Botulinum toxin in the treatment of recalcitrant mutational dysphonia

Mutational falsetto is the failure of the normal drop in vocal pitch at puberty. Voice therapy almost always achieves an appropriate pitch; however, in cases of failure, surgical treatment has also been recommended. We report a case of a 47-year-old man with an above-average fundamental frequency and a thin voice quality in the absence of any signs of androgen insufficiency. Laryngeal examination revealed atrophy of the vocalis muscle. Voice therapy was unsuccessful in achieving a stable voice. Injection of 15 units of botulinum toxin into each cricothyroid muscle initially resulted in aphonia, but the voice returned by 1 week. Average fundamental frequency was 84 Hz at 1 week, 104 Hz at 1 month, and 100 Hz at 1 year. We hypothesize that mutational dysphonia is an habitual dysfunction of the voice with inappropriate activation of the cricothyroid muscle and disuse of laryngeal adductor muscles. Temporary deactivation of the cricothyroid muscle enforces adoption of a more appropriate vocal mechanism. Botulinum toxin as an adjunct to voice therapy should be considered before surgical alteration of the glottis in patients with recalcitrant mutational falsetto.     

Relation between perceived voice register and flow glottogram parameters in males

The perception of modal and falsetto registers was analyzed in a material consisting of a total of 104 vowel sounds sung by 13 choir singers, 52 sung in modal register, and 52 in falsetto register. These vowel sounds were classified by 16 expert listeners in a forced choice test and the number of votes for modal was compared to the voice source parameters: (1) closed quotient (Q(closed)), (2) level difference between the two lowest source spectrum partials (H1-H2), (3) AC amplitude, (4) maximum flow declination rate (MFDR), and (5) normalized amplitude quotient (NAQ, AC amplitude/MFDR(*) fundamental frequency). Tones with a high value of Q(closed) and low values of H1-H2 and of NAQ were typically associated with high number of votes for modal register, and vice versa, Q(closed) showing the strongest correlation. Some singer subjects produced tones that could not be classified as either falsetto or modal register, suggesting that classification of registers is not always feasible.     

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.     

The Relationship Between Cepstral Peak Prominence and Selected Parameters of Dysphonia

Traditional measures of dysphonia vary in their reliability and in their correlations with perceptions of grade. Measurements of cepstral peak prominence (CPP) have been shown to correlate well with perceptions of breathiness. Because it is a measure of periodicity, CPP should also predict roughness. The ability of CPP and other acoustic measures to predict overall dysphonia and the subcategories of breathiness and roughness in pathological voice samples is explored. Preoperative and postoperative speech samples from 19 patients with unilateral recurrent laryngeal nerve paralysis who underwent operative intervention were analyzed by trained listeners and by measures of smoothed CPP (CPPS), noise-to-harmonic ratio (NHR), amplitude perturbation quotient (APQ), relative average perturbation (RAP), and smoothed pitch perturbation quotient (sPPQ). The data were analyzed with bivariate Pearson correlation statistics. Grade of dysphonia and breathiness ratings correlated better with measurements of CPPS than with the other measures. CPPS from samples of connected speech (CPPS-s) best predicted overall dysphonia. None of the measures were useful in predicting roughness.     

Current and Emerging Concepts in Muscle Tension Dysphonia: A 30-Month Review

The modern theory of hoarseness is that there are multifactorial etiologies contributing to the voice problem. The hypothesis of this study is that muscle tension dysphonia is multifactorial with various contributing etiologies. METHODS: This project is a retrospective chart review of all patients seen in the Voice Speech and Language Service and Swallowing Center at our institution with a diagnosis of muscle tension (functional hypertensive) dysphonia over a 30-month period. A literature search and review is also performed regarding current and emerging concepts of muscle tension dysphonia. RESULTS: One hundred fifty subjects were identified (60% female, 40% male, with a mean age of 42.3 years). Significant factors in patient history believed to contribute to abnormal voice production were gastroesophageal reflux in 49%, high stress levels in 18%, excessive amounts of voice use in 63%, and excessive loudness demands on voice use in 23%. Otolaryngologic evaluation was performed in 82% of patients, in whom lesions, significant vocal fold edema, or paralysis/paresis was identified in 52.3%. Speech pathology assessment revealed poor breath support, inappropriately low pitch, and visible cervical neck tension in the majority of patients. Inappropriate intensity was observed in 23.3% of patients. This set of multiple contributing factors is discussed in the context of current and emerging understanding of muscle tension dysphonia. CONCLUSIONS: Results confirm multifactorial etiologies contributing to hoarseness in the patients identified with muscle tension dysphonia. An interdisciplinary approach to treating all contributing factors portends the best prognosis.     

Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy

A combined-modality treatment program consisting of botulinum toxin injection (Botox) and voice therapy was used to treat 17 subjects diagnosed with adductor spasmodic dysphonia (ADD SD). Ten subjects with ADD SD served as the control and were given Botox only. Voice therapy after Botox injection was directed toward reducing the hyperfunctional vocal behaviors, primarily glottal overpressure at voice onset and anterior-posterior squeezing. The results indicated that subjects who underwent combined-modality treatment maintained significantly higher mean airflow rates for significantly longer periods. Moreover, there was a carryover effect in these patients when they received Botox only. Adductor spasmodic dysphonia is treated most effectively when intrinsic laryngeal muscle spasms are reduced or eliminated by Botox injection and extrinsic hyperfunctional vocal behaviors are treated with voice therapy     

Deviant Vocal Fold Vibration as Observed During Videokymography: The Effect on Voice Quality

Videokymographic images of deviant or irregular vocal fold vibration, including diplophonia, the transition from falsetto to modal voice, irregular vibration onset and offset, and phonation following partial laryngectomy were compared with the synchronously recorded acoustic speech signals. A clear relation was shown between videokymographic image sequences and acoustic speech signals, and the effect of irregular or incomplete vocal fold vibration patterns was recognized in the amount of perceived breathiness and roughness and by the harmonics-to-noise ratio in the speech signal. Mechanisms causing roughness are the presence of mucus, phase differences between the left and right vocal fold, and short-term frequency and amplitude modulation. It can be concluded that the use of simultaneously recorded videokymographic image sequences and speech signals contributes to the understanding of the effect of irregular vocal fold vibration on voice quality.     

Differences Among Mixed,Chest, and Falsetto Registers: A Multiparametric Study

IntroductionTypical singing registers are the chest and falsetto; however, trained singers have an additional register, namely, the mixed register. The mixed register, which is also called “mixed voice” or “mix,” is an important technique for singers, as it can help bridge from the chest voice to falsetto without noticeable voice breaks.ObjectiveThe present study aims to reveal the nature of the voice-production mechanism of the different registers (chest, mix, and falsetto) using high-speed digital imaging (HSDI), electroglottography (EGG), and acoustic and aerodynamic measurements.Study DesignCross-sectional study.MethodsAerodynamic measurements were acquired for twelve healthy singers (six men and women) during the phonation of a variety of pitches using three registers. HSDI and EGG devices were simultaneously used on three healthy singers (two men and one woman) from which an open quotient (OQ) and speed quotient (SQ) were detected. Audio signals were recorded for five sustained vowels, and a spectral analysis was conducted to determine the amplitude of each harmonic component. Furthermore, the absolute (not relative) value of the glottal volume flow was estimated by integrating data obtained from the HSDI and aerodynamic studies.ResultsFor all singers, the subglottal pressure (P_Sub) was the highest for the chest in the three registers, and the mean flow rate (MFR) was the highest for the falsetto. Conversely, the P_Sub of the mix was as low as the falsetto, and the MFR of the mix was as low as the chest. The HSDI analysis showed that the OQ differed significantly among the registers, even when the fundamental frequency was the same; the OQ of the mix was higher than that of the chest but lower than that of the falsetto. The acoustic analysis showed that, for the mix, the harmonic structure was intermediate between the chest and falsetto. The results of the glottal volume-flow analysis revealed that the maximum volume velocity was the least for the mix register at every fundamental frequency. The first and second harmonic (H1-H2) difference of the voice source spectrum was the greatest for the falsetto, then the mix, and finally, the chest.ConclusionsWe found differences in the registers in terms of the aeromechanical mechanisms and vibration patterns of the vocal folds. The mixed register proved to have a distinct voice-production mechanism, which can be differentiated from those of the chest or falsetto registers.     

