Electroglottographic tracking of phonatory response to Botox.

Botox injection into the thyroarytenoid muscle is thought to alter the glottal competence and laryngeal adduction of patients with adductor spasmodic dysphonia (ADSD). Hypofunctional responses to treatment have been rated subjectively and inferred from postinjection breathy voice, aphonia, midline glottal gap, or subclinical aspiration. Clinical experience suggests that temporary hypofunction varies in duration and severity among patients. This study used electroglottographic measures to examine changes over time in glottal competence during the relatively stable phonation produced by 5 patients with ADSD. Hierarchical linear modeling was used to test 3 hypotheses: (a) that reduced laryngeal adduction would occur during the first 3 weeks postinjection, followed by a reversal; (b) that patients' hypofunctional response curves would differ one from another; and (c) that changes in adduction, if present, would be related to changes in severity ratings of ADSD symptoms. For 3 participants, significant hypoadduction occurred after injection and reversed toward preinjection level over an 8-week period. Two participants demonstrated a flat or increasing vocal fold contact response curve during the early postinjection period. Observations were consistent with the previously reported differences and possibly complex relation between the resolution of breathy hypofunction and ultimate return of ADSD symptoms.     

A comparison of type I thyroplasty and arytenoid adduction

Glottal incompetence is a common laryngeal disorder causing impaired swallowing and phonation. The resultant voice has been characterized as weak and breathy with a restricted pitch range. Currently, medialization thyroplasty and arytenoid adduction are two of the surgical treatments for patients with glottal incompetence. However, few studies have evaluated the changes in objective measures of speech with type I thyroplasty and arytenoid adduction. In this study, 59 patients with glottal incompetence underwent either type I thyroplasty or arytenoid adduction. Acoustic (jitter, shimmer, and harmonics-to-noise ratio) and aerodynamic (airflow, subglottic pressure, and glottal resistance) measures were obtained both pre- and postoperatively. No significant differences were found among acoustic or aerodynamic measures for operation type. However, a significant pre/postsurgery effect was observed for translaryngeal airflow. In addition, no significant differences were found among the measures for patients with traditional compared with nontraditional operative indications. Patients who developed glottal insufficiency due to previous laryngeal surgery (e.g., vocal fold stripping) demonstrated no statistically significant improvement in acoustic or aerodynamic measures following thyroplasty or arytenoid adduction.     

Does botulinum toxin alter laryngeal secretionsand mucociliary transport?

Localized botulinum toxin injection disrupts cholinergic transmissionand has potential to cause focal dysautonomia. Mucociliary transport and laryngeal secretions are thought to be mediated in part by autonomic, cholinergic transmission. We questioned whether patients who receive Botox® injection for adductor spasmodic dysphonia (ADSD) report postinjection symptoms possibly related to altered mucociliary clearance or laryngeal secretions. Medical histories, audiotaped interviews, and symptom ratings were retrospectively examined for 29 patients with ADSD who were followed after one or more Botox injections. Patients had received bilateral, percutaneous Botox injections of 2.5 units using an EMG-guided approach. One or more weeks after injection, four patients reported either burning, tickling, or irritation of the larynx/throat, excessive thick secretions, or dryness. Symptoms recurred with subsequent injections in two patients and were not associated with swallowing difficulty. These symptoms are consistent with, but not diagnostic of, the known effects of botulinum toxin on cholinergic, autonomic transmission.     

The abduction quotient related to vocal quality

The abduction quotient, a measure of effective glottal width, was obtained for electroglottographic recordings from a professional operatic baritone singer. The subject produced repeated tokens of the voice qualities breathy, normal, and pressed (or constricted) in both a speech and a singing manner. In the singing manner, the subject produced the three vocal qualities at three pitch levels and three loudness levels. The abduction quotient decreased from breathy to pressed voice, suggesting that the measure corresponds to effective glottal width. The measure was found to be consistently low during all conditions of singing, suggesting that the subject produced all singing tokens with relatively strong laryngeal adduction at the vocal process level. Although the results of this study support the validity and usefulness of the abduction quotient, further verification is needed.     

