Voice Assessments in Patients with Spasmodic Dysphonia Kiyoshi Makiyama1), Masanobu Kumada2', Takeo Kobayashi3' Abstract: This study reviewed the usef
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1 Voice Assessments in Patients with Spasmodic Dysphonia Kiyoshi Makiyama1), Masanobu Kumada2', Takeo Kobayashi3' Abstract: This study reviewed the usefulness of voice assessment methods for evaluation of the severity of spasmodic dysphonia (SD). The methods reviewed were the mora method, acoustic and aerodynamic analyses, and a questionnaire for patients concerning inconvenience in daily living. There was a strong correlation between results by the mora method and the perceptual rating score. The mora method was useful also for severity assessments during follow-up. The time required to read sentences aloud and the sum of the acoustically silent periods during reading (phonatory breaks) were evaluated. The ratio of the sum of phonatory breaks to reading time (aphonetic time ratio) was also studied. The aphonic time ratio, shimmer, SNR, and standard deviation of the flow correlated significantly with the perceptual rating score, A questionnaire for evaluation of inconvenience in various situations of daily living due to SD was prepared, and its results were compared with the perceptual rating score. Inconvenience experienced by patients in their daily living, some of which cannot be detected during consultations, could be assessed by the questionnaire. From the results obtained, we propose the following parameters for 1) Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Nihon University : , Kandasurugadai, Chiyoda, Tokyo ) Department of Speechphysiology, Graduate School of Medicine, The University of Tokyo : 7-3-1, Hongo, Bunkyo, Tokyo )Department of Otorhinolaryagolosy, Teikyo University Ichihara Hopital : Anegasaki, Ichihara, Chiba
2 Vol. 42 No. 4, evaluation of the severity of SD: : severity according to perceptual evaluation, time of counting from 1 to 20, time of reading aloud, MPT, mora method, jitter, shimmer, SNR, STD FO, sum of phonatory breaks, aphonetic time ratio, and the patient's self-evaluation of inconvenience. Key words: : spasmodic dysphonia, voice assessment, mora method, phonatory breaks, inconvenience in daily living 1. 1, A voice that is variably squeezed, strained, choked, staccato, stuttering-like, jerky, grunting, groaning, effortful, pinched, grating and has periodic breaks in phonation. It has a tendency to be monopitched and reduced in loudness, and vowels are initiated with hard glottal attacks. 2. The abnormal voice occurs only during voluntary phonation for communication purpose and not during singing, vowel prolongation, laughing, or crying. 3. The abnormal voice is the effect of hyperadduction of the true and false vocal folds. 4., The disorder is caused by psychoneurosis from either occupational stress or emotional trauma, such as family conflicts, accidents, terrifying events, or accumulated frustrations. Arnold GE. Spastic dysphonia.z~r dysphonia.2) æ è ²
