Michael J. Hammer

Laryngeal somatosensory deficits in Parkinson's disease: implications for speech respiratory and phonatory control

Parkinson’s disease (PD) is often associated with substantial impairment of speech respiratory and phonatory control. However, the degree to which these impairments are related to abnormal laryngeal sensory function is unknown. This study examined whether individuals with PD exhibited abnormal and more asymmetric laryngeal somatosensory function compared with healthy controls, and whether these deficits were associated with disease and voice severity. Nineteen PD participants were tested and compared with 18 healthy controls. Testing included endoscopic assessment of laryngeal somatosensory function, with aerodynamic and acoustic assessment of respiratory and phonatory control, and clinical ratings of voice and disease severity. PD participants exhibited significantly abnormal and asymmetric laryngeal somatosensory function compared with healthy controls. Sensory deficits were significantly associated with timing of phonatory onset, voice intensity, respiratory driving pressure, laryngeal resistance, lung volume expended per syllable, disease severity, and voice severity. These results suggest that respiratory and phonatory control are influenced by laryngeal somatosensory function, that speech-related deficits in PD are related to abnormal laryngeal somatosensory function, and that this function may degrade as a function of disease severity. Thus, PD may represent a model of airway sensorimotor disintegration, highlighting the important role of the basal ganglia and related neural networks in the integration of laryngeal sensory input for speech-related motor control.

Ultrasonic output from the excised rat larynx.

The source of ultrasonic vocalizations (USVs) produced by rats is thought to be within the larynx. The purpose of this investigation was to determine if the rat larynx is capable of producing ultrasounds with the full range of frequencies reported in vivo. Acoustic output of excised rat larynges with and without vocal fold constriction was measured. At biologically-reasonable airflow rates and pressures, only larynges with a constriction produced the full range of ultrasounds reported in vivo, providing support for the hypothesis that a constriction within the larynx is likely the source of rat USVs.

Design of a New Somatosensory Stimulus Delivery Device for Measuring Laryngeal Mechanosensory Detection Thresholds in Humans

Laryngeal control is essential for airway protection, breathing, deglutition, speech, and voice. Unfortunately, integration of laryngeal sensory assessment in research and clinical practice is limited by technical and practical limitations of commercially available technology. A commercial device is available, but reported limitations include procedural complexity requiring two or three individuals to operate, limited stimulus dynamic range, device generated noise, and questionable stimulus reproducibility. The objective of this study was to design a new laryngeal somatosensory stimulus delivery device that provides direct, reliable control over the timing, duration, and dynamic range of stimulus presentation, and test the device in individuals who may manifest a laryngeal sensory deficit. The new device operates silently and has more than four times greater stimulus dynamic range than the commercial device. Testing with the new device revealed laryngeal mechanosensory detection thresholds in an individual with Parkinsons disease that were seven times higher than those of healthy controls. These data would have otherwise gone undetected due to limited stimulus dynamic range in the commercial device. The new design resulted in a new assessment instrument that is simple to use for routine clinical assessment, yet sufficiently versatile for integration within rigorous clinical research protocols.

Evaluating the Tongue-Hold Maneuver Using High-Resolution Manometry and Electromyography

The tongue-hold maneuver is a widely used clinical technique designed to increase posterior pharyngeal wall movement in individuals with dysphagia. It is hypothesized that the tongue-hold maneuver results in increased contraction of the superior pharyngeal constrictor. However, an electromyographic study of the pharynx and tongue during the tongue-hold is still needed to understand whether and how swallow muscle activity and pressure may change with this maneuver. We tested eight healthy young participants using simultaneous intramuscular electromyography with high-resolution manometry during three task conditions including (a) saliva swallow without maneuver, (b) saliva swallow with the tongue tip at the lip, and (c) saliva swallow during the tongue-hold maneuver. We tested the hypothesis that tongue and pharyngeal muscle activity would increase during the experimental tasks, but that pharyngeal pressure would remain relatively unchanged. We found that the pre-swallow magnitude of tongue, pharyngeal constrictor, and cricopharyngeus muscle activity increased. During the swallow, the magnitude and duration of tongue and pharyngeal constrictor muscle activity each increased. However, manometric pressures and durations remained unchanged. These results suggest that increased superior pharyngeal constrictor activity may serve to maintain relatively stable pharyngeal pressures in the absence of posterior tongue movement. Thus, the tongue-hold maneuver may be a relatively simple but robust example of how the medullary swallow center is equipped to dynamically coordinate actions between tongue and pharynx. Our findings emphasize the need for combined modality swallow assessment to include high-resolution manometry and intramuscular electromyography to evaluate the potential benefit of the tongue-hold maneuver for clinical populations.

