Spread of dystonia in patients with idiopathic adult-onset laryngeal dystonia.

BACKGROUND AND PURPOSE: Adult-onset laryngeal dystonia (LD) can be isolated or can be associated with dystonia in other body parts. Combined forms can be segmental at the onset or can result from dystonia spread to or from the larynx. The aim of this study was to identify the main clinical and demographic features of adult-onset idiopathic LD in an Italian population with special focus on dystonia spread. METHODS: Data were obtained from the Italian Dystonia Registry (IDR) produced by 37 Italian institutions. Clinical and demographic data of 71 patients with idiopathic adult-onset LD were extracted from a pool of 1131 subjects included in the IDR. RESULTS: Fifty of 71 patients presented a laryngeal focal onset; the remaining subjects had onset in other body regions and later laryngeal spread. The two groups did not show significant differences of demographic features. 32% of patients with laryngeal onset reported spread to contiguous body regions afterwards and in most cases (12 of 16 subjects) dystonia started to spread within 1 year from the onset. LD patients who remained focal and those who had dystonia spread did not show other differences. CONCLUSIONS: Data from IDR show that dystonic patients with focal laryngeal onset will present spread in almost one-third of cases. Spread from the larynx occurs early and is directed to contiguous body regions showing similarities with clinical progression of blepharospasm. This study gives a new accurate description of LD phenomenology that may contribute to improving the comprehension of dystonia pathophysiology.

Spasmodic dysphonia follow-up with videolaryngoscopy and voice spectrography during treatment with botulinum toxin.

Spasmodic dysphonia (SD) is a focal dystonia of laryngeal muscles seriously impairing quality of voice. Adductor SD (ADSD) is the most common presentation of this disorder that can be identified by specialized phoniatricians and neurologists firstly on a clinical evaluation and then confirmed by videolaryngoscopy (VL). Botulinum toxin (BTX) injection with electromyographic guidance in muscles around vocal cords is the most effective treatment. Voice Handicap Index (VHI) questionnaire is the main tool to assess dysphonia and response to treatment. Objective of this study is to perform VL and voice spectrography (VS) to confirm the efficacy of BTX injections over time. 13 patients with ADSD were studied with VHI, VL and VS before and after 4 consecutive treatment with onobotulinumtoxin-A. For each treatment vocal improvement was proved by a significant reduction of VHI score and increase of maximum time phonation and harmonic-to-noise ratio while VL showed the absence of spasm in most of patients. No change of the response to BTX was found between injections. This study supports the efficacy of the treatment of SD with BTX with objective measurements and suggests that the efficacy of recurring treatments is stable over time.

Qualitative and quantitative measurement of the singing voice.

OBJECTIVE: The aim of the study was to clarify the mechanisms underlying the singing voice. PATIENTS AND METHODS: Forty-eight professional opera singers underwent flexible and rigid endoscopy, spectrographic analysis and perceptual evaluation. RESULTS: The data provided by voice analysis were not as clear and relevant to the aim of our study as those commonly obtained for speech evaluation. Laryngoscopy with rigid and flexible fiber optics and the singing power ratio (SPR) measurement provided more applicable data. Indeed, the former allowed us to assess laryngeal position, the glottic pattern and vocal tract modifications during the actual singing performance. The latter, already recommended by other authors as a reliable vocal emission index, also yielded more relevant information in comparison with the assessment of voice quality. Specifically, SPR provided data directly correlated to both the years of singing activity and the vocal category of each singer (the higher the singing pitch, the wider the vocal extension). More importantly, the data fully reflected the subjective assessment of each phoniatrician. CONCLUSIONS: We suggest that the SPR indices can be used as the electroacoustic equivalent of the subjective judgment of vocal focus.

Functional vocal results after CO2 laser endoscopic surgery for glottic tumours.

