Speech disorder and vocal tremor in postural instability/gait difficulty and tremor dominant subtypes of Parkinson's disease.

Hypokinetic dysarthria is a multidimensional impairment affecting all main speech subsystems with variable patterns and severity across individual Parkinson's disease (PD) patients. We can thus assume that inter-individual abnormal speech patterns are related to the various clinical subtypes of PD with different prominent motor symptoms. The aim of this cross-sectional study was to compare speech disorder between patients with the postural instability/gait difficulty (PIGD) and tremor-dominant (TD) motor phenotypes of PD. Speech samples were acquired from a total of 63 participants, including 21 PIGD patients, 21 TD patients, and 21 healthy controls. Quantitative acoustic vocal assessment of 12 unique speech dimensions related to phonation, vocal tremor, oral diadochokinesis, articulation, prosody and speech timing was performed. Speech impairment was more pronounced in the PIGD group than in the TD group, with an area under the curve of 0.76. Patients in the PIGD group manifested abnormalities in pitch breaks, articulatory decay, decreased rate of follow-up speech segments and inappropriate silences, apart from monopitch and irregular AMR that were affected in TD group as well. An abnormal vocal tremor was present in only 10% of PD patients, with no differences between the PD phenotypes. We found a correlation between non-motor symptom severity and speech timing (r = - 0.40, p = 0.009). The present study demonstrates that speech disorder reflects the underlying motor phenotypes. Vocal tremor appeared to be an isolated phenomenon that does not share similar pathophysiology with limb tremor.

Thalamic Deep Brain Stimulation for Essential Tremor Also Reduces Voice Tremor.

OBJECTIVE: Voice tremor is a common feature of essential tremor (ET) that is difficult to treat medically and significantly affects quality of life. Deep brain stimulation (DBS) of the ventral intermediate nucleus (Vim) of the thalamus is effective in improving contralateral distal limb tremor and has been shown in limited studies to affect voice tremor. Our objective was to retrospectively evaluate whether Vim-DBS used to treat patients with essential motor tremor also effectively treated underlying concurrent voice tremor and assess whether particular lead locations were favorable for treating vocal tremor. MATERIALS AND METHODS: In this retrospective cohort study, patients had unilateral or bilateral lead placement and were monitored for up to 12 months. We used the Fahn-Tolosa-Marin (FTM) subscore to assess vocal tremor. Changes in vocal tremor before and after stimulation and over several sessions were assessed. RESULTS: Of the 77 patients who met the inclusion criteria and were treated for essential tremor, 20 (26%) patients had vocal tremor prior to stimulation. Active Vim-DBS decreased the amplitude of voice tremor by 80% (p < 0.001). The mean FTM score as 1.24 pre-operation, 1.08 post-implantation (consistent with a lesion effect), and 0.25 with stimulation. The effect magnitude was maintained at last follow-up with slight improvement over time (p < 0.05). Unilateral and bilateral stimulation resulted in similar degrees of tremor reduction. A model of the centroid of stimulation showed that Vim thalamic stimulation that is more anterior on average yielded better voice tremor control, significantly so on the left side (p < 0.05). Additionally, there was improvement in head, tongue, and face tremor scores (p < 0.05). CONCLUSIONS: Unilateral and bilateral Vim-DBS targeted to treat the motor component of essential tremor also dramatically decreased the amplitude of voice tremor in this group of patients, suggesting a potential benefit of this treatment for affected patients.

Deep brain stimulation for vocal tremor: a comprehensive, multidisciplinary methodology.

Tremulous voice is a characteristic feature of a multitude of movement disorders, but when it occurs in individuals diagnosed with essential tremor, it is referred to as essential vocal tremor (EVT). For individuals with EVT, their tremulous voice is associated with significant social embarrassment and in severe cases may result in the discontinuation of employment and hobbies. Management of EVT is extremely difficult, and current behavioral and medical interventions for vocal tremor result in suboptimal outcomes. Deep brain stimulation (DBS) has been proposed as a potential therapeutic avenue for EVT, but few studies can be identified that have systematically examined improvements in EVT following DBS. The authors describe a case of awake bilateral DBS targeting the ventral intermediate nucleus for a patient suffering from severe voice and arm tremor. They also present their comprehensive, multidisciplinary methodology for definitive treatment of EVT via DBS. To the authors' knowledge, this is the first time comprehensive intraoperative voice evaluation has been used to guide microelectrode/stimulator placement, as well as the first time that standard pre- and post-DBS assessments have been conducted, demonstrating the efficacy of this tailored DBS approach.

