Differentiation of adductor-type spasmodic dysphonia from muscle tension dysphonia by spectral analysis

Objectives

To determine the utility of spectral analysis in the differentiation of adductor-type spasmodic dysphonia (AdSD) from muscle tension dysphonia (MTD).

Study Design

Prospective blinded study.

Methods

Forty-seven samples of AdSD-connected speech spectrograms from 27 subjects and 17 samples of MTD-connected speech spectrograms from 15 subjects were selected from clinical charts and de-identified. These spectrograms were reviewed independently and blindly by two speech language pathologists experienced in spectrography. The speech language pathologists designated the spectrogram as consistent with AdSD and MTD, and these designations were compared with actual clinical diagnoses.

Results

The ability to differentiate AdSD from MTD with spectral analysis was 94% for rater #1 and 98% for rater #2. No MTD subjects were incorrectly diagnosed as having SD (100% specificity).

Conclusions

This study suggests that experienced speech language pathologists can distinguish AdSD from MTD with a high degree of sensitivity and specificity based on spectral analysis. Spectral analysis is especially useful in cases where perceptual analysis and clinical evaluation alone are insufficient.

Study of Lubricant-Induced Changes in Chronic Snorers

Problem: The efficacy of many of the noninvasive treatments for snoring has not been evaluated in controlled trials. This study seeks to evaluate the efficacy of an oil-based spray in the treatment of snoring, in a double-blinded, placebo-controlled, cross-over trial using objective acoustic analysis and subjective questionnaires.

Methods: Participants were randomized to use both oilbased oral spray (treatment) and water-based oral spray (placebo) during a 2-night in-home study period. Questionnaires were completed by the participant and his/her bed-partner; these were evaluated along with audiotape recordings, which were analyzed for frequency, duration, and mean energy of snoring.

Results: Greatest snoring rate demonstrated 30% = benefit; 40% = no change; 30% = adverse effect (n = 20). percent time snoring yielded: 30% = benefit; 15% = no change; 55% = adverse effect (n = 20). Study data results for mean energy were (n = 12): 17% = benefit; 33% = no change; 50% = adverse effect. Bed-partner observations (n = 17) demonstrated 37% = benefit; 38% = no change, 25% = adverse effect.

Conclusion: Objective and subjective evaluation of the performance of the oil-based Snoreless spray in comparison to placebo demonstrated a lack of efficacy in snoring reduction.

Significance: Study findings indicate that oil-based oral sprays are not effective in the treatment of snoring.

Support: None reported.

Fascia Augmentation of the Vocal Fold: Graft Yield in the Canine and Preliminary Clinical Experience

INTRODUCTION

Glottal insufficiency resulting from vocal fold bowing, hypomobility, or scar is frequently treated by injection augmentation. Injection augmentation with fat, collagen, gel foam, polytef, and recently, fascia lata has been previously reported. Variable graft yield and poor host-tissue tolerance have motivated the continued search for an ideal graft substance.

STUDY DESIGN

A prospective trial of autologous fascia augmentation of the vocal cord in the human and in an animal model.

METHODS

Autologous fascia injection augmentation (AFIA) was evaluated in 8 canines and 40 patients at our institution between 1998 and 2000. The animal study compared graft yield from AFIA with autologous fat yield. The outcome measure was graft yield calculated from histological examination of larynges 12 weeks after injection augmentation. Clinical trial outcome measures included symptom surveys, acoustical voice analyses, and subjective voice assessments. Mean follow-up was 9 months.

RESULTS

In the canine larynx, the mean graft yield for AFIA was 33% (range, 5%-84%) compared with autologous lipoinjection (47%; range, 7%-96%; P =.57). Subjective improvement in vocal quality was reported by 95% of patients (38 of 40) after AFIA. Preoperative and postoperative voice analysis data were obtained from 26 patients. Subjective voice rating demonstrated a significant improvement after AFIA (P <.0001). Acoustical parameters of jitter, shimmer, noise-to-harmonic ratio, phonatory range, and degree unvoiced improved significantly (P <.05) in all patients after fascia augmentation.

CONCLUSIONS

Based on the animal study, we concluded that graft yields are excellent but variable for AFIA. The result is similar in variability and overall yield to autologous lipoinjection. Subjective and objective analyses of voice outcomes after AFIA are universally improved. Fascia appears to be an excellent alternative to lipoinjection in properly selected cases of glottic insufficiency.

Occult laryngeal pathology in a community-based cohort

BACKGROUND

Little information is available regarding the prevalence of laryngeal pathology in adults.

PURPOSE

To estimate the prevalence of occult laryngeal pathology in a community-based cohort of adults over 40 years of age.

METHODS

One hundred consecutive volunteers over age 40 with no history of voice disorders were enrolled. All completed a self-administered laryngeal symptom questionnaire and underwent a comprehensive head and neck examination including transnasal fiberoptic laryngoscopy.