Voice Handicap Index Results for Older Patients with Adductor Spasmodic Dysphonia

Adductor spasmodic dysphonia (ADSD) adversely affects a speaker's ability to effectively communicate. For many individuals suffering with ADSD, botulinum toxin (Botox) is the chosen treatment to remediate the symptoms. Although Botox's effects on symptom remediation have been examined before, patient perception of improvement post-Botox has been examined less frequently. Further, no studies have addressed the symptomatic changes in older adults that occur after Botox treatment. The Voice Handicap Index (VHI) was used as the instrument to assess older patient's (>65 years) perception of how ADSD impacts certain areas of their life pre- and post-Botox injection. The outcome of the VHI was related to a clinical judgment of voice severity. Participants also completed the Social Readjustment Rating Scale (SRRS) to examine overall stress level, and the outcome of the SRRS was correlated to postinjection VHI scores. Results indicated no significant correlation between VHI scores and voice severity or SRRS ratings. The current study suggests further study of voice outcomes with older adults with ADSD is needed.     

Analysis of spasmodic dysphonia by aerodynamic and laryngostroboscopic measurements

Sequential assessment of laryngeal function using laryngostroboscopy and phonatory air flow assessment was carried out in 18 patients with spasmodic dysphonia (SD). Comparison was made between findings in patients before treatment (n = 18), after unilateral recurrent nerve block by lidocaine (n = 6), after bilateral injections of botulinum toxin (Botox) (n = 13), and prior to Botox reinjection (n = 3). Unilateral nerve block resulted in higher mean phonatory airflows than after bilateral Botox injections. Both unilateral nerve block and Botox injections increased fluctuant or alternating flow source (AC); however, unilateral nerve block resulted in more unmodulated airflow leakage. Phonation time on a single breath was longer than with Botox injection. Bilateral Botox injections resulted in better glottal closure, fewer instances of vocal fold level differences, and, better vocal fold vibrations with phase symmetry, as determined by laryngostroboscopy. Partial bilateral denervation using Botox resulted in laryngeal function, which appeared to be intermediate between that of tightly squeezed pretreatment status and a breathy voice with incomplete adduction after unilateral nerve block. Of all treatments assessed, bilateral partial denervation by Botox appeared to be the most physiologic in restoring normal vocal fold vibratory function and airflow.     

Botulinum Toxin Therapy for Abductor Spasmodic Dysphonia

Botulinum toxin has been widely accepted as an effective therapy for controlling the symptoms of adductor spasmodic dysphonia (ADSD). Reported experience with botulinum treatment for abductor spasmodic dysphonia (ABSD) has been less impressive. Factors that may impair outcomes for ABSD include differences in the pathophysiology of ADSD and ABSD and limitation of maximal dose from airway restriction with posterior cricoarytenoid muscle (PCA) weakness. We report our experience with botulinum injection of the PCA with an asymmetric dose escalation protocol, based on clinical observations that in ABSD, abductor spasms are often stronger on one side, usually the left. The nondominant side was injected with 1.25 units. Dominant side dose began at 5 units, with step-wise increments of 5 units per week until one of three endpoints was reached: Elimination of breathy voice breaks, complete abductor paralysis of the dominant side, or airway compromise. Fourteen of 17 patients achieved good or fair voice, with dominant-side doses ranging from 10 to 25 units. Exercise intolerance limited PCA dose in two patients. One patient had persisting breathiness that improved with medialization thyroplasty. Asymmetric botulinum toxin injection into PCA muscles can suppress abductor spasm in patients with ABSD, but breathiness may persist, because of inadequate glottal closure.     

