Neurogenic Voice Disorders

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Neurogenic Voice Disorders

• Courtney Lippe
• Kristina Curro

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Organic Voice Disorders

• Structural involve something physically wrong
  with a speech mechanism.
• Neurogenic are caused by a problem with the CNS
  or PNS.

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Spasmodic Dysphonia

• SD is characterized by abnormal involuntary
  movements that are action induced and task
  specific Stemple et al.
• Movement during vocalization that produces
  involuntary co-contraction of the muscles used to
  produce sound.
• Normal structure!

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Spasmodic Dysphonia

• 3 types Adductor vs. Abductor and rare form of
  mixed dysphonia
• Recent evidence suggest that it is a focal
  dystonia of the CNS
• Extrapyramidal in origin
• Supranuclear lesion locus in area of the Basal
  Ganglia

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Spasmodic DysphoniaComplaints

• Poor vocal quality
• Loss of vocal control
• Rapid fatigue and strain involved in speech
• Cannot be understood due to decrease in
  intelligibility

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Spasmodic Dysphonia

• Diane Rehm NPR talk radio voice

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Spasmodic Dysphonia Treatments

• Midline type 2 Thyroplasty (surgical)
• Sectioning or removal of the recurrent laryngeal
  nerve (surgical)
• Botox injection
• Chiropractics (derotation of 1st and 2nd
  vertebrae)
• Behavioral therapy

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Midline type 2 Thyroplasty
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Benign Essential Tremor

• Neurologic movement disorder that primarily
  involve upper body and limbs but can also involve
  head, voice, tongue or palate
• Not related to any other disease process
• Usually absent at rest
• Average age of onset 45 years

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Benign Essential Tremor
Katherine Hepburn
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Benign Essential Tremor Complaints

• Poor vocal quality
• old sounding voice
• Decrease in volume
• Fatigue with vocal use

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Benign Essential Tremor

• Team neurologist, otolaryngologist and speech
  Language Pathologist
• There is no cure for organic voice tremor but the
  symptoms can be treated.
• Botox is an option if there is co-occuring
  spasticity
• Speech therapy to improve respiratory support
• Prognosis poor

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Current Therapy

• Beta-adrenergic blockers(medication)
• Primidone(medication)
• Benzodiazepines(medication)
• Botulinum A(injections)
• Alcohol
• Thalamotomy(surgical)
• Thalamic Stimulation(surgical)
• Non-Pharmacologic Treatment

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Neurogenic Vocal Fold Paralysis
Figure 5. Unilateral vocal cord paralysis. (Left)
Larynx in abduction. (Right) Larynx in adduction,
showing paralyzed vocal cord (arrow).
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Vocal Fold Paralysis

• Nerve impulses to the vocal folds are either
  partially or completely interrupted which
  results in limited or no movement of the muscles
  of the larynx.
• Can occur at any age
• Results Voice changes, problems with airway,
  dysphagia

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Complaints

• Hoarseness
• Breathy
• Diplophonia
• Shortness of breath
• Stridor
• Ineffective cough
• Coughing or choking with food
• globus sensation

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Neurologic Causes

• Arnold-Chiari malformation
• Meningomyelocele
• Diabetes mellitus
• Amyotrophic lateral sclerosis
• Myasthenia Gravis
• Mobius syndrome
• Charcot-Marie-Tooth syndrome
• Postpolio syndrome
• Lyme Disease

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Medical Therapy

• Corticosteroids work for some conditions
• Glucose management for diabetes
• Reflux medication

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Parkinsonss Disease/Parkinsonism/resulting in
Hypokinetic Dysarthria

• Cause/Site of lesion Degeneration of the
  substantia nigra, causing a decrease in the
  amount of dopamine in the brain and thereby
  inhibiting movement.
• Drug-induced, such as exposure to heroin
• Post-encephalitic, thought to be due to exposure
  to a virus, although evidence is weak at best.
• Idiopathic, possibly due to the aging process or
  heredity.

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Vocal quality complaints

• Hard to get speech started
• Quiet or weak voice
• Fatigue during speech
• Reports stuttering, or repeating sounds or
  words.

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• Hypokinetic dysarthria voice characteristics
  (Duffy, 2005)

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Phonation

• Mono-pitch
• Mono-loudness
• Harsh Voice Quality
• Breathy voice
• Low pitch (reduced f0)
• Reduced intensity
• Voice tremor
• Increased jitter/shimmer

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Respiration

• Reduced maximum vowel prolongation
• Reduced airflow
• Reduced respiratory excursions
• Reduced vital capacity
• Paradoxical respiratory movements

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Articulation/Prosody

• Reduces Stress
• Imprecise Consonants
• Variable Rate
• Repeated phonemes
• Inappropriate pauses
• Continued voicing during voiceless consonants

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Resonance

• Increased nasalization is possible, but usually
  normal.

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Laryngeal Characteristics

• Bowed vocal folds despite solid, non-flaccid
  appearance
• Tremulousness of arytenoid cartilages
• Asymmetry of structure movement

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Treatment options and effectiveness

• LSVT to promote volume and breath support (Ramig
  and Verdolini, 1996)
• Prosodic exercises (as reported in Scott and
  Caird, 1983, from Ramig and Verdolini, 1996)

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Drug Treatment

• Most drug treatment is for PD in general, not
  specifically for treatment of the voice disorder
  itself.
• levodopa-carbidopa (dopamine precursors),
  bromocriptine (dopamine agonist) etc. (Kolb and
  Wishaw, 1996)

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Surgical Treatment

• Collagen injection into vocal folds (Sewall et
  al. 2006) to improve glottal closure. Pt.
  subjectively reported improvement of vocal
  quality (Vocal Handicap Index), and objective
  CAPE-V measurements also showed improvement.
  However, small sample size and short duration of
  monitoring.
• Deep brain stimulation and fetal cell
  transplantation were shown to help reduce overall
  symptoms of PD, but had a negative impact on
  speech quality (Trail et al. 2005)

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Other Treatments

• Transcranial Magnetic Stimulation (Dias et al.,
  2006) showed that stimulating the primary motor
  cortex (M1)-mouth area provided objective and
  subjective improvements in speech and may be used
  in future treatment.