Tremor Makes a Difference: A Comparative Study of the Demographics and Treatment Outcomes in Patients With Adductor Spasmodic Dysphonia With or Without Vocal Tremor.

OBJECTIVES: This study aims to evaluate the demographic differences between those with adductor spasmodic dysphonia with vocal tremor (AdSD(+)VT) and those without vocal tremor (AdSD(-)VT) and to analyze their response to treatment with botulinum neurotoxin (BoNT-A). STUDY DESIGN: Retrospective cohort study. METHODS: A database review of all spasmodic dysphonia patients treated with BoNT from 1989 to 2018 at the Mayo Clinic in Arizona was performed. Only patients who had received ≥4 injections of BoNT-A for AdSD were included. Patients were divided into two cohorts: those with coexistent vocal tremor (AdSD(+)VT) and those without vocal tremor (AdSD(-)VT). RESULTS: The final analysis included 398 patients, with 210 AdSD(+)VT patients (53%) and 188 AdSD(-)VT patients (47%). The length of follow-up and median number of treatments were similar between cohorts. AdSD(+)VT patients were more likely to be female (P < 0.001), and older at onset (P < 0.001) and first injection (P < 0.001). The mean maximal benefit was significantly lower for the AdSD(+)VT cohort (P < 0.01), however the mean length of benefit was similar (P = 0.70). CONCLUSIONS: Demographic differences exist between AdSD(+)VT and AdSD(-)VT patients. AdSD(+)VT patients benefit from BoNT-A treatment; however, our analysis suggests that the degree of their maximal benefit is less than in those without VT.

Assessing and Improving the Effectiveness of Online Patient Education Materials on Essential Vocal Tremor: A Comprehensive Evaluation.

INTRODUCTION: Health literacy, a strong indicator of health outcomes, is an important aspect of good patient care. With an increasing reliance on the Internet for health information, online patient materials should be easily understood by the average reader. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that patient education materials be written at a sixth-grade level. Creating effective digital information requires careful consideration of not only word choice, but also many other factors including actionability, comprehensiveness, evidence, and visual organization. To support the creation of valuable online health content, the Office of Disease Prevention and Health Promotion (ODPHP) published Health Literacy Online, a research-based guide that discusses why and how to design digital health information tools.This study aims to assess the effectiveness of online patient education materials regarding vocal tremor, assess the effectiveness of patient education materials published by the American Laryngological Association, and to evaluate the usefulness of the Health Literacy Online guide in creating effective online patient education materials on laryngological diseases. METHODS: The first 50 unsponsored search results for the terms "vocal tremor" and "essential vocal tremor" were evaluated. Each website was analyzed using the Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) readability tests, the DISCERN instrument, and the Patient Education Materials Assessment Tool (PEMAT). The resources published by the American Laryngological Association were also evaluated in this manner. RESULTS: Of the 100 websites identified from the initial queries, 14 websites were included in this analysis. The average FRES and FKGL scores were 47.21 ± 10.47 and 10.96 ± 2.46, respectively, indicating that readers need a 11th-grade education to comprehend the materials. The average DISCERN score was 22.50 ± 9.76, indicating "very poor" quality with serious shortcomings and not appropriate sources of information about treatment choices. The average PEMAT understandability score was 68.43% ± 9.80% with an actionability score of 20.00% ± 23.53%, indicating the information was fairly difficult to process and do not help identify next steps. For the materials published by the American Laryngological Association (ALA), the average FRES and FKGL scores were 38.33 ± 12.81 and 12.56 ± 2.15, respectively, indicating a 12th-grade reading level. A DISCERN score of 27 was consistent across each item, indicating "very poor" quality. A PEMAT understandability score was 45% with an actionability score of 0%, indicating they are difficult to process and do not help identify next steps. After writing a revised sample of the information provided by the ALA based on the ODPHP's Health Literacy Online tool, the new FRES and FKGL score was 75.6 and 5.9, respectively. The new DISCERN score was 35. The new PEMAT understandability scores was 79% with actionability scores of 80%. CONCLUSION: This study found that most publicly available online patient education materials on essential vocal tremor and other laryngological diseases do not use plain language and require reading levels too advanced for the average reader to comprehend. In addition, most websites were of very poor quality readability, and were therefore less likely to benefit individuals in their decision-making. In an age where most people seek information on the Internet, the lack of easily understood online patient resources reduces the usefulness of these resources for many individuals. Professional organizations and societies like the American Laryngological Association may consider the use of the Health Literacy Online tool as a resource to provide both accurate and easily understandable patient education resources.