Effects of Muscle Tension Dysphonia on Tone Phonation: Acoustic and Perceptual Studies in Vietnamese Female Teachers

Muscle tension dysphonia (MTD) is a hyperfunctional voice disorder commonly seen in professional voice users. To date, published acoustic studies of this disorder have mainly focused on nontonal language speakers, and no publication has documented its impact on lexical tone characteristics. In this study, we examined whether and how this voice disorder affected acoustically and perceptually the characteristics of tones in Vietnamese teachers. Voice data were obtained from 42 Vietnamese female primary school teachers diagnosed with MTD and 30 vocally healthy teachers. Tonal data were analyzed using Computerized Speech Lab (CSL-4300B) and Speech Analyzer. Parameters analyzed included the two most important acoustic cues in Vietnamese tones, that is, tonal fundamental frequency (F₀) and laryngealization. Tonal F₀ was assessed using a factorial analysis of variance with group and career durations as independent variables. Tonal samples were also perceptually assessed by a panel of native speakers of the same dialect. The results showed that MTD lowered tonal F₀ in high tones and tones with extensive fundamental frequency variation. There was also a significant main effect for career duration; in MTD group, tonal F₀ was lower in teachers with longer career duration. The teachers with MTD showed different patterns of laryngealization compared with the control group. Tone perception was poorer for tones with extensive fundamental frequency variation and without a typical phonation type. The results in this group of teachers supported our hypothesis that MTD impairs lexical tone phonation.     

Comparing closed quotient in children singers' voices as measured by high-speed-imaging, electroglottography, and inverse filtering

The closed quotient, i.e., the ratio between the closed phase and the period, is commonly studied in voice research. However, the term may refer to measures derived from different methods, such as inverse filtering, electroglottography or high-speed digital imaging (HSDI). This investigation compares closed quotient data measured by these three methods in two boy singers. Each singer produced sustained tones on two different pitches and a glissando. Audio, electroglottographic signal (EGG), and HSDI were recorded simultaneously. The audio signal was inverse filtered by means of the decap program; the closed phase was defined as the flat minimum portion of the flow glottogram. Glottal area was automatically measured in the high speed images by the built-in camera software, and the closed phase was defined as the flat minimum portion of the area-signal. The EGG-signal was analyzed in four different ways using the matlab open quotient interface. The closed quotient data taken from the EGG were found to be considerably higher than those obtained from inverse filtering. Also, substantial differences were found between the closed quotient derived from HSDI and those derived from inverse filtering. The findings illustrate the importance of distinguishing between these quotients.     

Diplophonia reappraised

The acoustic structure of diplophonia was investigated spectrographically and in terms of perturbation measures, while the perception of diplophonia among other voice qualities was confirmed auditorily by trained listeners. Recordings of pathological voices were presented to listeners for systematic evaluation, and narrowband spectrography was used to quantify the subharmonics within each sample. Subharmonics strongly correlated with the perception of diplophonia, but occurrence was mostly intermittent, and structure was highly variable between samples. Uniquely among voice qualities identified perceptually, diplophonia was found to correlate positively with the number of subharmonics (irrespective of percentage of occurrence) and with perturbation parameters measured separately. Exceptions to these group results indicated that diplophonia was perceived sometimes in the absence of subharmonic structure, and subharmonic structure was observed without a commensurate perception of diplophonia. In light of these data, a less deterministic relation between diplophonia and subharmonic structure is proposed.     

Neurovegetative symptoms and complaints before and after voice therapy for nonorganic habitual dysphonia

In a previous study, female patients in all age categories with a nonorganic dysphonia were found to report significantly more autonomic symptoms and complaints than healthy controls. This could not be confirmed for the male subgroup. The present study is to corroborate and nuance this observation by investigating larger groups, and to determine if, after voice therapy, the number of autonomic symptoms and complaints-particularly those ones that have no obvious relation to voice function-decreases. It is a prospective study with a matched control group; 184 patients with nonorganic dysphonia and 126 normal controls answered a questionnaire of 46 questions with 3 subsets and a consistency control. One hundred and one patients received functional voice therapy and completed the questionnaire before and after treatment. A matched control group of 42 normal subjects also filled in the questionnaire two times, with an interval of about 6 months. Neurovegetative symptoms and complaints-voice related and not related-are reported in highly significant excess by patients (especially but not exclusively females) with habitual nonorganic voice disorder. After therapy, there is a highly significant reduction in the number of autonomic symptoms and complaints (related or not related to voice), to such an extent that patients report on average no more general neurovegetative symptoms and complaints than healthy controls (even less). The number of neurovegetative symptoms and complaints connected with voice function is also strongly reduced in patients after therapy, but remains in significant excess when compared with controls.     