Quantifying Contributions of the Cricopharyngeus to Upper Esophageal Sphincter Pressure Changes by Means of Intramuscular Electromyography and High-Resolution Manometry:

Objectives: We sought to determine whether the association between cricopharyngeus muscle activity and upper esophageal sphincter pressure may change in a task-dependent fashion. We hypothesized that more automated tasks related to swallow or airway protection would yield a stronger association than would more volitional tasks related to tidal breathing or voice production. Methods: Six healthy adult subjects underwent simultaneous intramuscular electromyography of the cricopharyngeus muscle and high-resolution manometry of the upper esophageal sphincter. Correlation coefficients were calculated to characterize the association between the time-linked series. Results: Cricopharyngeus muscle activity was most strongly associated with upper esophageal sphincter pressure during swallow and effortful exhalation tasks (r = 0.77 and 0.79, respectively; P < .01). The association was also less variable during swallow and effortful exhalation. Conclusions: These findings suggest a greater coupling for the more automatic tasks, and may suggest less coupling and more flexibility for the more volitional, voice-related tasks. These findings support the important role of central patterning for respiratory- and swallow-related tasks.

Subthalamic nucleus deep brain stimulation changes velopharyngeal control in Parkinson's disease

PURPOSE Adequate velopharyngeal control is essential for speech, but may be impaired in Parkinsons disease (PD). Bilateral subthalamic nucleus deep brain stimulation (STN DBS) improves limb function in PD, but the effects on velopharyngeal control remain unknown. We tested whether STN DBS would change aerodynamic measures of velopharyngeal control, and whether these changes were correlated with limb function and stimulation settings. METHODS Seventeen PD participants with bilateral STN DBS were tested within a morning session after a minimum of 12h since their most recent dose of anti-PD medication. Testing occurred when STN DBS was on, and again 1h after STN DBS was turned off, and included aerodynamic measures during syllable production, and standard neurological ratings of limb function. RESULTS We found that PD participants exhibited changes with STN DBS, primarily consistent with increased intraoral pressure (n=7) and increased velopharyngeal closure (n=5). These changes were modestly correlated with measures of limb function, and were correlated with stimulation frequency. CONCLUSION Our findings suggest that STN DBS may change velopharyngeal control during syllable production in PD, with greater benefit associated with low frequency stimulation. However, DBS demonstrates a more subtle influence on speech-related velopharyngeal control than limb motor control. This distinction and its underlying mechanisms are important to consider when assessing the impact of STN DBS on PD. LEARNING OUTCOMES As a result of this activity, the participant will be able to (1) describe the effects of deep brain stimulation on limb and speech function; (2) describe the effects of deep brain stimulation on velopharyngeal control; and (3) discuss the possible reasons for differences in limb outcomes compared with speech function with deep brain stimulation of the subthalamic nucleus.

Airway Somatosensory Deficits and Dysphagia in Parkinson's Disease

BACKGROUND Individuals with Parkinsons disease (PD) often experience substantial impairment of swallow control, and are typically unaware of the presence or severity of their impairments suggesting that these individuals may also experience airway sensory deficits. However, the degree to which impaired swallow function in PD may relate to airway sensory deficits has yet to be formally tested. OBJECTIVE The purpose of this study was to examine whether airway sensory function is associated with swallow impairment in PD. METHODS Eighteen PD participants and 18 healthy controls participated in this study and underwent endoscopic assessment of airway somatosensory function, endoscopic assessment of swallow function, and clinical ratings of swallow and disease severity. RESULTS PD participants exhibited abnormal airway somatosensory function and greater swallow impairment compared with healthy controls. Swallow and sensory deficits in PD were correlated with disease severity. Moreover, PD participants reported similar self-rated swallow function as healthy controls, and swallow deficits were correlated with sensory function suggesting an association between impaired sensory function and poor self-awareness of swallow deficits in PD. CONCLUSIONS These results suggest that control of swallow is influenced by airway somatosensory function, that swallow-related deficits in PD are related to abnormal somatosensation, and that swallow and airway sensory function may degrade as a function of disease severity. Therefore, the basal ganglia and related neural networks may play an important role to integrate airway sensory input for swallow-related motor control. Furthermore, the airway deficits observed in PD suggest a disintegration of swallow-related sensory and motor control.