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Prognosis

• New research suggests a combination of LSVT and
  collagen injections may provide the greatest
  improvement to voice quality.
•  

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Flaccid Dysarthria

• Cause/Site of lesion Lower motor neuron
  involvement. In Myasthenia Gravis (MG) Failure
  of neuromuscular transmission wherein
  acetylcholine degrades too quickly because the
  immune system attacks its own AchRs. This lack
  of Ach reaching the neuronal terminals causes
  flaccid dysarthria that recovers after a period
  of rest.

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Complaints

• Breathy or quiet voice, inability to move
  articulators
• In MG Weakness and fatigue after muscle use, for
  example, weakness increases towards the end of a
  conversation, and recovers with a period of rest

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Phonation

• Breathiness
• Short phrases
• Audible inspiration

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Respiration

• Insufficient breath support, although isolated
  respiration difficulty is rare.
• Poor posture
• Reduced exhalation control
• Slow breathing

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Articulation/Prosody

• Harsh voice
• Monoloudness
• Monopitch

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Resonance

• Imprecise consonants (although this occurs with
  may other dysarthrias)
• Increased nasalization and nasal emission (may be
  the first sign of ALS)

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Treatment options and effectiveness

• MG General treatment includes thymectomy to
  reduce antibody formation, but its effect on
  voice treatment specifically is not addressed.
• Thyroplasty surgery to enhance function of the
  larynx
• Palatal lifts if the velum is affected

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Ataxic dysarthria

• Location/site of lesion bilateral cerebellar
  involvement
• Complaints of patient imprecise articulation,
  laborious speech, may be observed groping for
  sounds, sound substitution

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Phonation

• Breathy
• Hoarse
• Tremor
• Mono-pitch
• Mono-loudness

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Respiration

• Shallow inhalation and reduced exhalation control
• Rapid breaths
• Irregular and suddenly forced patterns

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Articultion/Prosody

• Imprecise, slow and irregular
• Explosive syllable stress
• Explosive loudness, outbursts
• Abnormal prolongations of phonemes

44
Treatment options and effectiveness

• Intense phonomotor treatment (Kendall et al.
  2006) in a single case study found that intense
  phonomotor treatment increased ease of production
  of single sounds but generalization to connected
  speech did not occur.
•  

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References

• Cannito, Michael P. et al. Perceptual Analysis of
  Spasmodic Dysphonia Before and After. Arch
  Otolaryngol Head Neck Surg.,1301393-1399
• Daya, Hamid FRCS et al.(2006) Pediatric Vocal
  Fold Paralysis. Arch Otolaryngol Head Neck
  Surg.,vol 12621-25
• Dias, A.E., Barbosa, E.R., Coracini, K., Maia,
  F., Marcolin, M. A., Fregni, F. (2006). Effects
  of repetitive transcranial magnetic stimulation
  on voice and speech in Parkinson's disease. Acta
  Neurologica Scandinavica. 113(2), 92-99
• Duffy, J.R. (2005). Motor Speech Disorders
  Substrates, Differential Diagnosis, and
  Management. Elsevier Mosby St. Louis.
• Dworkin, J.P. (1991). Motor Speech Disorders.
  Mosby New York.
• Dysphonia by Surgical Myectomy A Preliminary
  Report. Annals of Otology, Rhinology
  Laryngology. 115(2)97-102, 2006.

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References

• Kendall, D.L., Rodriguez A.D., Rosenbek, J.C.,
  Conway T., Gonzalez Rothi L.J.Influence of
  intensive phonomotor rehabilitation on apraxia of
  speech. Journal of Rehabilitation Research and
  Development. 43(3). 409-18
• Kolb, B., Wishaw, I.Q. (1996). Fundamentals of
  Human Neuropsychology 4th Edition. W.H.
  Freeman Company New York.
• Neurogenic dysphonia (1994). Ann Otol Rhinol
  Laryngol. Jan-Feb93(1 Pt 1)57-64. PMID
  6703599 PubMed - indexed for MEDLINE
• Rajish, Pahwa. (2003) Essential Tremor
  differential diagnosis and current therapy. The
  American Journal of Medicine. 115(2), 134-142

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References

• Ramig, L.O., Verdolini, K. (1998). Treatment
  Efficacy, Voice Disorders. Journal of Speech,
  Language, and Hearing Research. 41(1), S101
  S116.
• Sapienza CM, Murry T, Brown WS (1998) Variations
  in adductor spasmodic dysphonia Acoustic
  evidence. J Voice, 12(2) 214-222
• Stemple, J.C., Glaze, L.E., Klaben, B.G. (2000).
  Clinical Voice Pathology- Third Edition. Singular
  Publishing Group Canada.
• Sewall G.K., Jiang J., Ford C.N. (2006).
  Clinical evaluation of Parkinsons related
  dysphonia. Laryngoscope. Oct116(10)1740-4
• Trail, M., Fox, C., Ramig, L.O., Sapire, S.,
  Howard, J, and Lai, E.C. (2005). Speech
  treatment for Parkinsons Disease.
  NeuroRehabilitation. 20, 205221.
• http//www.parkinsonsdisease-rhodeisland.org/Treat
  ing20the20voice.htm as retrieved on 3/1/2007.