Acoustic Analysis of Voice Quality with or without False Vocal Fold Displacement After Cordectomy

Conventional cordectomy by means of a laryngofissure is one of the therapeutic options for treatment of early glottic cancer. To improve the poor voice quality related to this kind of operation, many authors have developed different techniques to repair the mucosal defect. We analyzed voice quality acoustically and compared it after cordectomy alone and after cordectomy with the reconstruction of the vocal cord in a group of 14 patients affected by T1 glottic carcinoma. All the patients underwent postoperative speech therapy. Three patients who underwent cordectomy with reconstruction showed the presence of diplophonia, while two patients without reconstruction showed the presence of bitonality. The differences of the acoustic parameters (jitter, shimmer, harmonic-to-noise ratio) between the two groups of patients were not statistically significant. Reconstruction of the vocal cord does not seem to improve voice quality after cordectomy even in combination with postoperative speech therapy.     

Effects of lung volume on the glottal voice source

According to experience in voice therapy and singing pedagogy, breathing habits can be used to modify phonation, although this relationship has never been experimentally demonstrated. In the present investigation we examine if lung volume affects phonation. Twenty-four untrained subjects phonated at different pitches and degrees of vocal loudness at different lung volumes. Mean subglottal pressure was measured and voice source characteristics were analyzed by inverse filtering. The main results were that with decreasing lung volume, the closed quotient increased, while subglottal pressure, peak-to-peak flow amplitude, and glottal leakage tended to decrease. In addition, some estimates of the amount of the glottal adduction force component were examined. Possible explanations of the findings are discussed.     

Membranous and cartilaginous vocal fold adduction in singing

While vocal fold adduction is an important parameter in speech, relatively little has been known on the adjustment of the vocal fold adduction in singing. This study investigates the possibility of separate adjustments of cartilaginous and membranous vocal fold adduction in singing. Six female and seven male subjects, singers and non-singers, were asked to imitate an instructor in producing four phonation types: "aBducted falsetto" (FaB), "aDducted falsetto" (FaD), "aBducted Chest" (CaB), and "aDducted Chest" (CaD). The phonations were evaluated using videostroboscopy, videokymography (VKG), electroglottography (EGG), and audio recordings. All the subjects showed less posterior (cartilaginous) vocal fold adduction in phonation types FaB and CaB than in FaD and CaD, and less membranous vocal fold adduction (smaller closed quotient) in FaB and FaD than in CaB and CaD. The findings indicate that the exercises enabled the singers to separately manipulate (a) cartilaginous adduction and (b) membranous medialization of the glottis though vocal fold bulging. Membranous adduction (monitored via videokymographic closed quotient) was influenced by both membranous medialization and cartilaginous adduction. Individual control over these types of vocal fold adjustments allows singers to create different vocal timbres.     

Psychogenic spasmodic dysphonia: A case study with expert opinions

Spasmodic (spastic) dysphonia (SD) is considered by some to be a neurologic syndrome and by others a symptom complex of multiple etiologies, neurologic and psychogenic. A case of a 26-year-old female psychiatric nurse with psychogenic SD (PSD) is presented. The dysphonia was alleviated within one session of voice therapy. Psychogenic etiology was established by the author, based on three diagnostic criteria—symptom incongruity, symptom reversibility, and symptom psychogenicity. Seven nationally recognized voice experts listened to audio-recorded samples of the patient's pre- and posttherapy voice during conversational speech. The experts agreed that the dysphonia was psychogenic and characterized it as staccato-like speech, effortful phonation, and interrupted flow of speech; six characterized it with intermittent voice arrests (voice stoppages); five with hoarse-harsh voice; and four with waxing and waning, strained-strangled phonation. These are often described as salient features of SD. Nevertheless, the experts disagreed among themselves as to whether the dysphonia was characteristic of SD and should be labeled as such. The author argues that as long as the voice characteristics and pathophysiologic findings that constitute SD are not well delineated, and as long as the diagnosis of SD is based on symptoms alone, patients with psychogenic or poorly understood voice disorders are likely to be misdiagnosed with organic (neurologic) SD and thus subjected to undue medical treatment. The author also argues that the debate over the etiology of SD can be resolved if SD is considered a neurologic syndrome, PSD a nonorganic phonatory disorder that mimics the syndrome, and if the voice symptoms and pathophysiologic characteristics of SD are well defined and agreed on.     