A multisensor approach to improve manometric analysis of the upper esophageal sphincter

High‐resolution manometry (HRM) improves on previous manometric systems by including a greater number of sensors that are more densely placed. Due to deglutitive movement of the HRM catheter and upper esophageal sphincter (UES), it is unclear which HRM sensors capture pressure in the UES. To address this issue, we present two complementary studies to describe UES pressure patterns using HRM + videofluoroscopy and HRM + electromyography (EMG).

Voice-related modulation of mechanosensory detection thresholds in the human larynx

Rapidly adapting mechanoreceptors within the laryngeal mucosa provide the central nervous system with perceptual and proprioceptive afference for a variety of essential yet diverse human functions including voice sound production and airway protection. It is unknown why mechanosensory information that yields a defensive response when an individual breathes may go largely unnoticed when the individual voices. Therefore, a central question is whether there is voice-related modulation of laryngeal mechanosensory detection. Such modulation would be consistent with current models of afferent laryngeal control, and may be important to maintain fluent voice in the presence of potentially distracting sensory input. Therefore, we employed endoscopic assessment of laryngeal mechanosensory detection thresholds in ten healthy adults during tidal breathing and a voice task. We tested the hypothesis that laryngeal mechanosensory detection thresholds would be higher during the voice task. We found that thresholds were significantly higher for all participants during the voice task and that these changes were significantly more modest in women. Our findings suggest that the laryngeal sensorium may modulate mechanosensory afference to attenuate the potentially distracting influence of sensory input during voice. The finding that women maintain a greater sensitivity during the voice task than men (lower thresholds) may have important implications for the higher prevalence of sensorimotor voice disturbances in women. Our results are consistent with the presence of mechanosensory modulation in other motor systems and with observed sensory differences between women and men. Such modulation has important implications for understanding the underlying neural mechanisms of laryngeal control and how these mechanisms may operate in individuals with laryngeal disturbances.

Aerodynamic Assessment of Phonatory Onset in Parkinson's Disease: Evidence of Decreased Scaling of Laryngeal and Respiratory Control

BACKGROUND Phonatory onset is important for speech and voice and may be substantially impaired in people with Parkinsons Disease (PD). However, the physiologic contributions of laryngeal and respiratory control to phonatory onset in PD are not well understood. Acoustic measurement of phonatory onset in neurological disease has been limited due to the confounding effects of dysarthria and the limited yield of physiologic detail. OBJECTIVE The purpose of this study was to test whether air flow measures would be useful to characterize respiratory and laryngeal contributions to phonatory onset, whether acoustic and air flow measures of phonatory onset were aberrant in PD, and whether deficits were significantly associated with voice severity. METHODS Twenty-one PD participants were tested and compared with 25 healthy controls. Testing included acoustic and air flow measures of phonatory onset during syllable production ([pa]) and measures of voice severity. RESULTS Air flow assessment was possible for all participants; acoustic assessment was only possible for 86% of PD participants. Air flow and acoustic measures revealed shorter phonatory onset times for PD participants than controls. Air flow measures also revealed that PD participants expelled less lung air volume per syllable. Aberrant timing of phonatory onset and reduced lung air volume were associated with increased voice severity. CONCLUSIONS These findings suggest that air flow measures may be useful to assess the laryngeal and respiratory contributions to phonatory onset. These results also suggest that both respiratory and laryngeal control deficits may contribute to phonatory errors in PD, and that phonatory onset deficits are associated with voice severity.