Analgesia in Transcutaneous Laryngeal Botulinum Toxin Injections: A Randomized Crossover Trial.

OBJECTIVES: There is an absence of data in the literature regarding methods to improve the patient experience during the performance of awake in-office laryngeal injections. This study sought to evaluate whether the use of local anesthetic or a vibrating instrument decreased overall pain experienced by patients with laryngeal dystonia, frequently referred to as spasmodic dysphonia (SD), undergoing transcervical botulinum toxin injections. METHODS: This was an unblinded, prospective randomized control trial with a crossover design where each patient received transcutaneous transcricothyroid injection of botulinum toxin with alternating use of no anesthesia, local anesthesia (2% lidocaine in 1:100,000 epinephrine), and vibrating instrument in three consecutive laryngeal injections to treat adductor SD. Patients were randomized to the order they received these treatments. Patients measured pain on a 0-10 visual analogue scale (VAS) and selected their preferred technique after receiving all three analgesic modalities. RESULTS: Thirty-two patients completed the study. There was no statistically significant difference in pain between the three analgesic techniques (p = 0.38). The most preferred analgesic technique was the vibrating wand (44% (14/32)). Lidocaine was the second most preferred (37% (12/32)) and 19% (6/32) of patients preferred nothing. When combining the wand and nothing groups, 63% of patients preferred one of these two methods (95% exact CI: 44%-79%). CONCLUSION: There was no statistically significant difference in median pain experienced by patients during laryngeal botulinum toxin injection between these different analgesic modalities. More than half of the patients selected a preference for a technique that did not include lidocaine. This data supports individualization of analgesia during transcutaneous laryngeal injections. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:2277-2281, 2024.

Voice Improvement After Essential Tremor Treatment via Focused Ultrasound and Deep Brain Stimulation.

OBJECTIVES: The primary objective of this study was to determine whether two neurosurgical procedures, deep brain stimulation (DBS) and focused ultrasound (FUS), to treat essential tremor (ET) of the upper limb also reduce vocal tremor (VT) in patients with comorbid dysphonia. METHODS: Twelve patients with ET and concomitant VT scheduled for neurosurgical intervention (FUS or DBS) or returning for follow-up after DBS implantation were assessed. FUS patients were assessed pre- and post-intervention and DBS patients were assessed with the electrodes turned on and off post-implantation. Three voice recordings of a sustained /a/ were obtained for each participant condition. Percent fundamental frequency variability (FFV) was calculated for each recorded sustained vowel. Additionally, blinded expert perceptual VT rating (VTR) was performed to assess subjective changes in tremors. RESULTS: Of the 12 patients, seven underwent unilateral FUS, and five underwent bilateral DBS. Mean FFV without neurosurgical intervention was 18.3%, SD = 7.8 and with neurosurgical intervention was 6.3%, SD = 3.0 (t (70) =8.7, p < 0.001). Mean FFV decreased in the FUS cohort from 22.0%, SD = 7.1 pre-ablation to 6.7%, SD = 2.4 post-ablation (t (40) = 7.7, p < 0.001). Mean FFV also decreased in the DBS cohort from 15.7%, SD = 7.0 to 6.0%, SD = 3.3 when stimulation was turned on (t (28)=5.7 p < 0.001). In the FUS group, mean VTR decreased from 4.0 to 1.4 post-ablation (Z = 7.8, p < 0.001). In the DBS group, mean VTR decreased from 3.3 to 2.1 with stimulation (Z = 4.1, p < 0.001). CONCLUSION: Neurosurgical interventions for ET (bilateral DBS and unilateral FUS) demonstrate acoustic and perceptual benefits for VT. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:367-373, 2024.

Treatment of vocal tremor with bilateral magnetic resonance imaging-guided focused ultrasound of the ventral intermediate thalamic nucleus: illustrative case.

BACKGROUND: Essential vocal tremor is a difficult disease entity to treat with a poor response to existing medical management and limited options for surgical management of the disease. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an emerging treatment modality with encouraging results for limb tremor in patients with essential tremor, but data are limited for the treatment of vocal tremor. OBSERVATIONS: This is the case of a 69-year-old male with a history of essential vocal tremor severely limiting his ability to perform his occupation as an opera singer. He underwent staged bilateral ventral intermediate nucleus of the thalamus thalamotomy with MRgFUS for the treatment of his bilateral upper extremity tremor with near complete resolution of his vocal tremor after a second procedure. LESSONS: Bilateral MRgFUS may be a safe and efficacious option for the treatment of essential vocal tremor. Further research into optimal patient selection, precise target location, and treatment parameters is needed.