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5 36 音 声 言語 医学 図4PS77Eに よ る 症 例2-13の 発声機能 検査 結 果.基 本 周 波 数,音 圧,呼 気 流 率,特 に呼気 流 率 に非 周 期 的 な 変 動 が 認 め られ る. 周 期 的 な 変 動 を 示 し た.PS77Eに よる検 査 の 中で は 基 本 周 波 数 や 音 圧 よ り も呼 気 流 率 の 方 が 変 動 が 大 き か っ た. 表3に 各 症 例 の 測 定 結 果 を示 し た.聴 果 と朗 読 時 間,無 音 区 間,無 覚的 重症 度結 音 区間比 の間 には有 意 の 関 係 は な か っ た.た だ,無 音 区 間 比 のP値 あ り,危 険 率5%以 上 で あ るが,重 傾 向 が あ る と推 測 で き た.同 は0.0602で 症 度 との 間 に相 関 様 に モ ー ラ 法 との 関 係 を 検 討 した が や は り明 ら か な 相 関 関 係 は な か っ た.図5 はJitter, Shimmer, SNR, STD-FOお よ びSTD-Flow と聴 覚 的 重 症 度 結 果 を 比 較 し た グ ラ フ で あ る.Shim図3 ジ ャ ッ ク と豆 の 木 の 冒 頭 の 文 章 の サ ウ ン ド ス ペ ク ト ル グ ラ フ ィ ー.上 2-3,あ よ り 正 常 例,症 例 髭fダll2-5 mer(po.0085),snk(po.0019),std-flow(p= )は STD-FOはP値 た.モ た.最 終 的重症 度評 価点 数 は各検 者 の平均値 を採用 し た.相 関 関 係 の 検 証 に はSpeannanの い た.し た が っ てP値 のP値 2.結 は す べ てSpearman順 果 常 者 に比 較 す る と 者 で は朗 読 中 に お け る音 声 信 号 が 途 切 れ て い る っ た.こ 読 に 要 す る時 間 も長 か れ ら の 結 果 はWolfeandBacon4やZwit. が1970年 SNR(p=0.04/3)と P値 が0.0566で 3.考 あ り相 関 傾 向 が 認 め ら れ 相 関 関 係 に あ っ た.STD-Flawは あ り相 関 傾 向 が 認 め られ た. 察 用 い てSD患 ジ ャ ッ ク と豆 の 木 の 冒 頭 の 文 章 の サ ウ ン 時 間 が 長 い の が 読 み 取 れ る.朗 man5略 位補 正 後 が0.0513で ー ラ 法 との 関 係 で は,Shimmer(p=0.Ol21), 今 回 の 研 究 は す で に 記 録 さ れ て い る音 声 サ ン プ ル を ド スペ ク トル グ ラ フ ィー で あ る.正 SD患 順 位相 関 法 を用 を表 す. 図3は 重 症 度 との 間 に 相 関 関 係 が 認 め ら れ た. 代 に報 告 し たSDの サ ウ ン ド スペ ク 者 の 定 量 的 な 評 価 を試 み た もの で あ る. 録 音 の 際 に は 読 む速 度 に関 し て 特 別 な 指 示 を 与 え な か っ た.こ の こ と が朗 読 時 間 や 無 音 区 間 の 時 間 と聴 覚 的 重 症 度 との 間 の 関 係 が低 か っ た 理 由 の 一 つ で あ ろ う. こ の よ うな 検 査 を行 うた め に は 音 声 サ ン プ ル を 録 音 す る際 に 出 来 る だ け 速 く朗 読 す る と い った 速 度 に 関 す る 設 定 が 必 要 で あ る.呼 気 流 量 は 図4の よ う にSD トル グ ラ フ ィ ー 上 の 特 徴 と 一 致 す る.図4はPS77E 患 者 で は大 き く変 動 す る パ ラ メ ー タ ー の 一 つ で あ り, に よ る発 声 機 能 検 査 結 果 で あ る.SD患 非 周 期 的 な 声 帯 の 緊 張 状 態,頸 常 パ タ ー ン を 示 す 例 もあ っ た が,大 者 の中 には正 部 分 の患者 で は非 部 の筋 群 や呼吸 筋 の過 緊 張 状 態 な ど に 影 響 さ れ る.STD-FiOwが 重 症 度 と相
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10 1) Traube, L.: Spastishe Form der Nervosen Heiserkeit. In: Traube L, ed. Gesammelte zu Pathologie and Physiologie. Vol 2. Berlin : Hirschwald, pp , ) Arnold, G. E.: Spastic dysphonia: I. Changing interpretations of a persistent affliction. Logos, 2: 3-14, ) Aronson, A. E.: Clinical voice disorders: An interdisciplinary approach 2 nd edition. Thieme Inc, New York, 1985, pp , ) Wolfe, V. I., Bacon, M.: Spectrographic comparison of two types of spastic dysphonia. J Speech Hear Disord, 41: , ) Zwitman, D. H.: Bilateral cord dysfunctions: abductor type spastic dysphonia. J Speech Hear Disord, 44: , ) Cannito, M. P., Johnson, J. P.: Spastic dysphonia: a continuum disorder. J Communication Disorder, 14: , ) Izdebski, K.: Overpressure and breathiness in spastic dysphonia: an acoustic (LTAS) and perceptual study. Acta Otolaryngol (Stockh), 97: , ) Ludlow, C. L., Naunton, R. F., Bassich, C. J. Procedures for the selection of spastic dysphonia patients for recurrent laryngeal nerve section. Otolaryngol Head Neck Surg, 92: 24-31, ) Hartman, D. E., Abbs, J. H., Vishwanat, B. Clinical investigations of adductor spastic dysphonia. Ann Otol Rhinol Laryngol, 97: , ) Merson, R. M., Ginsberg, A. P.: Spasmodic dysphonia: Abductor type. A clinical report of acoustic aerodynamic and perceptual characteristics. Laryngoscope, 89: , ) Aronson, A. E., Hartman, D. E.: Adductor spastic dysphonia as a sign of essential (voice) tremor. J Speech Hear Disord, 46: 52-58, ) Hartman, D. E., Aronson, A. E.: Clinical investigation of intermittent breathy dysphonia. J Speech Hear Disord, 46: , ) Davis, P. J., Boone, D. R., Carroll, R. L., et al.: Adductor spastic dysphonia: Heterogeneity of physiologic and phonatory characteristics. Ann Otol Rhinol Laryngol, 97: , ) Ludlow, C. L., Naunton, R. F., Sedory, S. E., et al.: Effects of botulinum toxin injections on speech in adductor spasmodic dysphonia. Neurology, 38: , ) Makiyama, K., Bless, D. M., Ford, C. N. Contrasts in voice characteristics with adductor and abductor spasmodic dysphonia. NCVS Status and Progress Report, 2: , ) Blitzer, A., Brin, M. F., Fahn, S., et al.: Letter to the editor. Laryngoscope, 96: , ) Blitzer, A., Brin, M. F.: Treatment of spasmodic dysphonia (laryngeal dystonia) with local injections of Botulinum toxin. J Voice, 6: , ) Ford, C.N., Bless, D. M., Patel, N.Y.: Botulinum toxin treatment of spasmodic dysphonia: Techniques, indications efficacy. J Voice, 6: , ) Kobayashi, T., Niimi, S., Kumada, M., et al. Botulinum toxin treatment for spasmodic dysphonia. Acta Otolaryngol (Stockh) Suppl, 504: , ) Kumada, M., Bell-Berti, F., Kobayashi, T., et al. The Syllable Method: The Proportion of Impaired Syllables as an Indicator of Spasmodic Dysphonia Severity. Folia Phoniatrica Logopaedia, Folia Phoniatr Logop, 53(1): 19-27, ) Kumada, M., Bell-Berti, F, Honorof, D. N.: Comparing materials for the evaluation of symptom severity in the read speech of spasmodic dysphonia patients. CD-ROM of Collected Papers of 137th Meeting of the Acoustical Society of America and 2nd Convention of
11 342 the European Acoustic Association. 4 ASCB-2, ) Silverman, F. H.: Stuttering and other fluency disorders. Englewood Cliffts, NJ ) Cannito, M. P., Burch, A. R., Watts, C., et al. Disfluency in spasmodic dysphonia: A multivariate analysis. J Speech Language Hearing Res, 40: , ) Aronson, A. E., Brown, J.R., Litin, E. M., et al. Spastic dysphonia I: voice, neurologic, and psychiatric aspects. J Speech Hear Disord, 33(3): , ) Bloch, C. S., Hirano, M., Gould, W. J.: Symptom improvement of spastic dysphonia in response to phonatory tasks. Ann Otol Rhinol Laryngol,94 (1): 51-54, ) Finitzo, T., Freeman, F.: Spasmodic dysphonia, whether and where: results of seven years of research. J Speech Language Hearing Res, 32: , ) Izdebski, K., Dedo, H. H.: Selecting the side of recurrent laryngeal nerve section for spastic dysphonia. Otolaryngol Head Neck Surg, 89(3): , ) Ludlow, C. L., Connor, N. P.: Dynamic aspects of phonatory control in spasmodic dysphonia. J Speech Language Hearing Res, 30: , ) Schonweiler, R., Wohlfarth, K., Dengler, R., et al.: Supraglottal injection of botulinum toxin type A in adductor type spasmodic dysphonia with both intrinsin and extrinsic hyperfunction. Laryngoscope, 108: 55-63, ) Crevier-Buchman, L., Laccourreye, O., Papon, J. F., et al.: Adductor spasmodic dysphonia: case reports with acoustic analysis following botulinum toxin injection and acupuncture. J Voice, 11(2): ) Sapienza, C. M., Murry, T., Brown, W. S.: Variations in adductoe spasmodic dysphonia Acoustic evidence. J Voice, 12(2): , ) Sapienza, C. M., Walton, S., Murry, T.: Acoustic variations in adductor spasmodic dysphonia as a function of speech task. J Speech Language Hearing Res, 42: , ) Higgins, M. B., Chait, D. H., Schulte, L. Phonatory air flow characteristics of adductor spasmodic dysphonia and muscle tension dysphonia. J Speech Language Hearing Res, 42: , ) Ludlow, C. L., Naunton, R. F., Swdory, M. A., et al.: Effects of botulinum toxin injections on speech in adductor spasmodic dysphonia. Neurol, 38: , 1998.
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