INTRODUCTION: Vocal results after endoscopic cordectomy have not yet been well defined. The aim of this study was to assess the vocal function of patients who had undergone CO2 laser cordectomy. DESIGN: Retrospective, observational and control group study, conducted in a tertiary care medical department. METHODS: One hundred and thirty-five male patients (age range 36-83 years) underwent different types of endoscopic cordectomy. Forty age-matched, euphonic male subjects were selected as controls. Patients were classified according to the main site of the phonatory neo-glottis. Outcome measures were maximum phonation time, vocal intensity and harmonic/noise ratio. Mann-Whitney and rank Spearman tests were used for statistical analysis. RESULTS: Findings indicated statistically significant differences for all parameters, comparing patients and controls (p<0.001), and a direct positive relation between type of functional compensation and outcome measures in the study patients (p<0.001). CONCLUSIONS: The results indicate that functional compensation and outcome measures were related, and that no functional compensation enabled the study patients to achieve a voice quality comparable with that of controls.

Dysphonia and laryngopharyngeal reflux.

The correlation between laryngo-pharyngeal reflux and dysphonia has been evaluated in patients without significant laryngoscopic findings and without vocal misuse. Studies were performed, using a validated questionnaire on typical reflux symptoms as well as instrumental means, e.g. videolaryngoscopy, multi-electrode 24-hr oesophageal pH monitoring, vocal acoustic analysis, gastro-oesophagoscopy, on 62 patients (51 male, 11 female) with dysphonia for > or = 3 months, selected from 350) consecutive patients presenting with voice disorders. Standard criteria were: absence of laryngeal neoformation (benign or malignant) and correct use of voice. Anti-reflux treatment was prescribed in all selected patients. A group of 62 selected patients without laryngo-pharyngeal disease were studied as controls. Mean values of the harmonic to noise ratio and maximum phonation time were pathological in all patients with dysphonia and significantly correlated (p = 0) with the entity of the larynx alteration. The 24-hour pH monitoring revealed gastro-oesophageal reflux in all cases with a clear prevalence of episodes in the upright, compared to supine, position. From a multiple regression analysis of pH-metric values, considered important in predicting maximum phonation time and harmonic to noise ratio alteration. the significant predictors (p < 0.01) were those parameters indicating the existence of a laryngo-pharyngeal reflux disease: in an upright position, the prevalence of the number of refluxes and of time of pH < 4. In conclusion, the association between electro-acoustic reliefs and laryngoscopic data, as well as an alteration in maximum phonation time and harmonic to noise ratio in patients with pH-metric indicative parameters of laryngo-pharyngeal reflux disease led to the hypothesis of a possible correlation between entity and duration of the reflux and dysfunction of the arytenoid muscles, upon which chronic vocal fatigue, with consequent laryngeal compensatory stress, depends.

Montgomery thyroplasty. Case report focusing on endoscopic and functional findings.

The case is described of a 58-year-old male with cord paralysis submitted to Montgomery thyroplasty, attention being focused on the electro-acoustical findings. The usefulness is underlined of these indices which provide the opportunity to establish the phonatory advantages and results of this surgical procedure: Videolaryngostroboscopy and spectrographic analyses were carried out before and after surgery. Phonatory results were, in fact, evaluable 24 hours after surgery and found to be excellent whereas the perceptive evaluation and subjective symptoms were seen to be comparable to those in normal subjects one week after surgery.

Aerodynamic study of velopharyngeal insufficiency before and after logopedic treatment.