Voice-Related Outcomes in Deep Brain Stimulation in Patients with Vocal Tremor: A Systematic Review and Meta-Analysis.

OBJECTIVES: The effectiveness of deep brain stimulation (DBS) in treating vocal tremors is currently a subject of debate. To assess the efficacy of DBS therapy in adults with vocal tremors (VT), we analyzed its impact on voice tremor severity, voice-related quality of life, fundamental frequency, voice intensity, and emotional state. METHODS: We conducted a systematic review with meta-analysis to investigate the impact of DBS therapy on voice tremor severity, voice-related quality of life, fundamental frequency, voice intensity, and emotional state in adults with vocal tremors (PROSPERO/CRD42023420272). The PubMed, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials databases were searched up to September 20, 2022. Primary outcome measures included voice tremor severity and voice-related quality of life (V-RQOL), while fundamental frequency (F0) and voice intensity, along with emotional state, were selected as secondary outcome indicators. We employed the Cochrane Collaboration's tool for assessing bias risk in randomized trials. Meta-analysis (standardized difference of means and weighted mean differences) and heterogeneity analysis (I2) were performed. RESULTS: Our search identified 1186 studies, of which nine studies involving 61 patients met the inclusion criteria. The severity of voice tremor (SMD = -1.08; 95% CI: -1.80 to 0.35; P = 0.02) and V-RQOL (SMD = -1.39; 95% CI: -2.68 to -0.09; P = 0.04) in patients with vocal tremor significantly improved after DBS "on". Subgroup analyses revealed that the stimulation site may contribute to high heterogeneity. Specifically, Vim DBS showed significant improvement in voice tremor severity (SMD = -0.97; 95% CI: -1.84 to -0.09; I2 = 51.01%), while STN DBS did not demonstrate a clear benefit in addressing vocal tremor. There was no significant difference between DBS "on" and DBS "off" in terms of F0, voice intensity, or emotional status. CONCLUSION: DBS therapy is effective in enhancing voice quality and voice-related quality of life in patients with vocal tremors. Notably, Vim DBS demonstrates a significant improvement in voice tremor severity, particularly in VT patients with ET and SD.

Behavioral Therapy for Tremor or Dystonia Affecting Voice in Speakers with Hyperkinetic Dysarthria: A Systematic Review.

INTRODUCTION: Hyperkinetic dysarthria is characterized by atypical involuntary movements within the speech mechanism that may affect the respiratory, laryngeal, pharyngeal-oral, or velopharyngeal-nasal subsystems and may alter speech production. Although articulatory impairments are commonly considered in hyperkinetic dysarthria, speakers with hyperkinetic dysarthria may also present with changes in voice quality, pitch, and loudness. In approximately 70% of speakers with hyperkinetic dysarthria, these voice alterations are associated with tremor or dystonia. The purpose of this systematic review was to investigate the association between behavioral therapy for tremor or dystonia affecting voice in speakers with hyperkinetic dysarthria and improvement in the functional, perceptual, acoustical, aerodynamic, or endoscopic characteristics of voice. METHOD: MEDLINE (PubMed), Embase, PsycINFO, and ClinicalTrials.gov online databases were searched in August 2017, December 2018, and April 2020 for relevant studies. The searches provided 4,921 unique records, and six additional unique records were added from other sources. Twelve studies met the criteria for inclusion in the systematic review. Participants who received concurrent medical treatment were included in this review to ensure that the search was inclusive of all relevant studies and informative for typical clinical scenarios. RESULTS: The most commonly administered treatment ingredient was relaxation training, which was investigated in three of the four studies on tremor and three of the eight studies on dystonia. Of these six studies, only one used an experimental design and administered relaxation training as the only behavioral approach. This single-case experiment reported a significant reduction in participant ratings of tremor severity and interference with activities of daily living, although the speaking subscale reportedly did not improve and oral medications were administered concurrently. In two group studies that tested potential behavioral therapy targets, production of a low pitch improved acoustical measures for participants with essential tremor and improved auditory-perceptual judgments for participants with laryngeal dystonia. Behavioral therapy improved functional, acoustical, and aerodynamic outcomes in participants with laryngeal dystonia who were also receiving botulinum toxin injections in a randomized cross-over study and a non-randomized controlled study. Because one study employed easy onset and breathing exercises, while the other employed loud voice exercises, the mechanism of action for improvement in voice associated with behavioral therapy requires further investigation. CONCLUSION: This systematic review describes the current evidence for treatment of tremor and dystonia affecting voice in speakers with hyperkinetic dysarthria and highlights the need for future research on behavioral therapy for these disorders.