Laryngeal adduction in resonant voice

The primary question in this study was whether subjects with nodules and subjects with healthy larynges would produce “resonant voice” with a similar laryngeal configuration. A second question regarded whether the electroglottographic closed quotient (EGG CQ) could be used to noninvasively distinguish resonant from other voice types. Twelve adult singers and actors served as subjects, including 6 persons with healthy larynges and 6 persons with nodules. Performers were used as an attempt to maximize token validity and stability. Subjects produced repeated tokens of resonant, pressed, normal, and breathy voice during sustained vowels. Laryngeal adduction was directly estimated using blinded, ordinal, visual-perceptual ratings based on videoscopic views of the larynx. EGG CQs were further calculated based on separate trials. The perceptual ratings indicated that subjects in both groups produced resonant voice with a barely adducted or barely abducted laryngeal configuration that was distinct from configurations for pressed and breathy (but not normal) voice. Previous literature suggests that this configuration may be relevant in many cases of voice therapy (I). Average CQs distinguished resonant from pressed voice, but inconsistently distinguished resonant from breathy voice. Further CQs were reliably different across healthy subjects and subjects with nodules. Thus, the utility of this measure to noninvasively estimate resonant voice may be limited, particularly without ongoing subject-specific calibration procedures.     

Characteristics of vocal fold adduction related to voice onset

This study examined whether vocal fold kinematics prior to phonation differed between hard (glottal), normal, or breathy onsets in men and women. Glottal landmarks were identified and digitized from videotape recorded with a rigid laryngoscope during different voice onset types. Significant linear relationships (p 0.0055) were found among onset types on measures of (a) gesture duration when moving from 80% to 20% of maximum distance during adduction, (b) maximum velocity, (c) duration between the completion of adduction and phonation onset, and (d) ratios of maximum velocity to maximum distance between the vocal processes, an estimate of stiffness. The gesture duration was greatest for breathy onsets and least for hard onsets, while the maximum velocity, latency between adduction and phonation onset, and estimated stiffness were greatest for hard onsets and least for breathy onsets. The results suggest that one trajectory seems to be used with increases in gesture duration being accompanied by decreases in articulator stiffness when moving from hard to normal to breathy voice onset types.     

Spectral Amplitude Measures of Adductor Spasmodic Dysphonic Speech

Spectral amplitude measures are sensitive to varying degrees of vocal fold adduction in normal speakers. This study examined the applicability of harmonic amplitude differences to adductor spasmodic dysphonia (ADSD) in comparison with normal controls. Amplitudes of the first and second harmonics (H1, H2) and of harmonics affiliated with the first, second, and third formants (A1, A2, A3) were obtained from spectra of vowels and /i/ excerpted from connected speech. Results indicated that these measures could be made reliably in ADSD. With the exception of H1(*)-H2(*), harmonic amplitude differences (H1(*)-A1, H1(*)-A2, and H1(*)-A3(*)) exhibited significant negative linear relationships (P < 0.05) with clinical judgments of overall severity. The four harmonic amplitude differences significantly differentiated between pre-BT and post-BT productions (P < 0.05). After treatment, measurements from detected significant differences between ADSD and normal controls (P < 0.05), but measurements from /i/ did not. LTAS analysis of ADSD patients' speech samples proved a good fit with harmonic amplitude difference measures. Harmonic amplitude differences also significantly correlated with perceptual judgments of breathiness and roughness (P < 0.05). These findings demonstrate high clinical applicability for harmonic amplitude differences for characterizing phonation in the speech of persons with ADSD, as well as normal speakers, and they suggest promise for future application to other voice pathologies.     

The relationship among voice onset, voice quality, and fundamental frequency: a dynamical perspective

In dynamical motor theory, skill acquisition occurs as a modification of preexisting coordination patterns or attractor states. The purpose of this study was to assess how different levels of voice onset, voice quality, and fundamental frequency (F₀) combine to form the attractor states common to voice motor control. Three levels of voice onset (glottal, simultaneous, and breathy), voice quality (modal speech, mixed, and falsetto), and fundamental frequency (low, mid, and high) were manipulated by vocally untrained, female subjects. Percent correct of acquisition trials and self-report of effort were used as measures of stable phonations indicative of an attractor state. Using intensity as a covariate, the results provided support for two of the three predicted triads representing attractor states in female speakers: (1) glottal onset/modal speech quality/low F₀; and (2) breathy onset/falsetto quality/high F₀. The results of this study suggest that certain parameters of voice motor control, such as onset, quality, and F₀, exist as part of a dynamical system that can be identified and manipulated in voice motor acquisition and learning.     

