Arnold E. Aronson

Double-blind controlled study of botulinum toxin in adductor spasmodic dysphonia

The treatment of adductor spasmodic dysphonia using botulinum toxin A was conducted in 13 patients as a double‐blind, placebo‐controlled study. Patients were diagnosed independently by an interdisciplinary team consisting of speech pathologists, an otolaryngol‐ogist, and a neurologist. The toxin or saline was injected into each thyroarytenoid muscle under electro‐myographic and laryngoscopic guidance. Botulinum toxin A markedly reduced perturbation, decreased fundamental frequency range, and improved the spectrographic characteristics of the voice. Fundamental frequency and phonation time remained unchanged. Patients injected with botulinum toxin A noticed significant improvement in their voices in comparison with the placebo‐treated group. Excessive breathiness of the voice occurred in two patients, and mild bleeding in one patient in the botulinum toxin A‐treated group. Injection with saline resulted in edema of the vocal cord in one patient. Botulinum toxin A proved to be an effective and safe treatment of adductor spasmodic dysphonia.

Telemedicine and the Diagnosis of Speech and Language Disorders

OBJECTIVE To summarize results of telemedicine evaluations of speech and language disorders in patients in a small, rural hospital and in large multidisciplinary medical practices. MATERIALS AND METHODS Eight patients underwent assessment as part of experiments with the National Aeronautics and Space Administration-launched Advanced Communications Technology Satellite. A second clinician was on-site with patients to assess the reliability of satellite observations. Twenty-four previously videotaped samples of speech disorders were also transmitted to assess agreement with original face-to-face clinical diagnoses. In addition, results of 150 telemedicine evaluations among Mayo Clinic practices in Minnesota, Arizona, and Florida were examined retrospectively. RESULTS Evaluations were reliable, and patient satisfaction was good. Diagnoses were consistent with lesion localization and medical diagnosis when they were known, and they frequently had implications for lesion localization and medical diagnosis and management when they were previously unknown. The frequency of uncertain diagnosis (13%) for evaluation among the Mayo practices was only slightly higher than that encountered in face-to-face practice. Face-to-face evaluations were considered necessary for only 6 of the 150 patients (4%). CONCLUSION Telemedicine evaluations can be reliable, beneficial, and acceptable to patients with a variety of acquired speech and language disorders, both in rural settings and within large multidisciplinary medical settings.

Tongue strength and alternate motion rates in normal and dysarthric subjects

Tongue strength and alternate motion rates were measured in 50 normal subjects and in 18 subjects who had different neuropathologic types of dysarthria. The dysarthric subjects did not differ significantly from one another on any of the test measures. However, as a group they differed significantly from their normal counterparts in that they demonstrated weaker tongue strength, reduced and unsustained levels of maximum tongue strength effort, and slower alternate motion rates. Clinical implications are discussed.

Singing as therapy for apraxia of speech and aphasia: Report of a case

A 48-year-old woman suffered a stroke, with sudden onset of apraxia of speech, aphasia, right hemiplegia, and right hemianopsia. Conventional speech and language therapy was undertaken for 1 mo, but progress was limited. Then a form of singing therapy was introduced, and the patient found herself able to sing words and phrases that she was unable to say. The patient can function in her home environment with her limited speech ability, but the pitch, melody, and quality of her voice are different from that prior to her cerebral vascular accident.

Botulinum toxin injection for adductor spastic dysphonia: Patient self‐ratings of voice and phonatory effort after three successive injections

Ten patients (aged 35 to 70 years) with neurologic adductor spastic dysphonia rated themselves on a 7-point scale of severity for degree of voice improvement and physical effort after a series of three injections of botulinum toxin. Symptoms were noticeably reduced 24 and 48 hours after injection; this improvement was followed by considerable fluctuations in voice quality and phonatory effort. With successive injections, patients differed in their post-injection experiences, the time required to reach optimal voice, and the total duration of benefit. The study shows that the course of voice change after botulinum toxin injection is not predictable, uniform, or equal among patients with spastic dysphonia.

Aphonia after closed head injury: Aetiologic considerations

This report describes two patients with closed head injuries and post-traumatic aphonia who regained their voices within one session of symptomatic voice therapy. Their abilities to cough and swallow were intact, and articulation was only mildly impaired. One patient had an ataxic dysarthria and the other had spastic (pseudobulbar) dysarthria. Neither patient had oral-verbal apraxia. The findings argue against laryngeal paralysis or apraxia of phonation as the underlying cause of the aphonia. Neuropsychologic assessment revealed mild generalised intellectual impairment and frontal lobe signs but no aphasia. We postulate that the aphonia may have been due to a frontal lobe-limbic system disturbance, which affected these patients’ motivation, personality, and judgment. Diagnostic and therapeutic aspects of post-traumatic aphonia are discussed.

No morphometric abnormality of recurrent laryngeal nerve in spastic dysphonia

Spastic dysphonia is a disorder of phonation that is usually markedly improved by surgical resection of one recurrent laryngeal nerve (RLN). In this study, biopsies of the RLN were obtained at surgery from nine patients with spastic dysphonia (disease group) and eight patients with laryngeal cancer (control group). The RLN was found to be composed of several nerve regions having characteristic fiber compositions. For the various nerve regions and for the whole nerve, we evaluated morphology, median fiber diameter, density, and size distribution of fibers. The morphologies of teased fibers were also evaluated. We found no significant differences between the nerves of the disease and control groups. Therefore, we were unable to verify previous reports of neuropathic abnormality of the RLN in spastic dysphonia.

A comparison of EEG activity in the left and right cerebral hemispheres by power-spectrum analysis during language and non-language tasks

In 10 female subjects, power-spectrum analysis was performed on the alpha activity elicted during the resting state, 4 right hemispheric tasks, and 3 left hemispheric tasks. The data were treated in 3 ways: approach 1, comparing the right and left hemispheric alpha activity; approach 2, comparing the right and left hemispheric alpha activity adjusted for the resting state; and approach 3, comparing the right and left hemispheric alpha activity adjusted for the previous task. Approaches 1 and 2 revealed few significant differences in the alpha activity of the hemispheres, but approach 3 provided data that better fit the theory of decreased power spectrum of attenuation of activity in the activated hemisphere. Thus, approach 3 may be useful in developing an electroencephalographic test for determining cerebral dominance for language.

Dysarthria and apraxia of speech associated with FK-506 (tacrolimus).

The immunosuppressive agent FK-506 (tacrolimus) is one of the agents most commonly used to prevent rejection after liver transplantation. Neurologic toxicity related to FK-506 has been reported, including speech disorders; however, a detailed analysis of the speech disorder associated with use of FK-506 has not been presented. Herein we describe a patient who exhibited mutism, then severe apraxia of speech with a concomitant hypokinetic, spastic, and ataxic dysarthria after administration of FK-506. His residual mixed dysarthria, without radiographic evidence of a structural lesion, suggests dysfunction of one or more neurochemical systems. The pathophysiologic mechanisms underlying this intriguing entity remain obscure.

Coexisting psychogenic and neurogenic dysphonia: a source of diagnostic confusion

Four patients are described who had neurologic disease and accompanying dysphonia that proved to he partially or entirely psychogenic. The findings suggest that the association of a speech disorder with organic disease does not necessarily imply a causal relationship, even when the speech signs seem to arise from the site or organ system affected by disease. The potential for psychogenic factors to confuse the differential neurologic diagnosis of speech disorders is emphasised.