Exploring Patient's Preference of Patient-Reported Outcome Measures in Laryngeal Movement Disorders.

BACKGROUND: Despite many available patient-reported outcome measures (PROMs) for laryngeal movement disorders, there is a lack of patient input regarding which PROM most accurately and conveniently captures aspects related to their vocal disease. This study aimed to assess patients' preferences among a selection of voice-related PROMs (Voice Handicap Index-10 [VHI-10], OMNI-Vocal Effort Scale [OMNI-VES], Communicative Participation Item Bank-General Short Form [CPIB-10], and Visual Analog Scales [VAS]) within the laryngeal movement disorder population and investigate associations between selected instruments. METHODS: Prior to botulinum toxin A injection, patients with laryngeal dystonia and/or essential tremor of the vocal tract were administered the VHI-10, OMNI-VES, CPIB-10, and three novel VAS questions in a randomized order. Patients rank ordered the four PROMs based on the PROMs' reflection of their voice problems. Pearson's correlation coefficients evaluated pairwise associations among PROM scores. Fisher's exact test compared the preferred PROM rankings. RESULTS: Seventy patients (53 female, mean age = 60.7 years) participated. The VHI-10 and CPIB-10 were most preferred at 33.9% and 27.4% respectively. The OMNI-VES and VAS scales were less favored (19.4%, each). When analyzed by age ≥60 years, the CPIB-10 was most favored (33.3%), but for age <60 years, VHI-10 was most preferred (42.3%). There was a strong correlation between scores of all administered PROMs (strongest correlation between OMNI-VES and VAS, r = 0.8, p < 0.001; the weakest correlation between OMNI-VES and VHI-10, r = 0.6, p < 0.001). CONCLUSIONS: With an increasing trend in PROMs usage and a strong correlation between all evaluated outcome instruments, insight regarding patients' PROM preferences is an area for further consideration. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1448-1454, 2023.

Effect of Ventral Intermediate Nucleus Deep Brain Stimulation on Vocal Tremor in Essential Tremor.

Background: There is a paucity of literature examining the effect of Ventral Intermediate Nucleus (VIM) deep brain stimulation (DBS) on voice in patients with vocal tremor (VT). Objective: Investigate the effect of unilateral and bilateral VIM DBS on voice in patients with Essential Tremor (ET) and VT. Methods: All patients receiving VIM DBS surgery underwent voice evaluation pre- and six-months post-operatively. We collected patient-reported quality-of-life outcome measures and acoustic voice measures of sustained phonation and connected speech. Acoustic measures specific to VT included amplitude tremor intensity index (ATRI), frequency tremor intensity index (FTRI), rate and extent of F0 modulation, and rate and extent of intensity modulation. Results: Five patients, age 72.8 ± 2.6 years, 4 female, 1 male with mean disease duration of 29 ± 26.2 years met the inclusion criteria and were included. Two subjects had bilateral procedure and three had unilateral. We observed significant improvements in measures of vocal tremor including ATRI, FTRI, rate of F0 modulation, rate of intensity modulation, and extent of intensity modulation, as well as patient reported voice-related quality of life measured by VHI-10. Bilateral VIM DBS cases showed greater improvement in VT than unilateral cases. Conclusion: Both unilateral and bilateral VIM DBS resulted in significant improvement of VT, with more improvement demonstrated in patients having bilateral as compared to unilateral VIM DBS. In addition, patients also reported significant improvements in voice-related quality of life. If larger studies confirm our results, VIM DBS has the potential to become a treatment specifically for disabling VT.

Breathy Voice as a Compensatory Strategy for Essential Vocal Tremor: A Single Case Experiment Across Participants.

OBJECTIVE: Essential vocal tremor (EVT) manifests as nearly rhythmic modulations of fundamental frequency (fo) and intensity and causes a shaky voice. Although research on behavioral therapy for EVT is limited, previous studies have shown that a breathy voice reduces the perception of simulated EVT and might be an effective compensatory strategy. The current study aimed to measure the acoustical and perceptual effects of a breathy voice strategy in speakers with EVT. STUDY DESIGN: A single-case experimental design (SCED) was used to investigate acoustical effects, and a pair comparison listening task was used to investigate perceptual effects. METHODS: Three participants with EVT matched five different levels of breathiness produced by a computational model. Acoustical analyses of the rate and extent of fo and intensity modulation were performed to estimate EVT severity for baseline and treatment trials. Statistical analyses were completed using Tau-U. Twenty novice listeners participated in the perceptual study to determine if treatment trials sounded less "shaky" than baseline trials. Statistical analyses were completed using one sample t tests. RESULTS: The acoustical effects were variable across different levels of breathiness for all three participants. All participants were able to adjust their levels of breathiness based on auditory models and verbal cues but did not achieve the target levels of breathiness. Listeners did not perceive the breathy trials to be less "shaky" than baseline trials for any level of breathiness. CONCLUSION: The breathy voice strategy had variable effects on the acoustical measures of EVT, supporting the use of a single-case experimental design to investigate the effectiveness of behavioral treatment for EVT. Listeners perceived breathy trials to be "shakier" than baseline trials, which was inconsistent with our hypothesis and previous studies of EVT. Future research should evaluate the use of a breathy voice in speakers with confirmed laryngeal tremor, optimize cueing for breathiness, and provide more opportunities to practice the breathy strategy.