Stroboscopic and acoustic measures of inspiratory phonation

Inspiratory phonation (IP) is the production of voice as air is taken into the lungs. Although IP is promoted as a laryngeal assessment and voice treatment technique, it has been described quantitatively in very few speakers. This study quantified changes in laryngeal adduction, fundamental frequency, and intensity during IP relative to expiratory phonation (EP). We hypothesized that IP would increase laryngeal abduction and fundamental frequency. The experiment was a within-subjects, repeated measures design with each subject serving as her own control. Participants were 10 females (ages 19-50 years) who underwent simultaneous transoral videostrobolaryngoscopy and acoustic voice recording. We found that membranous vocal fold contact decreased significantly during IP relative to EP, while the trends for change of ventricular fold squeeze during IP varied across individuals. Vocal fundamental frequency increased significantly during IP relative to EP, but intensity did not vary consistently across conditions. Without teaching or coaching, changes that occurred during IP did not carry over to EP produced immediately following IP within the same respiratory cycle.     

Relationship among glottal area, static supraglottic compression, and laryngeal function studies in unilateral vocal fold paresis and paralysis

In this study, we evaluated the relationship between laryngeal function measures and glottal gap ratio and normalized measures of supraglottic behaviors in patients with unilateral vocal fold paresis (UVFP). Thirty-one patients were found to have unilateral vocal fold paresis by videoendoscopy and laryngeal electromyography, and 13 controls participated in this study. Patients with UVFP demonstrated significantly larger glottal gap ratios (p = 0.016) than control subjects. The nonparalyzed or contralateral vocal fold was associated with significantly more static false vocal fold compression (p = 0.03) compared with the paralyzed vocal fold or with the controls. Patients with unilateral vocal fold paresis were divided into subgroups: those with normal or abnormal maximum phonation time, flow, or pressure measures. Smaller glottal gap ratios were identified in patients with normal maximum phonation times and flow measures. Greater false vocal fold activity was identified in unilateral vocal fold paresis patients with normal laryngeal function measures than in unilateral vocal fold paresis patients with abnormal measures. These findings suggest that some patients with documented unilateral paresis and glottal incompetence can compensate for vocal fold weakness such that their acoustic and aerodynamic measures are normal.     

Voice Characteristics of Young Girl Role in Kunqu Opera

Three electroglottographic parameters, fundamental frequency, contact quotient, and speed quotient were analyzed for two singers of Young girl role in Kunqu Opera. Each singer performed three conditions, singing, stage speech, and reading lyrics. The phonation types adopted in different conditions were explored based on electroglottographic parameters. Fundamental frequency, contact quotient, and speed quotient showed different distributions among conditions. Five phonation types were used in singing and stage speech, which include (1) breathy voice, (2) modal voice with low degree of posterior glottal adduction, (3) modal voice, (4) falsetto, and (5) falsetto with high degree of posterior glottal adduction. The phonation strategies partly showed differences between singers. Different phonation type collocations were employed in singing and stage speech. The relationship between phonation types and pitch was complex. The phonation types actually used were different from and more complex than those in traditional Kunqu Opera singing theory.     

Vocal fold bulging effects on phonation using a biophysical computer model

Glottal adduction is a primary laryngeal variable that helps to determine glottal configuration and phonatory output. Greater adduction of the vocal folds can be produced by narrowing the gap between the vocal processes or by bulging the medial surface of the vocal folds. This study examined phonatory effects due to changing the degree of bulging using a computational model. Bulging was modeled as a quadratic surface and was related to active muscle stress. Results indicated that bulging had a significant effect on glottal flow resistance, maximum glottal width and area, and mean glottal volume velocity. The results are discussed relative to clinical issues of hyperfunction.     

