Vocal aging and adductor spasmodic dysphonia: Response to botulinum toxin injection

Figures & data

Figure 1 Spectrograms of the phrase “… raindrops in the air …” spoken by a 38 year old female: normal control subject is depicted on the top panel, ADSD before BT injection is on the middle, and ADSD after BT injection is on the bottom panel.

Figure 2 Spectrograms of the phrase “When the sunlight …” spoken by a 74 year old female: normal control subject is depicted on the top panel, ADSD before BT injection is on the middle, and ADSD after BT injection is on the bottom panel.

Figure 3 Coronal section of the larynx from 56 year old female illustrating major structural landmarks. Safran-Hematoxylin Stain, 2.5x original magnification. 1 – epiglottis, 2 – unossified thyroid cartilage, 3 – ossified portion of thyroid cartilage, 4 – unossified cricoid cartilage, 5 – ossified portion of cricoid cartilage, 6 – lamina propria of vocal fold, 7 – thyroarytenoid muscle (the major constrictor of vocal fold), 8 – laryngeal ventricle (lined of glandular epithelium), 9 – vestibular fold with G – mucous-serous glands, 10 – conus elasticus, 11 – glottal space.

Figure 4 Coronal sections of the vocal fold from 21years old (A), 63 years old (B) and 72years old (C) females illustrating age related changes in the epithelium and lamina propria. Safran-Hematoxylin Stain, 20x original magnification. E – epithelium, S – superficial layer of the lamina propria, I – intermediate layer of the lamina propria, D – deep laryner of the lamina propria. Portions of the adjacent thyroarytenoid muscle (TA), which form a part of the body of the vocal fold, are also illustrated.

Figure 5 Endoscopic pictures of the vocal folds of a 58 year old woman during phonation, who presents with bowing of the vocal folds, thinning lamina propria and a persistent glottal chink.

Figure 6 Diagrammatic representation of the major structures contributing to the peripheral speech mechanism. Structures of the upper and lower respiratory tracts are functionally interfaced and programmed by the CNS to produce voice and speech.

Table 1 Characteristics of speakers with adductor spasmodic dysphonia

Age years	Gender	Initial severity	Years SD	Injection type	Dosage units	Days post injection
22	F	Moderate	5	Unilateral	2.5	31
28	F	Mild	3	Unilateral	2.5	36
31	F	Mild	2	Unilateral	5	31
31	F	Severe	4	Unilateral	15	45
32	F	Mild	2	Bilateral	5	32
33	F	Moderate	4	Unilateral	2.5	50
38	F	Severe	9	Unilateral	15	38
38	F	Mild	5	Unilateral	2.5	23
38	F	Profound	4	Bilateral	2.5	22
41	F	Profound	16	Bilateral	2.5	34
41	F	Mild	4	Bilateral	10	44
42	F	Mild	4	Unilateral	2.5	27
42	M	Moderate	9	Unilateral	7.5	22
44	F	Mild	7	Unilateral	2.5	22
45	F	Severe	12	Unilateral	15	45
46	F	Moderate	9	Unilateral	15	34
46	F	Severe	9	Bilateral	2.5	43
51	M	Severe	4	Unilateral	30	29
51	F	Severe	1	Unilateral	5	36
52	F	Mild	19	Bilateral	1.5	34
52	F	Moderate	24	Unilateral	5	35
54	F	Profound	4	Bilateral	2.5	30
54	M	Moderate	9	Unilateral	7.5	27
56	F	Profound	16	Unilateral	30	34
56	F	Moderate	13	Unilateral	15	31
57	F	Profound	14	Bilateral	2.5	38
60	F	Severe	6	Unilateral	15	37
61	F	Profound	9	Bilateral	5	31
63	F	Moderate	11	Unilateral	15	31
63	F	Severe	9	Bilateral	5	17
64	F	Profound	10	Unilateral	15	29
64	F	Profound	11	Bilateral	2.5	27
64	F	Mild	10	Unilateral	1.25	27
67	F	Profound	13	Bilateral	2.5	51
67	M	Moderate	8	Bilateral	5	20
70	F	Severe	5	Unilateral	5	48
71	F	Mild	20	Unilateral	7.5	29
71	M	Severe	19	Bilateral	5	36
72	F	Severe	8	Unilateral	7.5	42
74	F	Severe	9	Bilateral	2.5	36
77	F	Severe	8	Unilateral	5	27
79	M	Mild	5	Unilateral	5	36