Cannabinoid Use in the Treatment of Laryngeal Dystonia and Vocal Tremor: A Pilot Investigation.

OBJECTIVES/HYPOTHESIS: Laryngeal dystonia and vocal tremor can be debilitating conditions with suboptimal treatment options. Botulinum toxin chemodenervation is typically the first-line treatment and is considered the gold standard. However, patient response to botulinum toxin varies widely. There is anecdotal evidence for the use of cannabinoids in treating laryngeal dystonia with a scarcity of research investigating this potential treatment option. The primary objective of this study is to survey patients with laryngeal dystonia and vocal tremor to gauge how some people are using cannabinoids to treat their condition and to ascertain patient perceptions of cannabinoid effectiveness. STUDY DESIGN: This is a cross-sectional survey study. METHODS: An eight-question anonymous survey was distributed to people with abductor spasmodic dysphonia adductor spasmodic dysphonia, vocal tremor, muscle tension dysphonia, and mixed laryngeal dystonia via the Dysphonia International (formerly National Spasmodic Dysphonia Association) email listserv. RESULTS: 158 responses: 25 males and 133 females, (mean [range] age, 64.9 [22-95] years). 53.8% of participants had tried cannabinoids for the purposes of treating their condition at some point, with 52.9% of this subset actively using cannabis as part of their treatment. Most participants who have used cannabinoids as a treatment rank their effectiveness as somewhat effective (42.4%) or ineffective (45.9%). Participants cited a reduction in voice strain and anxiety as reasons for cannabinoid effectiveness. CONCLUSIONS: People with laryngeal dystonia and/or vocal tremor currently use or have tried using cannabinoids as a treatment for their condition. Cannabinoids were better received as a supplementary treatment than as a stand-alone treatment.

Laryngeal Dystonia, Dystonic Tremor and Vocal Tremor: Three Different Entities.

OBJECTIVE: The main objective of this study was to compare the demographic and clinical characteristics of patients with laryngeal dystonia (LD), dystonic tremor (DT), and vocal tremor (VT). STUDY DESIGN: This was a retrospective longitudinal study. METHODS: Data analysis from every patient diagnosed with LD, DT, or VT from January 1, 2010, to September 30, 2022, at a tertiary hospital center. Differential diagnosis between these entities was clinical (clinical history, voice assessment, and endoscopy) and confirmed by laryngeal electromyography. RESULTS: A total of 87 patients were included in this study: 50 patients with LD, 23 with DT, and 14 with VT. Age at diagnosis was significantly lower in patients with LD, with a mean age of 56.2 years when compared to DT (67.6 years; P = 0.002) and VT (70.5 years; P = 0.009). Furthermore, VT had a higher female prevalence (92.9%) when compared with LD (52%; P = 0.011). LD was mainly adductor, with only two patients diagnosed with abductor LD, and DT was adductor in every case. Tremor direction in patients with VT was horizontal in 50% and mixed (horizontal + vertical) in 50%, while in DT was mixed in 65.2% and horizontal in 34.8%. LD was more commonly an isolated laryngeal movement disorder (78%) when compared to DT (47.8%; P = 0.015) or VT (28.5%; P < 0.001), which were more often secondary to generalized neurological disorders. There were no differences between groups on Voice Handicap Index-10, self-reported grade of dysphonia on a visual analogic scale (0-10), maximum phonation time, and G, R, B, A, and I in the GRBAS-I scale at diagnosis (P > 0.05). S was significantly higher in LD when compared to VT (P < 0.001) and nonsignificantly higher than in DT (P = 0.075). CONCLUSIONS: LD, DT, and VT seem to be different entities with different demographics and clinical characteristics.

Comprehensive Evaluation of Voice-Specific Outcomes in Patients With Essential Tremor Before and After Deep Brain Stimulation.