The aerodynamic bases of articulatory defects which characterize velopharyngeal insufficiency are not yet well defined. The purpose of our investigation has been to establish the type and the severity of aerodynamic alterations correlated with this syndrome before and after logopedic treatment; thus we have exposed the phoneme magnitude of pi:/, produced by 20 control individuals and by 12 patients with velopharyngeal insufficiency, to an aerodynamic study by means of a computerized system (Aerophone II, FJ Electronics) able to record, at the same time, phonatory airflow, intraoral pressure, and sound intensity. The data collected were subjected to statistical analysis by using Student's t test. The results obtained before logopedic treatment documented: (1) a remarkable articulatory distortion during the implosion of magnitude of p by a two-phasic pressure wave with a reduced amplitude compared to the one registered in control group subjects (7.3 +/- 2.8 cm H2O vs. 10.9 +/- 2.7 cm H2O; mean +/- SD; p < 0.01); (2) the presence of a nasal airflow in this same phase (0.13 +/- 0.07 liters/s); (3) peak airflow relative to the explosion of magnitude of p inferior to the one recorded in the control group (0.41 +/- 0.08 liters/s vs. 0.57 +/- 0.11 liters/s; p < 0.01); (4) a mean ratio between the duration of the implosive phase of magnitude of p and that of whole articulatory cycle inferior to the value recorded in the control group (34.8 +/- 2.6% vs. 39.2 +/- 2.3%; p < 0.01). At the end of logopedic treatment the aerodynamic investigation allowed to correlate the improvement of the speech defects due to rehabilitation to precise aerodynamic data: (1) a monophasic pressure wave with a peak (14.9 +/- 4.7 cm H2O) that is higher than the one observed in the control group (p < 0.01) and the one observed in the control group (p < 0.01) and the one observed in patients before therapy (p < 0.01); (2) a significant reduction of the nasal airflow recorded before logopedic treatment (0.04 +/- 0.04 liters/s; p < 0.01); (3) a remarkable increase in peak airflow compared to the one recorded before logopedic treatment (0.93 +/- 0.25 liters/s; p < 0.01); (4) a further reduction of the mean percentage ratio between the duration of the implosive phase of magnitude of p and that of the whole articulatory cycle (29.2 +/- 2.0%; p < 0.01) as compared to the one recorded before logopedic treatment. The results of our investigation underline how many different aerodynamic factors are involved in the pathogenesis of articulatory defects of speech related to velopharyngeal insufficiency, and how they reciprocally interfere; furthermore, our data indicate that logopedic treatment does not always restore physiological conditions, but often facilitates the realization of particular articulatory strategies which are not found in normal conditions.

[Esophageal voice: a critical analysis of the results obtained by different rehabilitative technics]. / La voce esofagea: analisi critica dei risultati ottenuti con varie tecniche riabilitative.

In order to evaluate the phonatory results obtained with the use of tracheoesophageal prostheses, 38 laryngectomees were examined, 20 of which underwent erigmophonic voice rehabilitation while the other 18 were rehabilitated with the application of a prosthesis. In all cases electroglottography and spectrography of the voice were performed. In the erigmophonic-voice subjects, electroglottography gave a normal glottic wave while spectrography gave a tracing with frequent interruptions, scarce harmonics, altered by the presence of background noises. In the tracheoesophageal prosthesis patients, the electroglottogram showed regular hypopharynx vibratory activity while the spectrogram appeared free of interruptions activity while the spectrogram appeared free of interruptions and presented a uniform distributions and presented a uniform distribution of suffixes. The data obtained demonstrate that better results are obtained with the use of tracheoesophageal prosthesis as it allows the exhaled air to be used in phonation and thus respects respiratory dynamics and pneumophonic synergism. It also makes it possible to achieve a clear, fluent voice. Furthermore, the results obtained with patients with this prosthesis were constantly satisfactory when the long exercises required were performed.

[The use of Phonagel in glottic insufficiency]. / L'impiego del Phonagel nelle insufficienze glottiche.

The authors describe their experience concerning collagen implantation in case of glottic insufficiency after cordectomy by the CO2 Laser. Three different kinds of injection are indicated as follows: injection of 3/4 of collagen in the site responding to vocal fold removal on 1/4 in the survival fold after cordectomy with conservation of the thyroarytenoid muscle; implantation of 1/2 in the new fold and 1/2 in the surviving one after cordectomy with removing of the cricoarytenoid muscle; infiltration of the whole material in the residual vocal fold after cordectomy enlarged to the false vocal fold and the ventricule as well. Video laryngoscopic and spectrographic examinations documented good phonatory results after collagen implantation in 19 cases over 21; two cases had a persisting insufficiency depending on the fact they had been previously operated of enlarged cordectomy and the scar tissue was not sufficient for measures and consistency to obtain a satisfactory injection of collagen.