Table 2 Attributes of voice and fluency for perceptual scaling experiments

Attribute	Description	End points
Voice scaling experiment
Overall voice quality	A general perceptual impression of an appropriate degree of melodiousness periodicity, and richness of the tonal components of the voice exhibited across the speech sample	Extremely good/Extremely poor
Breathiness	Audible occurrence of breath noise or acoustic turbulence in the voice signal perceived either as “whispery” or “murmured” quality across the speech sample	Absent/Pervasive
Roughness	Audible occurrence of acoustic aperiodicity in the voice signal perceived as either “harsh,” “gruff” or “strained-strangled” quality across the speech sample.	Absent/Pervasive
Brokenness	Audible occurrence of the unexpected momentary absence of the voicing signal perceived as “gaps” or “cracks” in voicing across the speech sample	Absent/Pervasive
Fluency scaling experiment
Overall fluency	A general perceptual impression of the prompt, smooth, easy and continuous forward flow of speech exhibited across the sample.	Extremely good/Extremely poor
Tension struggle	Perceived occurrence of audible effort, hesitation and straining to initiate or maintain the forward flow of speech across the sample.	Absent/Pervasive
Disfluent syllables	Perceived occurrence of inappropriate syllables that are repeated, added, or prolonged within the ongoing flow of speech across the sample.	Absent/Pervasive
Vocal spasms	Perceived occurrence of quavering, squeezing or stoppage of the voice sufficient to disrupt the ongoing flow of speech across the sample	Absent/Pervasive

Reprinted with permission from Cannito MP, Woodson GE, Murry T, et al. 2004. Perceptual analyses of spasmodic dysphonia before and after treatment. Arch Otolaryngol Head Neck Surg, 130:1393–9. Copyright © (2004), American Medical Association. All rights reserved.

Figure 7 Age-group plots of the means and standard deviations of visual analog scaling (VAS) scores for the four voice attributes (overall voice quality, roughness, brokenness, breathiness).

Figure 8 Age-group plots of the means and standard deviations of visual analog scaling (VAS) scores for the four fluency attributes (overall fluency, tension struggle, vocal spasms, dysfluent syllables).

Table 3 Means and standard deviations of composite scores for voice, fluency, and overall scores are shown for three groups: controls, ADSD subjects before and after BT injection by age group*

Decades	Composite voice		Composite fluency		Composite overall
	Mean	SD	Mean	SD	Mean	SD
Non-dysphonic controls
30	97.51	1.67	98.57	1.72	98.04	1.61
40	96.65	2.47	99.06	0.54	97.85	1.34
50	96.90	1.19	98.36	0.91	97.63	0.73
60	96.43	1.83	97.03	2.54	96.73	2.10
70	93.59	3.72	96.08	2.72	94.84	2.62
Pre BT injection
30	57.31	24.99	58.18	26.80	57.74	25.72
40	55.99	23.05	57.26	27.06	56.62	24.93
50	40.09	18.85	40.71	20.68	40.40	19.61
60	44.61	13.29	42.81	22.74	43.71	17.92
70	48.88	20.46	48.99	24.0	48.93	22.05
Post BT injection
30	70.75	15.19	81.85	15.92	76.30	15.12
40	70.52	15.78	80.19	17.27	75.35	16.12
50	63.97	16.65	75.07	22.19	69.52	19.20
60	62.64	12.81	71.90	13.42	67.27	12.26
70	48.07	14.56	50.17	18.14	49.12	16.14

* Values adjusted for the covariates of severity and gender.

Figure 9 Interaction plots of decade by treatment condition for mean composite scores for voice for three groups: non-dysphonic controls, ADSD before BT injection and the same ADSD subjects after BT injection.

Figure 10 Interaction plots of decade by treatment condition for mean fluency composite scores by decade for three groups: non-dysphonic controls, ADSD before BT injection and the same ADSD subjects after BT injection.

Table 4 Treatment characteristics for five age groups of ADSD

Decade	N	Mean dosage (Total Units)	Mean days post injection	Type of injection No. Unilat	Type of injection No. Bilat
30 year olds*	9	5.83	34.22	7	2
40 year olds	8	7.19	33.88	5	3
50 year olds	9	11.00	32.67	6	3
60 year olds	9	7.36	30.00	4	5
70 year olds	7	5.36	36.29	5	2

* Two 20-year-olds were included in this group for statistical analysis.

CannitoMPWoodsonGEMurryTPerceptual analyses of spasmodic dysphonia before and after treatmentArch Otolaryngol Head Neck Surg20041301393915611398

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