OBJECTIVE: Deep brain stimulation (DBS) is a treatment for medically refractory essential tremor (ET), but there is a paucity of literature examining the effects of DBS on voice in patients with ET pre-DBS and post-DBS. This study aimed to report a comprehensive evaluation of voice in patients with ET pre-DBS and 6-months post-DBS. STUDY DESIGN: Case series. METHODS: Five patients receiving DBS for ET underwent voice evaluations pre-DBS and 6-months post-DBS. One patient had concurrent ET of the vocal tract (ETVT). The evaluation included patient-reported, perceptual, acoustic, and phonatory aerodynamic analyses of voice. Voice Handicap Index-10, Grade, Roughness, Breathiness, Asthenia, Strain Scale, perturbation measures, cepstral spectral index of dysphonia, cepstral peak prominence, and mean phonatory airflow measures were also among the data collected. RESULTS: Patients with ET presented with minimal changes in perceptual, acoustic, and phonatory aerodynamic parameters. Perceived vocal roughness significantly increased 6-months post-DBS (P = 0.047). The patient with ETVT presented with clinically significant improvement in almost all collected voice parameters 6-months post-DBS. CONCLUSION: This is the first study to provide data encompassing auditory perceptual voice analysis, voice-specific patient-reported quality of life measures, acoustic, and phonatory aerodynamic outcomes in patients pre-DBS and 6-months post-DBS for ET. The results of our preliminary study have implications for the use of a comprehensive voice assessment to identify and measure change in voice outcomes in patients with ET and ETVT pre- and postsurgery.

Treatment of Essential Vocal Tremor: A Scoping Review of Evidence-Based Therapeutic Modalities.

OBJECTIVES/HYPOTHESIS: Essential vocal tremor (EVT) is an uncommon but challenging condition to manage. Several medical and interventional treatment options have been reported but efficacy remains unclear. We performed a scoping review of high-quality clinical trials to identify effective evidence-based treatments for EVT. STUDY DESIGN: Scoping review. METHODS: Relevant studies were identified using the databases MedLine, Cochrane Central Register of Controlled Trials, and Embase. Subjective and objective outcomes for each modality were analyzed and the effect sizes were quantified using Hedges' g measure to allow comparison between studies. RESULTS: We identified 421 studies eligible for screening with 11 included in the final analysis. Evidence supporting effective EVT treatments was found for bilateral versus unilateral deep brain stimulation (DBS) (Hedges' g 0.65, 95% CI = 0.10-1.20) and octanoic acid (Hedges' g 1.15, 95% CI = 0.40-1.90). Evidence to support the use of methazolamide was not sufficient (Hedges' g 0.51, 95% CI = -0.64 to 1.66). Botulinum toxin (BT) injections were equivalent when comparing unilateral versus bilateral (Hedges' g -0.18, 95% CI = -1.06 to 0.70); BT did not display any advantage over propranolol (Hedges' g -0.47, 95% CI = -1.73 to 0.78) or injection augmentation (Hedges' g 0.068, 95% CI = -0.98 to 1.12). CONCLUSIONS: Our review finds very little high-quality evidence supporting any treatment for EVT. Octanoic acid reduced fluctuations in EVT but did not affect the perception of the tremor. In refractory cases, bilateral DBS was superior to unilateral DBS in improving subjective voice outcomes. Unilateral and bilateral BT injections were equivalent, and BT injection was not more effective than injection augmentation. Further direct comparison in well-designed prospective studies may help clarify optimal treatment for EVT patients.

Practice Patterns and Barriers in Botulinum Toxin Injection for the Treatment of Voice Disorders.

Laryngeal botulinum toxin injection is an important treatment modality for spasmodic dysphonia and other laryngeal disorders. We sought to compare usage patterns of laryngeal botulinum toxin injections for voice disorders and to identify and quantify inefficiencies and barriers in providing this treatment. A 26 item survey was written and approved for distribution by the American Academy of Otolaryngology-Head and Neck Surgery and the National Spasmodic Dysphonia Association. It was distributed to Otolaryngologists who perform laryngeal botulinum toxin injections via the e-mail lists of the National Spasmodic Dysphonia Association provider database, American Academy of Otolaryngology-Head and Neck Surgery Voice Committee and the American Laryngological Association Neurolaryngology Study Group. There were 81 survey participants who collectively reported performing >1700 laryngeal botulinum toxin injections for voice disorders monthly (Mean = 21.5 pts/month). Regarding botulinum toxin A (BtxA) vial use, 54% of participants reported using multiple doses per vial for different patients during a single clinic day, while 14% reported using pharmacy predrawn single use aliquots. A combination of usage practices was reported by 7% of participants. Using an individual vial per patient and discarding the unused remainder was reported by 26% of participants with an associated annual cost in wasted BtxA of $84,300 per physician. There is wide variation in injection practices regarding management of BtxA vials and adherence to an individual vial per patient policy is associated with significant waste of health care resources. Alternative approaches to BtxA vial use could positively impact health care resource utilization.