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.     

Reliability of calculating the cepstral peak without linear regression analysis

Measures of cepstral peak prominence, using the smoothing algorithm and linear regression analysis software developed by Hillenbrand, have been shown to be reliable predictors of dysphonia in voice samples.(1-4) Recently, the Computerized Speech Laboratory [(CSL) Kay Elemetrics, Pinebrook, New Jersey] has introduced cepstral analysis as a component of that software package. The cepstral peak, in this instance, is calculated by the voice clinician analyzing the phonatory sample by subtracting the value of the peak from the apparent baseline signal. This study compares the ability of cepstral peak values calculated from the CSL software to predict dysphonia reliably with that of the values produced by the smoothing algorithm and linear regression analysis of Hillenbrand. The results of this study show that linear regression analysis is an important step in calculating the cepstral peak prominence, thus limiting the usefulness of software programs that do not employ this step.     

Voice Therapy Improves Quality of Life in Age-Related Dysphonia: A Case-Control Study

The objective of the study is to determine the efficacy of voice therapy in the treatment of age-related dysphonia. The study was conducted using a retrospective case-control chart review. The medical records of 54 patients older than 60 years diagnosed with age-related dysphonia without complicating diagnoses were reviewed. Patients who chose to undergo voice therapy were grouped as cases. Patients who chose not to undergo voice therapy were grouped as controls. The voice-related quality of life (VRQOL) measure was used to measure outcomes before and after treatment in cases and at a minimum 2-month follow-up in controls. Of the 54 patients, 19 (10 female, 9 male; mean age 73 years) chose to undergo voice therapy and filled in >1 VRQOL questionnaire. Six patients (3 female, 3 male; mean age 66 years) chose not to undergo voice therapy and filled in >1 VRQOL questionnaire. The 19 cases experienced a mean improvement in VRQOL score of 19.21 (2-tailed matched pairs t test P=0.00038) after a mean of 4.1 voice therapy sessions and 5.1 months. The six controls experienced a mean change in VRQOL score of 0.42 (2-tailed matched pairs t test P=0.96) after a mean of 3.3 months. Voice therapy leads to statistically significant improvement in the VRQOL life in elderly patients with age-related dysphonia. It is an efficacious noninvasive therapy for this disease.     

Laryngeal electromyographic responses to perturbations in voice pitch auditory feedback

The present study was conducted to test the hypothesis that intrinsic laryngeal muscles are involved in producing voice fundamental frequency (F(0)) responses to perturbations in voice pitch auditory feedback. Electromyography (EMG) recordings of the cricothyroid and thyroarytenoid muscles were made with hooked-wire electrodes, while subjects sustained vowel phonations at three different voice F(0) levels (conversational, high pitch in head register, and falsetto register) and received randomized pitch shifts (±100 or ±300 cents) in their voice auditory feedback. The median latencies from stimulus onset to the peak in the EMG and voice F(0) responses were 167 and 224 ms, respectively. Among the three different F(0) levels, the falsetto register produced compensatory EMG responses that occurred prior to vocal responses and increased along with rising voice F(0) responses and decreased for falling F(0) responses. For the conversational and high voice levels, the EMG response timing was more variable than in the falsetto voice, and changes in EMG activity with relevance to the vocal responses did not follow the consistent trend observed in the falsetto condition. The data from the falsetto condition suggest that both the cricothyroid and thyroarytenoid muscles are involved in generating the compensatory vocal responses to pitch-shifted voice feedback.