RESULTS

The mean age of the cohort was 61 years. Vocal fold bowing (presbylaryngis) was present in 72% of the patients, and findings of laryngopharyngeal reflux were present in 64% of the cohort. In addition, other laryngeal pathology were identified in 21%. Only 12% had a completely normal laryngeal examination.

CONCLUSIONS

Occult laryngeal pathology is very common in persons over 40. Findings suggestive of laryngopharyngeal reflux are present in 64%, and vocal fold bowing is present in 72% of persons over 40.

Vocal fold paresis

Vocal fold paresis (VFP) is a relatively common and often overlooked condition that can be difficult to diagnose based on the laryngeal examination alone. A retrospective review of the records of 50 consecutive adult patients with VFP was performed. In each case, the diagnosis of VFP was confirmed by laryngeal electromyography. The presenting symptoms were dysphonia (100%), vocal fatigue (76%), diplophonia (40%), and odynophonia (12%), and the findings were unilateral vocal fold hypomobility (50%), unilateral bowing (36%), and bilateral bowing (22%). Laryngoplasty and/or lipoinjection was performed in 54% of the subjects, and significant vocal improvement was achieved in 85%. VFP appears to be underdiagnosed because many VFP patients have compensatory hyperkinetic disorders at presentation. Although the diagnosis of VFP may be suspected based on the patient's symptoms and findings, the diagnostic sine qua non is laryngeal electromyography. In addition, surgical treatment for VFP appears to be safe and effective.

Bilateral medialization laryngoplasty

OBJECTIVES

To present indications, techniques, and results of bilateral medialization laryngoplasty (BML).

STUDY DESIGN

Retrospective review of 39 consecutive patients who had BML for correction of glottal insufficiency attributable to presbylaryngis (n = 16), bilateral vocal fold paresis (n = 13), unilateral paralysis with contralateral bowing (n = 4), and other miscellaneous neurologic diseases (n = 6).

METHODS

Complete preoperative and postoperative clinical and acoustical data were analyzed for 74% (29/39) of the subjects. All 39 subjects completed a patient survey to assess their long-term outcomes.

RESULTS

Overall, 90% (35/39) of the patients who had BML experienced significant improvement in voice and swallowing function. Subsequently, 36% (14/39) of the patients underwent adjunctive lipoinjection for closure of small residual glottal gaps (vocal "fine-tuning"). Of the BML patients (with or without lipoinjection) who had complete preoperative and postoperative voice data, 83% (24/29) had complete glottal closure after surgery, resulting in normal or near-normal voices. Eighty-five percent (33/39) of the patients responded that they "would have surgery again." Of the six patients who said that they would not have surgery again, three had good results and one had progressive neurologic disease. The mean duration of follow-up was 17 months.

CONCLUSIONS

BML is an effective rehabilitative surgical treatment for symptomatic vocal fold bowing. In addition, lipoinjection is useful as an adjunct to BML to enhance the voice outcome in selected cases.

Functional voice disorders

Functional voice disorders (FVDs) are common. The diagnostic criteria for six types of FVD and the results of treatment in a large series of patients are reported. Voice therapy was effective in 69% of the patients. Failure of voice therapy usually correlated with continued tobacco use, noncompliance with therapy, or premature termination of therapy.

Vocal fatigue and dysphonia in the professional voice user: Bogart-Bacall syndrome

Over the past 5 years, the authors have treated 67 adult professional voice users with a musculoskeletal tension disorder involving the larynx and supporting structures and leading to vocal dysfunction. Common clinical features in both sexes were muscle tension in the neck, poor control of the breath stream, and an abnormally low-pitched speaking voice. Most of the men sounded like Humphrey Bogart and the women like Lauren Bacall. These cases represent a discrete clinical vocal fatigue syndrome, the treatment of which is patient education and voice therapy.

Classification and approach to patients with functional voice disorders

Functional voice disorders result from vocal misuse or abuse; they are more easily recognized than other psychosomatic disorders because the clinician is able to visualize the laryngeal structure and function. If those structures appear normal, then an aberration of voice quality can be assumed to be functional. Functional dysphonia with prolonged aberrant vocal usage may lead to development of secondary pathological lesions of the larynx, which, although true pathological entities, must be recognized as resulting from the underlying and preceding functional disorder. In this report, we present a classification of and an approach to the diagnosis and treatment of functional voice disorders. On the basis of our clinical experience with 52 patients, we distinguished five types of functional voice disorders: type 1, hysterical aphonia/dysphonia; type 2, habituated hoarseness; type 3, falsetto voice, type 4, vocal abuse; and type 5, postoperative dysphonia. Forty-eight of the 52 patients (92%) were followed for a median period of 16 months (range 2-51 months). Therapy yielded excellent results in patients with types 1, 2 and 3; good results with types 4 and 5.