Simultaneous Botox and Augmentation Injection Laryngoplasty in Patients With Adductor Spasmodic Dysphonia (ASD) and Tremor.

OBJECTIVE: Although Botulinum Toxin (BOTOX) is effective for adductor spasmodic dysphonia (ASD) and essential vocal tremor (EVT), the side effects of breathy dysphonia may result in reluctance to pursue BOTOX treatment. We sought to improve results in selected elderly tremor patients with EVT and in professional voice users with ASD by simultaneous BOTOX injection and injection laryngoplasty using Hyaluronic acid (HA/Botox). MATERIAL AND METHODS: Between July 2018 and March 2022, 23 simultaneous HA/Botox using LEMG control were done in eight patients with ASD and EVT (23 of 406 Botox Injections). All eight patients have previously reported unwanted side effects with poor voice results with Botox. Three patients had tremor with presbyphonia. Injection of Botox is performed first using LEMG control, followed by bilateral LEMG guided injection of 0.1 cc of HA. RESULTS: All HA/Botox injections were tolerated well. All patients reported some improved voice. Two patients did not go on to further HA injections while the others six have requested ongoing simultaneous HA/Botox injections. Patients with EVT and presbyphonia noted greater stability of voice than Botox alone. It lasted through the injection cycle. The professional voice users reported less breathy voice that allowed them to work right after the BOTOX injection. CONCLUSION: Simultaneous BOTOX injection with injection laryngoplasty using HA may be helpful in patients with tremor and presbyphonia. It also may be considered in professional voice users with ASD to reduce side effects of BOTOX.

The Effects of Remote Signal Transmission and Recording on Acoustical Measures of Simulated Essential Vocal Tremor: Considerations for Remote Treatment Research and Telepractice.

PURPOSE: Studies on medical and behavioral interventions for essential vocal tremor (EVT) have shown inconsistent effects on acoustical and perceptual outcome measures across studies and across participants. Remote acoustical and perceptual assessments might facilitate studies with larger samples of participants and repeated measures that could clarify treatment effects and identify optimal treatment candidates. Furthermore, remote acoustical and perceptual assessment might allow clinicians to monitor clients' treatment responses and optimize treatment approaches during telepractice. Thus, the purpose of this study was to evaluate the accuracy of remote signal transmission and recording for acoustical and perceptual assessment of EVT. METHOD: Simulations of EVT were produced using a computational model and were recorded using local and remote procedures to represent client- and clinician-end recordings respectively. Acoustical analyses measured the extent and rate of fundamental frequency (fo) and intensity modulation to represent vocal tremor severity and the cepstral peak prominence (CPPS) to represent voice quality. The data were analyzed using repeated measures analysis of variance (ANOVA) with recording as the within-subjects factor and sex of the computational model as the between-subjects factor. RESULTS: There was a significant main effect of recording on the rate of fo modulation and significant interactions of recording and sex for the extent of intensity modulation, rate of intensity modulation, and CPPS. Posthoc pairwise comparisons and analysis of effect size indicated that recording procedures had the largest effect on the extent of intensity modulation for male simulations, the rate of intensity modulation for male and female simulations, and the CPPS for male and female simulations. Despite having disabled all known software and computer audio enhancing options and having stable ethernet connections, there was inconsistent attenuation of signal amplitude in remote recordings that was most problematic for samples with a breathy voice quality but also affected samples with typical and pressed voice qualities. CONCLUSIONS: Acoustical measures that correlate to perception of vocal tremor and voice quality were altered by remote signal transmission and recording. In particular, signal transmission and recording in Zoom altered time-based estimates of intensity modulation and CPPS with male and female simulations of EVT and magnitude-based estimates of intensity modulation with male simulations of EVT. In contrast, signal transmission and recording in Zoom minimally altered time- and magnitude-based estimates of fo modulation with male and female simulations of EVT. Therefore, acoustical and perceptual assessments of EVT should be performed using audio recordings that are collected locally on the participant- or client-end, particularly when measuring modulation of intensity and CPP or estimating vocal tremor severity and voice quality. Development of procedures for collecting local audio recordings in remote settings may expand data collection for treatment research and enhance telepractice.