we computed polygenic risk score from 1804 genetic markers based on a genome-wide association study in another form of similar task-specific focal dystonia, musician's dystonia. We further examined the associations between the polygenic risk score, resting-state functional connectivity abnormalities within the sensorimotor network, and SD clinical characteristics. We found that the polygenic risk of dystonia was significantly associated with decreased functional connectivity in the left premotor/primary sensorimotor and inferior parietal cortices in SD patients. Reduced connectivity of the inferior parietal cortex was correlated with the age of SD onset. The polygenic risk score contained a significant number of genetic variants lying near genes related to synaptic transmission and neural development. Our study identified a polygenic contribution to the overall genetic risk of dystonia in the cohort of SD patients. Associations between the polygenic risk and reduced functional connectivity of the sensorimotor and inferior parietal cortices likely represent an endophenotypic imaging marker of SD, while genes involved in synaptic transmission and neuron development may be linked to the molecular pathophysiology of this disorder.

[High-speed digital imaging in the clinical analysis of voice change as a parameter of premenstrual syndrome]

Technique of high-speed digital imaging (HSDI) is unique technology, allowing assessment of real vocal fold vibrations.

AIM

The aim of the study is to present the usefulness of HSDI in the diagnosis of premenstrual dysphonia as a parameter of premenstrual syndrome (PMS).

MATERIALS AND METHODS

In study conducted by Department of Clinical Phonoaudiology and Logopedics at the Medical University of Białystok participated 21 women aged between 20-31 years old. HSDI technique with a digital High Speed HS camera was used for visualization of the larynx. The rigid endoscope with 90° optics was used for visualizing the vocal folds vibrations during phonation of "e" vowel, at the rate of 4000 frames per second. Playback of recorded sequence set at 15 frames per second, allowed to assess vocal folds vibrations in slow motion mode. Mucosal wave (MW), glottal closure (GTs), symmetry, regularity and synchrony of vocal fold vibration were analyzed. Kymography of the larynx was made for analyzing the value of the Open Quotient (OQ) in the assessment of degree of glottal insufficiency. Study was conducted in the follicular phase of the menstrual cycle and then repeated 2-3 days before menstruation.

RESULTS

In the analyzed group of patients studied before menstruation only 19% of women complained of hoarseness and fatigue of voice, and 81% reported no problems with his voice but the edematous changes in the larynx was recorded by HSDI technique. No women had premenstrual dysphonia in the follicular phase of the menstrual cycle.

CONCLUSIONS

HSDI allows objective assessment of the degree of severity of insufficiency of glottal closure and edematous changes in the vocal folds in premenstrual dysphonia, what is confirmed by the objective values of the OQ.

[High-speed digital imaging in the diagnosis of voice pathologies]

Technique of high-speed digital imaging (HSDI) is unique technique, allowing for assessment of real vocal fold vibrations.

AIM

The aim of the study is to present the usefulness of HSDI in the diagnosis of clinical type of dysphonia.

MATERIALS AND METHODS

The study group was diagnosed at the Department of Clinical Phonoaudiology and Logopedics at the Medical University of Białystok and treated at the Phoniatric Clinic in years 2012-2015. HSDI technique with a digital camera was used for visualization of the larynx. The rigid endoscope with 90° optics was used for visualizing the vocal folds vibrations during phonation of "e" vowel, at the rate of 4000 frames per second. Playback of recorded sequence set at 15 frames per second, what allowed to assess vocal folds vibrations in slow motion mode during over 8 minutes. Mucosal wave (MW), glottal closure, symmetry, regularity and synchrony of vocal fold vibration were analyzed. Digital kymography (DKG) of the larynx was made for analyzing the value of the Open Quotient (OQ) in the assessment of degree of glottal insufficiency.

RESULTS

In the analyzed group of patients, the functional dysphonia was diagnosed in 71%, organic dysphonia in 29% patients. In 68%, glottal insufficiency was registered in the rear part at the glottis. The oedematous-hypertrophic changes were diagnosed in 21% of the cases, hypertrophic changes of larynx - in 6%, vocal fold polyps - in 3% and vocal fold nodules - in 2% of patients.

CONCLUSIONS

Examination of the larynx by using HSDI technique is quick, non-invasive to patient. HSDI allows to objective assessment of the degree of severity of insufficiency of glottal closure, what is confirmed by the objective values of the OQ. Evaluation of MW allows for the differentiation of clinical type and severity of organic dysphonia.

Surgical planning of Isshiki type I thyroplasty using an open-source Digital Imaging and Communication in Medicine viewer OsiriX

CONCLUSION

Preoperative surgical planning of Isshiki type I thyroplasty with the Digital Imaging and Communication in Medicine (DICOM) viewer OsiriX can be used for strategic and predictable type I thyroplasty.

OBJECTIVES

The aim of this study was to determine the efficacy of the preoperative planning of type I thyroplasty using the DICOM viewer OsiriX.

METHODS

Five patients with unilateral vocal cord paralysis and severe breathy dysphonia were included in this study. Multidetector computed tomography (CT) DICOM data were obtained and breath holding was performed during image acquisition. Using three-dimensional multiplanar reconstruction, we outlined the optimal location for a window. Type I thyroplasty was performed using Isshiki's original method, and only the placement of the window was decided according to the preoperative simulation point. To verify the advantages of this method, we compared our data with the previous data for total operation time and voice quality at 3 months after the operation without the DICOM viewer planning.

RESULTS

All patients are free from dysphonia and their glottic closures have resolved satisfactorily. Postoperative CT revealed that appropriate implant positioning resulted in successful surgical intervention. The comparison of total operation time showed that with the new method, operation duration was shortened by 12 min.

The assessment methods of laryngeal muscle activity in muscle tension dysphonia: a review

The purpose of this paper is to review the methods used for the assessment of muscular tension dysphonia (MTD). The MTD is a functional voice disorder associated with abnormal laryngeal muscle activity. Various assessment methods are available in the literature to evaluate the laryngeal hyperfunction. The case history, laryngoscopy, and palpation are clinical methods for the assessment of patients with MTD. Radiography and surface electromyography (EMG) are objective methods to provide physiological information about MTD. Recent studies show that surface EMG can be an effective tool for assessing muscular tension in MTD.

Dysphonia and chest pain as presenting symptoms of pneumomediastinum

Spontaneous pneumomediastinum (SPM) is a rare but generally benign condition characterized by the presence of free air in the mediastinal space that is unrelated to trauma or medical procedure. We describe a case of a 25-year-old woman who presented to the emergency room with a chief complaint of dysphonia, and chest pain. An X-ray of the neck and CT of the chest were performed and showed findings consistent with a pneumomediastinum. Supportive treatment led to an uneventful recovery. We discuss the differential diagnosis of the coexisting chest pain and dysphonia in the diagnosis of SPM.