Source Characteristics of Aged Voice Assessed from Long-Term Average Spectra

This study is the first to investigate age-related changes in the source characteristics of dynamic speech using long-term average spectral analysis (LTAS). A total of 80 speakers divided equally by age and gender participated. All participants were healthy, active community members. From the first paragraph of the Rainbow Passage, spectral energy measurements were completed for all speakers at 50 frequency levels across the LTAS. In comparison with young women, elderly women demonstrated: (1) significantly higher spectral amplitude levels at the frequencies of 320, 6080, 6240, 6400, 6560, and 6720 Hz; (2) significantly lower levels at the frequencies of 3040 and 3200 Hz; and (3) a tendency toward higher levels at 160 Hz. These findings suggest that both young and elderly women demonstrate spectral features associated with breathy voice quality, while differing in the specific spectral regions in which breathiness is indicated. Elderly men demonstrated significantly higher spectral amplitude levels than young men at 160 Hz, as well as significantly lower levels at 1600 Hz. Findings for men provide acoustic support for previous laryngoscopic findings of an age-related increase in the incidence of glottal gaps.     

The effect of patient factors on response outcomes toBotox treatment of spasmodic dysphonia

Injection of botulinum toxin (Botox) into the laryngeal muscleshas become the treatment of choice for controlling the symptoms of spasmodic dysphonia (SD). Currently, no specific battery of objective tests to assess the outcome is universally accepted. The purpose of this study was to investigate demographic, clinical, and treatment factors with voice outcome following Botox injection. Sixty-eight patients with adductor SD who underwent at least one Botox injection during a 5-year period were studied. Voice outcome measures were made from patient self-reporting scales and included overall vocal quality, length of response, and duration of breathiness. Vocal quality was significantly correlated with the underlying severity of vocal symptoms prior to treatment, incidence of breathiness and unilateral versus bilateral injection. The length of response was greater in males and following bilateral injections. An increased period of breathiness significantly correlated with bilateral injections.     

Pushing exercise program to correct glottal incompetence

A voice therapy program using pushing exercises to correct glottal incompetence is described. The program utilizes various types of instrumentation to determine whether or not a given patient is likely to benefit from the treatment. The program also provides feedback of target voices. Three cases with incomplete glottal closure and subsequent vocal dysphonia characterized by an asthenic breathy quality are used to illustrate the program. Details of the program, termination criteria, and problems and precautions learned from treating 29 patients over a 3-year period are presented.     

Estimating perceived phonatory pressedness in singing from flow glottograms

The normalized amplitude quotient (NAQ), defined as the ratio between the peak-to-peak amplitude of the flow pulse and the negative peak amplitude of the differentiated flow glottogram and normalized with respect to period time, has been shown to be related to glottal adduction. Glottal adduction, in turn, affects mode of phonation and hence perceived phonatory pressedness. The relationship between NAQ and perceived phonatory pressedness was analyzed in a material collected from a professional female singer and singing teacher who sang a triad pattern in breathy, flow, neutral, and pressed phonation in three different loudness conditions (soft, middle, loud). In addition, she also sang the same triad pattern in four different styles of singing, classical, pop, jazz, and blues, in the same three loudness conditions. A panel of experts rated the degree of perceived phonatory press along visual analogue scales. Comparing the obtained mean rated pressedness ratings with the mean NAQ values for the various triads showed that about 73% of the variation in perceived pressedness could be accounted for by variations of NAQ.     

Incidence of supraglottic activity in males and females: a preliminary report

Supraglottic activity was rated from flexible endoscopic video recordings of subjects with normal laryngeal structure and function as they sustained vowels and repeated syllables and sentences. Judges rated these recordings for false vocal fold (FVF) adduction and anterior-to-posterior (A-P) compression at the initiation of the speech task, throughout the whole speech task (static supraglottic activity), and as brief individual adductions within a speech task (dynamic supraglottic activity). Significant differences in A-P (p < 0.0003) and FVF (p < 0.0000001) compression were found between tasks. Dynamic FVF activity was associated with glottal stops. Static A-P and FVF activities were present in males significantly more (p < 0.0001) than females. FVF activity associated with speech initiation was found in females significantly more (p = 0.0256) than males. Supraglottic activity plays a role in normal speech production, and should not necessarily be considered suggestive of a voice use pattern with excessive muscle tension.